7 Reasons PSA Testing Still Matters

29000 Men Comment
As I have stated before in this blog, it is my fervent belief that PSA testing currently is the only effective means of preventing prostate cancer deaths. It’s not knowing you have prostate cancer that causes over treatment, it is faulty patient decisions. I say patient decisions because ultimately each of us is responsible for the treatment we undergo. We cannot, and should not, place that responsibility on the medical community.

If you are interested in a balanced view of the current PSA testing controversy, read the following article by Dr. Ford Vox on his blog at

Begin Dr. Vox’s Blog Post:

The PSA Test: 7 Reasons It Still Matters
November 13, 2009 03:55 PM ET | Ford Vox | Permanent Link | Print

The U.S. Preventive Services Task Force asked doctors last year to stop checking PSA levels in elderly men—the very men who are most likely to have prostate cancer. By age 75, the officials reasoned, doctors are more likely to keep tinkering with their patients until they die of treatment side effects or something other than prostate cancer altogether. This spring, the New England Journal of Medicine published two long-term studies that questioned whether knowing a man's PSA level actually helps men survive. Healthcare commentators say that PSAs set off a cascade of overtreatment, endangering patients and tolerating wasteful medicine, and that patients should be wary.

You might expect that the surgical specialists at the center of prostate cancer treatment would have reined in their PSA testing, but they haven't. The American Urological Association actually lowered its recommendation for the age at which doctors should start offering patients the PSA test from 50 to 40. It was the first revision of the guidelines in nearly a decade. The next one, says Kirsten Greene, a urologist who worked on the committee, should take just a year, in light of the accelerating data and heightened public debate.

"The key change is how we react to abnormal tests and to a cancer diagnosis, which is generally less aggressively for some men than in the past," says Gerald Andriole, chief of urologic surgery at Barnes-Jewish Hospital/Washington University School of Medicine in St. Louis. Andriole says that men shouldn't be afraid to get diagnosed; good urologists avoid overtreating less-dangerous cancers. Active surveillance or targeted attacks on very small tumors that spare healthy prostate tissue are both popular options.

From the latest research, here are seven reasons why urologists are encouraging men of any age who expect to live at least another 10 years to think hard about getting a PSA test, even if they have to pay out of pocket:

1. Keeping tabs on PSA saves lives. Many urologists flat out reject a large study published in the New England Journal of Medicine earlier this year that found men who got the PSA test did worse than men who didn't. The dissenters say the results weren't trustworthy—many of the men who weren't supposed to get tested actually did, thanks to their proactive primary-care docs. Another recent large NEJM study found that nine years after entering the study, men who got regular PSA screening were 20 percent less likely to die of prostate cancer. One model suggests the PSA test has contributed to much of the 30 percent decline in prostate cancer deaths seen in recent decades.

2. There's no magic PSA number. In the urologists' latest recommendations, it is clear that there's no one-size-fits-all age at which to be tested or bad PSA number. For many years, a particular reading of 4 or above was a battle cry that called for a biopsy or aggressive treatment. In reality, any reading is suspect. Without knowing much more about him, studies give a middle-aged man a 10 percent chance of having visible cancer on biopsy even if his PSA level is zero. Today, doctors consider a single PSA number in the context of your specific health background, race, and family history (it may also help diagnose benign enlargement or an infection), and then suggest when to be tested next. If you do get a biopsy, the criteria for serious concern are stricter, and there are more conservative treatment options.

3. Velocity matters. Your first PSA test is neither your last nor your most important. Depending on your age and your current PSA number, the question is how much, and how fast, subsequent test numbers increase. Researchers are busy determining just how much velocity is normal. (Some researchers say a speed bump of more than 0.25 in one year for a 40-year-old man should prompt concern.) Every man generates a history of data points his doctors can interpret in light of the research.

4. There ' s more than one kind of PSA to measure . Enlarged but noncancerous prostates usually release "free" PSA that circulates through the body, while PSA produced by cancer cells tends to attach itself to proteins in your blood. By considering the ratio of the types of PSA, as is done by looking at the ratio of bad to good cholesterol for heart disease, doctors can offer you better advice about your risk and what you should do next.

5. The younger you are, the more meaningful the PSA test. Older prostates tend to get bigger and put out more PSA, complicating interpretation. Higher PSA levels at a younger age are an indicator of elevated risk and call for closer monitoring of factors like your PSA velocity. At the same time, prostate cancer therapies are most effective and sparing of function when the cancer is at an early stage.

