The Latest Advice on Screening for Prostate Cancer

The concept of screening for prostate cancer is a moving target. Screening for this common cancer in men has undergone significant changes in the past ten years. This blog is intended to provide you with advice on whether you should participate in prostate cancer screening.

 

Another progress being made is that men with early-stage tumors have been spared the side effects of treatment, such as erectile dysfunction (impotence) and urinary incontinence, which can be devastating. A recent report notes that 15 years after diagnosis, that 87% of men who underwent surgery and 94% of men who had radiotherapy were unable to engage in sexual intimacy.

 

So what do you need to know about prostate cancer screening?

 

Talk to your doctor about obtaining a PSA tests if you are at high risk for prostate cancer. These include African American men who are twice as likely to be diagnosed with prostate cancer and have an aggressive form of the disease and 2.4 times more likely to die from it than Caucasian men.

 

Men with a family history of prostate cancer are twice as likely to have prostate cancer and to die from it.

 

New tests for prostate cancer

We have been looking for a test that will better predict prostate cancer than an elevated PSA level. There are four new tests to enhance the diagnosis of prostate cancer.

 

A urine test, PCA3 looks for the presence of a specific prostate cancer gene. This test is more accurate than the PSA test in deciding whether a man needs a prostate biopsy.

 

The Prostate Health Index (PHI) blood test evaluates three different components of PSA to determine whether the elevated PSA level is due to infection, benign prostate disease or possibly prostate cancer.

 

The 4K score blood test is similar to the PHI test but looks at four components which can predict a man’s risk of developing prostate cancer.

 

Finally, the prostate MRI or magnetic resonance imaging test which can accurately diagnose aggressive prostate cancer.

 

If any of these four tests are positive, then the next step is a prostate biopsy.

 

So what is my “bottom line” on prostate cancer screening? I suggest a baseline PSA test for all men at age 50 and for higher risk patients at age 45. Men with very low PSA levels, less than 0.7ng\ml at baseline can have the PSA test every 5 years, and those 60 and older with levels less than 2.0ng\ml or lower may be able to avoid future PSA testing for the rest of their lives….as long as they remain symptom free. If you have any questions, check with your doctor.

Give a High Five to High PHI-Prostate Health Index.

For the past 20 years the PSA has been the metric for screening for prostate cancer. More recently the U.S. Preventive Services Task Forces issue a recommendation against the use of PSA-based screening for prostate cancer in all men because PSA screening contributed to over treatment and over diagnosis of prostate cancer.

The prostate health index (PHI) was approved by the FDA in 2012 as a blood test that calculates a score based on the combination of three separate tests” PSA, free PSA and p2PSA. These simple blood tests will help determine the probability of finding prostate cancer if you have a prostate biopsy.

PHI should be considered for men with PSA levels >3, who have not had a prostate biopsy as well as for me who had one prior negative prostate biopsy and who might be considered at higher risk for prostate cancer.

The PHI helps to distinguish between prostate cancer and benign prostate diseases like benign enlargement of the prostate gland and prostate infection. The PHI improves the diagnosis of prostate cancer with men who have a PSA between 2-10 where 4.0 is the cut off currently considered for men who should have additional studies, evaluations, or a prostate biopsy.

The PHI enhances the ability to detect prostate cancer in men with a normal physical examination and in men whose PSA is between 2-10. The PHI has helped to decrease the number of men who are subjected to a prostate biopsy, which leads to over diagnosis and over treatment.

Also the PHI can be used in men who have received a diagnosis of prostate cancer and have been placed on an active surveillance protocol, which means no treatment but regular examinations with a digital rectal exam and a blood test. Men followed on the active surveillance protocols who have a low PHI score can be followed without treatment. On the other hand, those with an elevated PHI score may be advised to have a repeat biopsy and consider for definitive treatment. Thus the PHI helps the patient and the doctor determine if the man has more aggressive prostate cancer and needs additional treatment.

