Health and Fitness

It is not the PSA test that is a problem but what one does with the results


Please forgive me for writing about this again. There has a been a lot of discussion recently about the effectives and wiseness of giving men PSA tests. I often say that I had PSA disease. From the time I was 50 (15 years ago), I had been getting regular PSA test as was the recommendation at the time. It was the view then that at PSA of under 4 was good but PSA’s above 4 were of potential concern. This was a pretty simple minded way to look at things. There are many factors that influence PSA such as weight, infections and just ones nature. My PSA was 4.1. My doctor suggested we wait a year and see what happen. We did it again a year later  and my PSA was 4.3. She then suggested I have a biopsy. So I went to a urologist. He said to me there was a 25% chance that they would find cancer. I was pretty sensitive to the issue of Prostate Cancer since Andy Grove with whom I had a lot of contact at Intel had been treated a year earlier for Prostate Cancer and wrote an cover article in Fortune that got a lot of attention. With one chance in four that I would have cancer , it seemed smart to find out. I had the biopsy (not a lot of fun) and waited for the results. The doctor scheduled the appointment for the end of a day. I did not think much about that at the time but later realized that was so he could spend some more time with me when he told me that I had indeed had Prostate Cancer and had a Gleason score of 6 (3+3). I won’t go into what the Gleason score is. You can read about it here. My score was not very high. That combined with my rather low PSA score of 4.3 meant that I had about an 80% chance that my cancer was confined to my prostate and had not spread. So like most urologist at the time, he recommend that I have my prosate removed. The idea was that if the cancer had not escaped from the prostate and you removed the prostate that you could not die of prostate cancer. I think the same logic is applied to breast cancer and ovaries (in women with high risk). Of course, I might have some side effect like not being able to have an erection (I was a single man or 51 years), urinary or even worse elimination problems. There were alternatives and I choose the same method as Andy Grove. I had a combination of internal (seed) and external beam radiation. The side effects are better in general and definitely in my case. What we now know (and maybe we knew then) was that most men who have Prostate Cancer do not die of it. They die with it. We also believe that there are many kinds of Prostate Cancer and the most are not life threatening. What should have been done in my case. We should have just do what is called watch and wait. We should have checked the PSA every year or even every six months to monitor the rate of increase. We might have done a biopsy ever year or two. I think there is a good chance that now at the age of 65, I would still have had my prostate. PSA tests are cheap. I understand that they only cost about nine dollars to perform (of course the labs charge more for them). It is important to monitor the PSA. If you have a PSA of lets say 10 and a Gleason score of 8 or more, you need to do something. But Urologist make a lot of money by taking out Prostates and they will play to the uncertain. I often have contact with men that have recently been diagnosed with Prostate Cancer. In cases similar to mine I suggest that they wait. Sadly none have.

30 thoughts on “It is not the PSA test that is a problem but what one does with the results

  1. Hi Avram,

    Good post! This is the situation my father is in, watch and wait, after first getting the seed and radiation treatment recommendation. He is now getting tested every 4-6 months. The tests could be done a lot less expensively and more frequently in the doctors office or even at home. I am working with a company on such a device. The preliminary PSA test data is very promising (they have new marker) Would love to discuss with you when you have time.

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  2. Pingback: Invasion of the Prostate Snatchers « Two Thirds Done

  3. Urologists make a lot of money taking prostates out? Huh…you had radiation by a radiation oncologist. In my humble opinion you and Mr. Grove did what you felt was best for you at the time and you have the peace of mind that it has been treated and you are not having PSA’s and biopsies all the time. I think you did good. Don’t be so hard on those poor ole urologists out there. Was your radiation guy and the hospital paid anything for their services? I wish you the best and I hope your PSA is negligible. JM ps…if you recommend to a friend active surveillance and he is that small percentage that succumbs to the disease because he waited, how would you feel?