6. PSA numbers reveal your prognosis and are critical in follow-up. If you do develop a serious form of prostate cancer that requires aggressive treatment, your PSA levels prior to treatment will help your medical team determine the risk of recurrence. It's one factor among many others, such as how the tumor looked under the microscope after surgery, but the latest studies show it's of real value. After surgery to remove the prostate, the PSA test is even more critical: Detection of extremely minute levels can signal cancer recurrence. The earlier doctors know the cancer is back, the earlier patients can decide about secondary treatments like radiation and hormonal therapy.

7. For now, PSA is the best we've got. Scientists are looking hard for a better "biomarker" than the PSA, ideally one that doesn't require so much deliberation. Candidates are surfacing, but they require more proof. Physical measures like the prostate's size can be misleading, as Mayo Clinic researchers reminded us this week. Studies show that a digital rectal exam plus a PSA test is the surest way to pick up prostate cancer. But if you've got to pick only one test, PSA is still the best.

So Easy a Caveman Can Do It!

We’ve all heard the Geico car insurance ad a million times, at least if we watch sports. So what does this saying have to do with prostate cancer? The answer is nothing and everything.

The research has just about reached the overwhelming stage that the Western diet, especially our American version - heavy on meat and dairy with their associated fat and toxic loads, is a major factor in prostate cancer development.

As a prostate cancer survivor, I’m pretty interested in ensuring that mine does not recur, so I started looking at the recurrence risk elements that are within my control. Basically, these factors are what I eat (my diet), what I do (exercise - or lack thereof), and what I think - laughter is great medicine.

On the food front, I decided to see how easily I could adopt a diet with no meat and dairy. But, I reasoned, it needs to be really EASY - there’s the caveman angle - because we guys (at least most of us) tend to graze on the first thing we see and things that are easy. Below is my first shot at doing green, the easy way.

I created what I think is a pretty passable salad using pre-washed vegetables - minimum preparation time. The ingredients: 1) pre-washed spinach; 2) pre-washed broccoli and romaine lettuce; 3) I peeled and diced some raw onions - it did require some peeling; and 4) I chopped in red peppers. Full disclosure; I did wash the red bell pepper. I drizzled extra virgin olive oil over the top along with some coarse sea salt, as I have a salt tooth. Et voila! A pretty good salad - very healthy - with almost no preparation. Make it as big as you like, there aren’t many calories but lots of great vitamins, minerals, phytonutrients, etc. A caveman really could do this because they had that all important opposable thumb. And all in about 11.5 minutes. Got brocolli?

Letter to the Editor, LA Times, on PSA Testing

29000 Men Comment
Below is a copy of my letter to the editor that was published in the LA Times on 10/27/2009. It was slightly shortened to conform to the 150 word limit. Eliminated was my comment that the annual prostate cancer death rate has dropped from the 40,000 men per year in the pre-PSA test era to the approximately 29,000 deaths per year today. If the current debate is successful in convincing men they do need to test and track their PSA, we very likely will see a return to the 40,000 per year death rate. This would mean that an additional 100,000 men would die unnecessarily from prostate cancer each decade.

I believe that we need to focus more on prostate cancer prevention and methods to effectively determine which cancers are the aggressive killers. See the Times letter below.

LA Times Opinion Section, October 27, 2009
Cancer risks and diagnoses

Re “With cancer, it’s always personal,” Oct. 25

Thank you for running Paul Lieberman's Op-Ed article on prostate and breast-cancer screening.

I would, however, retitle his article, "With Cancer, it's never real until it's personal. " My point is that one only comes to terms with cancer after we, personally, are diagnosed. The danger with the current discussion over prostate cancer testing is that the continual focus on possible post-treatment problems may drive the annual PSA testing rate below the current meager rate.

The principal issue with PSA testing is not with the number of men tested but with the treatment decisions made by cancer patients and their physicians. What men need is better information about prostate cancer risk and treatment options, but with real statistics about post-treatment side effects attached.

And, of course, the ability of physicians to be able to reliably differentiate between benign and aggressive forms of prostate cancer.

Robert W. Hess
Manhattan Beach

http://www.latimes.com/news/opinion/letters/

Mayo researchers find few side effects from radiation treatment given after prostate cancer surgery

29000 Men Comment
The following article came from by Cancer Weekly, a leading research newsletter for biotech and pharmaceutical professionals. For more information, go to http://www.newsrx.com/publication.php?pubID=74.

If correct, the results of the study detailed below should be reviewed by all men preparing to undergo prostate cancer surgery. In my case, the option was never mentioned. I’m now 5 1/2 years into my survivorship and recurrence is something I think about often.

“Mayo researchers find few side effects from radiation treatment given after prostate cancer surgery

The largest single-institution study of its kind has found few complications in prostate cancer patients treated with radiotherapy after surgery to remove the prostate. Men in this study received radiotherapy after a prostate-specific antigen (PSA) test following surgery indicated their cancer had recurred.