Bottom Line: Prostate cancer is most common cancer in men after skin cancer and the second most common cause of death after lung cancer. Now there are blood tests like the PHI that help fine-tune the diagnosis and help men decide to participate in close follow up or proceed to a prostate biopsy.

Treating Prostate Cancer By Close Monitoring or ActiveSurveillance

Prostate cancer is the most common cancer in older men and second most common cause of death due to cancer in men over the age of 50.  This year more than 180,000 men will be diagnosed with prostate cancer and more than 30,000 men will die of this disease.  There are multiple treatment options for prostate cancer including surgery, radiation, hormone therapy and now there’s a new option: watchful waiting or active surveillance.  Active surveillance means no treatment but careful monitoring with regular digital rectal exams, PSA testing, and possible other tests and\or imaging studies.  This blog is intended to help men who have received a diagnosis of prostate cancer to help guide them in the decision of active surveillance or more aggressive standard treatment options.

What you need to know

The prostate gland is a walnut-sized organ at the base the bladder and surrounds the urethra or the tube in the penis that transports urine from the bladder to the outside of the body.  The prostate gland’s function is to make the fluid that mixes with the sperm and provides the sperm with nourishment to help fertilize an egg and start the process of conception.

For the first part of a man’s life the prostate gland provides pleasure and enjoyment.  After age 50 for reasons not entirely known, the prostate gland starts to grow and compresses the tube or the urethra and produces difficulty with urination.  Again, for reasons not entirely known the prostate cells grow uncontrollably and this results in prostate cancer.

Prostate cancer is a very common as one in seven American men will develop prostate cancer.

There are two tests used to detect prostate cancer: 1) the digital rectal exam and 2) the PSA or prostate specific antigen test.  PSA is a protein made by the prostate gland.  An increased level of PSA can be a sign of prostate cancer but an elevation is also seen in men with prostate gland infections and benign enlargement of the prostate gland.

Active surveillance is now considered an acceptable management option in certain men with prostate cancer.  Active surveillance is a type of close follow up. In addition to the PSA and digital rectal exam, a repeat biopsy may be indicated.  A biopsy test called a fusion-guided biopsy is one of these newer tests that combines the MRI with real-time ultrasound images of the prostate.  Genomic tests are another development for prostate cancer assessment.  These tests look at the DNA of the cancer to decide if the cancer is stable or growing.  If any of these tests indicate that the cancer is growing, you may require additional treatment.

At the present time there is no universal agreement about how often the tests should be done for men who are participating in active surveillance.  Patients who are at low risk, that is have a low PSA and a biopsy that reveals a reasonably favorable pathology report, then he can have his PSA check every six months.  It is also common to have a repeat biopsy 12-18 months after the diagnosis.

Candidates for Active Surveillance

Men with early stage prostate cancer that is confined to the prostate gland are the best candidates for active surveillance.  Also, good candidates are men without symptoms and have prostate cancer that is slow growing.  Finally, older men with serious other medical problems which may interfere with treatment are potential active surveillance candidates.

The benefits of active surveillance is that it is low cost, safe, and has no side effects.  Men are able to maintain day-to-day quality of life and not have any of the complications of treatment such as impotence\ED or urinary incontinence.  The risk is that men can become complement and not follow up as often as they should and that the cancer can grow and become more aggressive.

Bottom Line:  Prostate cancer is a common problem in middle age and older men.  Most men if they live long enough will develop prostate cancer.  However, most men with the diagnosis of prostate cancer will die with the cancer and not from it.  My best advice is to have a conversation with your doctor and see if active surveillance is right for you and your cancer.

Prostate Cancer

What do Jose Torres, John Kerry, and Jerry Lewis have in common?  They all have prostate cancer and have been successfully treated.  Nearly 250,000 men will be diagnosed with prostate cancer this year and nearly 30,000 men will die of prostate cancer.  This article will discuss the symptoms of prostate cancer and what can be done to diagnose the

The most common prostate problems are an enlarged prostate, prostatitis and prostate cancer.

