Judging by the fact that my blog on the Growing Bolder site entitled, “Prostate Diaries” has been read 16,870 times as of this morning, there is an apparent considerable interest in the subject. The catalyst for me writing this particular blog was the fact that a friend of mine underwent a radical prostatectomy this week. That procedure probably saved his life, but it is not always the best option for a good number of men. That of course brings up the controversial subject of PSA testing – the test which starts one down the path of a very difficult decision making process.
One of the foremost experts in the world on the subject of prostate cancer is Dr. Mark Scholz, MD, the medical director of Prostate Oncology Specialists and the Executive Director of the Prostate Cancer Research Institute. He, along with Ralph Blum, a prostate cancer patient, is a co-author of the book, “Invasion of the Prostate Snatchers.” Interestingly, perhaps distressingly, there are only 100 oncologists in the country that deal exclusively with prostate cancer. The typical urologist is a bit prejudiced in his guidance in that if he is a surgeon (and most are), he will guide the patient towards that cure, etc., however the prostate cancer oncologist is able to make recommendations based on what’s best for the patient – not what’s best to enhance his own bank account. Below, you will find information from the latest research of Dr. Scholz that might save your quality of life (if not your life) in that prostate cancer approaches 100% as we age. We, in this country, are incredibly over treated for a condition that some physicians would rather label a chronic condition rather than use the term “cancer.” Read on for the latest and greatest information about PSA screening.
Most elderly men already have prostate cancer—they just don’t know they have it. And they might be better off remaining ignorant. Newly-diagnosed men are thrown into an eight-billion-per-year medical world that extols radical treatment. Over-treatment is so out-of-control that a New England Journal of Medicine study estimates that forty-eight men are getting unnecessary surgery or radiation for each individual who truly benefits from them.
Random Biopsy, Not PSA is the Real Problem
When PSA is elevated, primary care physicians usually refer to a urologist for an immediate 12-core random prostate biopsy. One million men are biopsiedannually in the United States. Few people realize that even when the PSA is normal, the biopsy will be positive 20% of the time. The problem is that a diagnosis of any prostate cancer, even the Low-Risk type, almost invariably leads to surgery or radiation.
Biopsies Are Not Benign
Over-diagnosing Low-Risk prostate cancer, and the attendant risk of over-treatment, is not the only problem caused by random biopsy. Consider the emotional devastation caused by a cancer diagnosis. Men are literally frightened to death by the discovery of prostate cancer: The first week after diagnosis, the risk of suicide and heart attacks jumps dramatically. In addition, 3% of men suffer biopsy-induced infections resulting in hospitalization. Fatal infections are estimated to occur in approximately one-thousand men undergoing random biopsy per year.
Stop PSA Screening?
Due to all these mounting negatives, the US Preventative Services Task Force now recommends that routine PSA testing cease altogether. The Task Force’s conclusion was that unnecessary treatment to over a hundred thousand men annually is too big a price to pay even though PSA screening saves lives. The Task Force fails to understand that overtreatment isn’t caused by PSA, it’s what physicians do with the information PSA provides—they automatically refer every patient for immediate random biopsy.
PSA Is Heavily Influenced by Prostate Size
Most PSA originates from the prostate gland, not from cancer. Therefore, when the cancer is relatively small, PSA is a reflection prostate gland size. In a man without cancer, PSA normally averages one-tenth of the prostate volume. For example, the average PSA for a 30cc prostate is 3; five for a 50cc prostate and 10 for a 100cc prostate with size determined by ultrasound or MRI.
Therefore, PSA can only be termed “abnormal” if it’s 50% higher than expected, based on a man’s prostate size. For example, an abnormal PSA for a 30cc prostate is 4.5, a 50cc prostate, 7.5 and a 100cc prostate, 15. Additional extraneous factors such as low-grade infections, lab variations and recent sexual activity can also cause PSA to vary. Repeat testing helps average out these variations so the “real” PSA can be determined.
Primary Care Doctors Are the Source for Balanced Counsel
Only the primary care physicians can stop the mindless rush to random biopsy. Instead of referring for random biopsy they can send their patients with elevated PSA for prostate imaging with multiparametric MRI or Color Doppler Ultrasound. Imaging can put the PSA elevation into context by determining the prostate size. Also, in the hands of an experienced radiologist, using state-of-the-art, three-Tesla MRI, high-grade cancer can be ruled out with 95 to 98% accuracy.
If imaging detects a high-grade lesion, primary physicians can then counsel their patients about whether a targetedbiopsy directed at the abnormal lesion should be performed. Alternatively they can recommend simple monitoring with a repeat imaging study six to twelve months down the road to determine if the lesion is growing. Lastly, if a targeted biopsy shows cancer, rather than being guided by a urologist, who is, after all, a surgeon, patients can obtain counsel from their primary physician, a non-surgeon who can provide unbiased assistance in selecting the best treatment.
Estimating Cancer Risk
If men are concerned about the risk of forgoing an immediate random biopsy they can estimate the percentage likelihood of harboring low-grade or high-grade disease with an online calculator by googling, “risk of biopsy-detectable prostate cancer.”
Imaging Rather than Biopsy
Prior to PSA screening men should be informed that if PSA is high, the first step should be imaging rather than random biopsy. Random biopsy can cause serious infections. It also diagnoses Low-Risk prostate cancer, a harmless condition that nevertheless, often leads to unnecessary treatment. PSA screening, while saving lives by detecting High-Risk cancer at an early stage, can also, if handled improperly, lead to unnecessary treatment with many lifelong side effects.
For further reading, scroll down into my blog archives for a recent piece I wrote on the subject of active surveillance as one tack for dealing with prostate cancer entitled, “An Important Read for All Men…”