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    • John, I appreciate your thoughtful reply. You are probably correct that people like Andy and I did what was best at that time. I am not sure really. I wish someone had told me to take my time.
      I would rather have had the chance to keep watching my PSA and have a biopsy periodically then have my prostate radiated. Someone else might make a different choice. What I want is that men are given a real choice and presented with the facts. Hopefully you support that?
      My experience is colored by my having something that is called PSA Bounce. As you probably know (I don’t if your an Urologist), this is a situation where the PSA goes up after treatment before it finally goes down. In my case it went up for 2 years. During that time, I was told by a number of oncologist and urologists that my cancer had spread. Some even suggested salvage surgery which would have really altered my like (I was just in my early 50s). Since then, I have learned that many men can have this experience which is very scary. So having a procedure does not mean that everyone is now free from worry. And even without the bounce, men have to continue to have regular PSA tests.

      I believe that if you have a a low PSA, a gleason score of 6, you should consider watching. I think there are a number of things that most men who are diagnosed with such prostate cancer can do to increase their life expectancy besides having their prosate removed. For instance is most men are over weight in the USA, they can loose weight. They can exercise. I think if you do the math, you will find out this will have better results than destroying their prostates.
      I would feel bad if I someone I had spoken too, waited and then died of prostate cancer but frankly, I don’t think I would have that experience. I don’t know that many people. I also give driving directions to people and I would not feel responsible if they had an accident following them.
      Anyway, it would not be my decision. I always make sure that the men I speak to about prostate cancer have all the facts and opinions including the ones that I do not agree with. I hope you approach your patients the same way.
      By the way, I am on very good terms with the doctors that treated me. We have all grown and learned.

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  4. My father, a 68 years old male, has recently undergone routine blood tests which revealed an out of range PSA blood level. (4.3 ng/mL ; normal values: 0-4 ng/mL).

    At the moment he has not got any urinary symptoms; what is really worrying is that only two years ago his PSA blood level was perfect (0,7 ng/mL !).

    Obviously I am aware that only an echography and a biopsy will sweep away all doubts, but I should like to know if it is likely that he has developed a prostate cancer despite this low PSA increasing.

    In the meanwhile I sent him back to the lab so that he could repeat the blood test (PSA total and PSA total-PSA free ratio) and then I reserved a date with a local Urologist.

    I ‘d only like to know if it could be a BPH, as the PSA total level is a bit higher than normal. Besides, should it be really a cancer, does the PSA low value indicate that the desease is still confined and therefore easy to treat? I apologize for my poor English and for all the mistakes I have made. I still hope it may be a benign prostatic hyperplasia. I’d like to thank by now all the kind people who will provide me with any further information about this issue. Thank you. Riccardo – ITALY

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    • RIccardo, as you are aware, there can be many reasons for your father’s PSA to change so quickly. It could be an infection for instance. Even if they find some cancer, the cancer might not be the cause of the increased PSA. But if it is cancer, the Gleason score will be very important in deciding what to do. But in any case, if there is cancer found, be sure your father takes time to fully understand the options. Good luck.

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    • I agree with you Craig and thank you for letting evyerone know of your experience. I really would like to add something to this story. To all veterans , if you can Please try to get a second opinion from a private doctor. We have experienced alot of misdiagnois from va doctors and i thank god my husband has a private insurance company as well as va benefits and is able to get these second opinions. If you feel something is not right with the system and treatment your getting , please seek help. I hope everything works out for you ..again thank you for sharing your story , hopefully it will help others in need.

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  5. I am new to this conversation, I am very upset and suffering from the anxiety of the unknown. I had a physical from one Dr. at a clinic who said all things were ok for this 64 year old body, I lost that Dr, and changed clinics. I also contracted sepsis and cellulitis prior to a second blood test that had a PSA score of 4,38. I was given the choice of waiting 3 month or doing biopsie. I am waiting for the results in fear. Any chance the sepsis and cellulitis may have effected my prostate ? I am fearful

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  6. Dennis, please relax. A PSA of 4.38 is nothing much to worry about. I would not have a biopsy if it was me. I would just do my PSA maybe every six months and see if it rises quickly or not. There are many reasons for a PSA of 4.38 and most have nothing to do with cancer. But even if you have prostate cancer it is extremely unlikely that it would that it would be life threatening. If you would like to communicate more with me please send me an email at avram@avrammiller.com. Good luck.

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  7. I’ve read all your views with interest, thanks.

    Would you offer the same advice to someone with a 4.3 score to a 55 year old?