Researchers say the findings from Mayo Clinic's campuses in Florida and Minnesota suggest that patients and their physicians should not overly worry about toxicity and side effects from the treatment, known as salvage external beam radiotherapy. The study findings will be published in the October issue of Radiotherapy and Oncology.

"There is a general fear of this kind of radiation treatment on the part of some patients and their physicians, but this study shows that it not only effectively eradicates the recurrent cancer in a substantial number of patients, but that there are few serious side effects," says the study's lead investigator, Jennifer Peterson, M.D., from the Department of Radiation Oncology at Mayo Clinic in Florida.

"It is really important that patients and their doctors watch PSA levels after a radical prostatectomy, which is a complete removal of the prostate," she says. In men who have an intact prostate, a PSA test can indicate either an enlarged prostate gland or development of cancer in the prostate, says Dr. Peterson. "But in men without a prostate, a rising PSA level indicates that cancer has recurred. After a recurrence is detected, there is only a narrow window of time during which radiotherapy will be beneficial in controlling their cancer."

"No other therapy besides salvage external beam radiotherapy has been shown to cure these patients," she adds.

In 2009, an estimated 192,000 American men will have newly diagnosed prostate cancer. Approximately one-third (about 64,000 men) will choose radical prostatectomy as their primary treatment, according to the National Cancer Institute. Large studies have shown that one-third of those men, about 21,000 patients, will experience a rising PSA - a recurrence of their cancer - within five to 10 years, says Dr. Peterson. "Two-thirds of these men, if left untreated, will have metastatic disease within 10 years, but the chances of that occurring are greatly reduced in patients given salvage radiotherapy," she says.

Lingering uncertainty about the effectiveness of salvage radiotherapy and its side effects have led many urologists not to recommend the treatment, says co-author Steven Buskirk, M.D., from Mayo Clinic in Florida.

This study, which lasted two decades, was undertaken to specifically document those side effects. It studied 308 patients with a median follow-up of 60 months after salvage external beam radiotherapy. Only one patient had a serious (grade 4) complication and three patients had a less serious (grade 3) side effect. None of these effects were fatal, and all were treated. Milder side effects were seen in an additional 37 patients, the researchers say, and all were successfully treated for these complications. Urinary leakage, a concern of many patients who choose not to use radiation, was not a common side effect of treatment.”

What We Eat and Do May be the Real Strategy for Beating Cancer

29000 Men Comment
“No matter how strange something is, if you give it enough time it becomes normal. American’s have now accepted heart disease, cancer, and other degenerative diseases as a normal part of American life.” (1)

Now approaching six years as a prostate cancer survivor and amateur student of wellness and cancer recurrence prevention, I have arrived at the conclusion that our best chance at avoiding or defeating this disease rests with our own habits.

I’ve been looking at this issue for five years now, and I recently read books by David Servan-Schreier, MD, PhD, Anti Cancer: A New Way of Life, and the RAVE Diet and Lifestyle by Mike Anderson.

I’ll be summarizing what my key takeaways from these books over the next series of posts, and I encourage your feedback - even “pushback.” I’ll also be posting some of my personal recipes for “quick eats that are so easy "Even a Guy can do them!”

Best regards, Robert


Anderson, Mike, The RAVE Diet, RAVEDIET.com, August, 2004.

Mild Incontinence

In case you have just a small bit of incontinence following surgery or radiation therapy, consider using women's panty liners. They are smaller than men's products, work really well, and are absolutely undetectable. If you are a numbers guys, you can get a small postal scale and track the degree of incontinence and watch as your kegel exercises begin to work.

To PSA or Not to PSA. Is that the Question?

29000 Men Comment
Below is a good description of some of the history of PSA testing and accepted PSA values for specific age ranges. The problem with guidelines is that there are the general rule and don’t cover the statistical outliers. For example, I am an accidental prostate cancer survivor. I was diagnosed at age 57 with a PSA value of 3.2, well within the acceptable range according to the standard. I also had a negative DRE, which was misleading because my tumors were sitting on top of the prostate where they could not be felt. My post treatment diagnosis was Stage 2, with a Gleason Score of 3+3. I am only here writing this blog because my urologist was super diligent and ordered a Free PSA test that came back with a very low ratio (.09; 9%).

Prostate cancer kills almost 29,000 men each year. It is up to each man individually to monitor his PSA, track the changes, and then get the facts. I am not suggesting a rush to treatment, but I do believe it is vitally important for men to know if they have prostate cancer as soon as possible. If you are unlucky and are one of the 1 in 6 men that is diagnosed, the next step is to work with the doctor to determine if you have an aggressive form of the disease.

Please visit us at 29000Men.org and participate in one of our prostate cancer awareness events.