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  8. Avram,

    Good blog. My PSA is 4.1 (I’m a 49 year old radiologist). I would recommend people do a freePSA % and a PCA3 urine test in addition. I also had an eMRI (endo rectal MRI ) done at Memorial Sloan Kettering, NYC. Only do the eMRI at a qualified place with someone reading it who reads a ton of prostate MRIs. So far, I have not done a biopsy as there is no mass or tumor on the MRI.

    I liked your views of watchful, thoughtful waiting when possible.

    PSA is a confusing test and PCa is proportional to age. For example, 50% of men in their 50s have prostate cancer in the gland that they might die with BUT not from the cancer itself.

    Darius M.
    NYC

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  9. Thank you all. I am a 53 year old who was just informed today that I had a 4.2 psa reading. I was also told I had a slightly elevated white blood cell count and I am wondering if the reading could be the result of a slight infection. My doctor bless his heart left this news on my voice mail and as it is Saturday I have no way to contact him until Monday and it of course freaked me out. He said he wanted to retest in 3 months. Reading everyone’s comments has helped me put this in perspective so I thank you for this blog.

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  11. Great posts! I am confused at this time. I am 52 and had a biopsy in May 2013 when PSA level was 3.6. Biopsy was negative. All DRE’s to date have been negative. 7 months after biopsy, PSA went from 3.6 to 4.1. Then 7 months after that (recently), went from 4.1 to 4.3. Dr. wants me to have MRI. I would like to wait until next PSA test in January 2015. Family history is that my dad always had high PSA levels (upwards of 16-18 at one time). Prostate removed when he was 76. NO cancer ever found. Most likely BPH. Of course, I have not seen my doctor in over a year, only is PA. You would think that if it was serious enough at this time, he would speak directly with me regarding the MRI. Seems like the past 2 visits have been a routine check-up with the PA only in attendance. In summary, would like to wait on the MRI. Comments appreciated. All the best!

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    • Dear Avram, Hi. Thanks for the kind response. Very much appreciated. Most likely because of this article I recently found: http://www.medpagetoday.com/hematologyoncology/prostatecancer/36407 Makes me wonder why they didn’t perform the MRI initially before my biopsy. More importantly, to have a Physicians Assistant tell me to have an MRI is what bothers me. You would think that my doctor would come in to discuss the procedure. More confused now than prior to the biopsy. Thank you kindly. All the best!

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    • As indicated above, I have lost quite a bit of faith and trust in my doctor. The PA had really no answers to my questions justifying an MRI other than stating ‘we want to perform this to make certain that we didn’t miss anything in the biopsy”. Unreal! The sad thing is that BPH was never discussed at all even with past family history. I am aware that PA’s are being used more and more these days for the doctors but why my physician never even entered the room to explain the procedure in more detail along with justification is beyond me. It is truly sad that this is what has happened as the physician’s continue to roll in the $$!

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  12. A 73 year old – – about to turn 74; just got news his PSA was 4.6. Have appointment with Doctor. Any thoughts about percentage chances for PC? Three years ago; PSA was 1.78. Is that an alarming rate of increase? Needless to say; suffering great anxiety! Appreciate informed opinions!

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  13. 58 m, recent blood test revealed psa score of 7.37. im in good health, exercise, try to eat healthy, no unusual symptoms…appointment with urologist later this month. no family history of prostate issues. any thoughts?

    ty

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  14. Your article and the comments following it are the best information I’ve read about the PSA test and follow up action anywhere. Thank you for the information and exchange of ideas.

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  15. I am 51 years old, and my life insurance company denied renewing my policy because my PSA was 4.6. It has been repeated 3 times at 6 month intervals since, and has dropped to 4.3, and 4.1 respectively. They still are not willing to offer me life insurance. All my DREs have been fine, and I now have a pending appointment with a urologist/surgeon in 4 days. I am averse to having a biopsy done. Should I ask to have a echo gram done first or eMRI?

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  16. Psa 8/25/15 (last time checked) 3.24 4/18/17 checked at 4.1 56 year old male in 2015 had biopsy was pretty painful and negative is this score alarming? Last year also had quadruple bypass heart surgery after 6 months 2 main viens died making low blood pressure a new kink in my armour is yohimbe supplements recommended ? Thanks for your time charley

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