Begin Quote of Referenced Material
The PSA Test

Understanding the PSA Test and Results

Prostate Specific Antigen (PSA) is a protein made in the prostate. Normally, very little should be found in the blood. Rising levels of PSA in the blood indicate a problem with the prostate, which could be cancer but could also be an enlarged prostate (BPH).

Annual screening should start at age 45 for the general population, but the right age to start PSA testing depends on your level of risk.

Doctors usually recommend further testing for men with a total PSA level of 2.5 or more nanograms of PSA per milliliter of blood (ng/ml). This cut-off level has been set by the National Comprehensive Cancer Network, a large network of cancer experts who establish industry wide standards.

As PSA levels increase, so do the odds that it’s due to prostate cancer. About 25 percent of men with a PSA level from 4 to 10 have prostate cancer. About 67 percent of men with a PSA above 10 have the disease.

The change in your PSA level over time, PSA velocity, is very important. Even if your PSA is 4.0 ng/ml or below, an increase of 50 percent or more in one year may indicate prostate cancer. If your PSA is above 4.0 ng/ml, an increase of 75 percent or more in one year could indicate an aggressive case of the disease.

There are some factors that you and your doctor may want to consider when it comes to interpreting your score:

* Your age. Doctors may use age-adjusted PSA ranges to account for the natural increase in PSA with age when considering further testing.
* The size of your prostate. PSA Density is a measure that relates your PSA level to the size of your prostate, to account for the increase in PSA caused by prostate enlargement.
* Your weight. Body Mass Index, a measure of obesity, may also be a factor. The relationship between obesity and lower PSA levels may cause doctors to miss early prostate cancer cases in overweight men.
* Ejaculation within 48 hours before taking a PSA test can also cause a higher reading of your PSA level.

Some doctors recommend the following PSA cut-off levels adjusted by age and ethnicity:

Age Caucasian or Hispanic African American Asian

40 to 49 2.5 2.0 2.0

50 to 59 3.5 4.0 3.0

60 to 69 4.5 4.5 4.0

70 to 79 6.5 5.5 5.0

PSA Test Standards

Today, because there are two standards for PSA tests, the same cutoff should not be used across all PSA tests. It is important for you and your physician to know which type of test your clinic’s lab uses and how to correctly interpret the results.

The Hybritech PSA test established 4.0 ng/mL as the cutoff for a normal test. This means men with a score above 4.0 should be referred for further testing, such as a biopsy. Men with a result lower than 4.0 may not be referred for biopsy, depending on their physician’s instructions. As other manufactures developed PSA tests, they aligned their tests to the same standard, which became known as the "Hybritech standard," and other manufacturers used the same recommended cutoff of 4.0.

By the mid-1990s, some researchers began to recognize that test results from different test manufacturers could be slightly different and joined together to create a common calibration standard to better align results from different PSA tests. This standard was accepted by the World Health Organization (WHO) and soon became known in the medical community as the “WHO standard” PSA test. To establish this new standard, a different scientific process to measure molecular weight of PSA was used and found that weight to be 20 percent higher than was used for the Hybritech test. Because of the way this is calculated, a WHO test would show a proportionately lower PSA concentration level than would a Hybritech test for the same sample. As a result, the cutoff point at which men are referred for further testing would more appropriately be set about 20 percent lower than the 4.0 used for the Hybritech test.

To find out which type of test you have received, your physician should contact his or her lab to determine which brand of test was used for their PSA testing and whether it is WHO or Hybritech calibrated.

Types of PSA Tests

Some of the PSA in the blood is bound to enzymes (complexed) while some is freely circulating (free). Unless otherwise noted, the PSA levels generally refer to total PSA (or tPSA), a combination of complexed and free PSA.

Free-PSA or fPSA refers to the percentage of PSA in the blood that is not bound to enzymes. Doctors are now recommending further testing for men with a free-PSA of less than 25 percent. This is a helpful indicator for men who may be uncertain whether to get a biopsy, such as those with PSA levels between 4 and 10, and negative DRE results.

Complexed PSA or cPSA refers to the measure of one type of bound or complexed PSA. This measure is as accurate as total PSA and may be better at ruling out some people from further testing. Cut-off levels are different for cPSA, so make sure you know whether your PSA test is complexed or total. For example, a cPSA level of 2.2 is equivalent to the cut-off level of tPSA at 2.5.

PSA and Recurring Prostate Cancer

The PSA test is also used to detect and monitor recurrence of prostate cancer after initial treatment. PSA levels should drop dramatically after initial treatment. If they rise again, they are a good indicator that the initial treatment did not catch all the cancer cells.

Source: Zero: The Project to End Prostate Cancer http://www.zerocancer.org/site/PageNavigator/PSA_Test