Prostate cancer frequently has no symptoms and most men will have prostate cancer and not be aware of the diagnosis.  Symptoms that occur as a result of any prostate condition including benign enlargement of the prostate gland and prostate cancer include:

• Frequent urination
• Getting up at night to urinate
• Pain with urination
• Difficulty starting to urinate
• Blood in the urine
• Bone pain
• Impotence or Erectile dysfunction (ED)

 

Risk factors associated with prostate cancer include:

The condition is rare in men under 40 years of age, but most cases are found in men aged 50 or older. At age 80+ nearly all men will have prostate cancer but will seldom succumb to the disease or they have prostate cancer but will not die from it. 

Genetic factor may contribute to prostate cancer risk. Men who have a father, brother, uncle or cousin with prostate cancer are 2 to 3 times more likely to get the condition as compared to men without prostate cancer in a close relative. 

African-American men also have an increased risk of having prostate cancer. It is suggested that African-American men start seeing a doctor for a digital rectal exam and a PSA test after age 40.

Studies have found that obese men have a greater risk of developing more advanced prostate cancer as well as a higher risk of metastasis and death from the condition.

Many studies have found a link between smoking and getting prostate cancer as well as an increased the risk of dying from the condition.

High fat diet has been shown to put men at high risk of prostate cancer. Some studies show that men who have diets high in red meat may raise a person’s chances of developing prostate cancer. 

Bottom Line:  Prostate cancer is the second most common cause of death in men due to cancer (lung cancer is number one), and is very treatable if the diagnosis is made early.  This can be accomplished with a rectal examination and a PSA test.  Speak to your doctor for more information.

 

PSA Testing for Prostate Cancer-To Screen or Not to Screen That is the Question

Today, nothing is more confusing for men than the concept of screening for prostate cancer.  Prostate cancer is the second most common cancer in men, following lung cancer, and there are 250,000 men each year diagnosed with prostate cancer and causes nearly 30,000 deaths a year.  About one in seven men will be diagnosed with prostate cancer during his lifetime.

But some prostate cancers develop slowly, and, as the disease is more common in elderly men, most men with prostate cancer die with it and not from it. Thus, screening, diagnosis and treatment of the disease are controversial.

There is no consensus about prostate cancer screening as early diagnosis can be associated with very bothersome side effects such as erectile dysfunction and urinary incontinence.  Also screening has not been universally shown to increase survival or decrease the death rate from prostate cancer.  This article will discuss the pros and cons of PSA screening for men.

Men who opt for screening undergo a digital rectal exam and a blood draw to measure a chemical called PSA or prostate specific antigen. This level of PSA can be increased in men with prostate cancer. Other conditions may cause the increase in the PSA such as benign enlargement of the prostate gland and prostate infections.

The best way to detect an early potentially deadly case is to collect yearly PSA tests over three to five years so trends can be assessed.

I like most other urologists are concerned about over treatment of prostate cancer — in other words, being too aggressive in using surgery or radiation when a small amount of potentially slow-growing cancer is found on a biopsy.

The federal government has also become concerned about this issue. A large medical research trial called the Prostate Lung Colorectal and Ovarian (PLCO) Cancer Screening Study released results from 2009 showing no benefit from screening for prostate cancer when comparing a large group of unscreened men to a large group of aggressively screened men.

Researchers across the country are assessing the effects of the USPSTF recommendations on prostate cancer mortality since 2012. In a recent study from Northwestern University in Chicago, researchers found a significant increase in the cases of advanced prostate cancer already spread to other parts of the body from 2004 to 2013. As a result we could be missing serious cancers because of decreased screening.

Prostate cancer also has a hereditary predilection and men with a father, brother, cousin, or uncle should consider having screening around age 40.  This also applies to African-American men who have a greater risk of prostate cancer than Caucasian men and should also have testing after age 40.

My best advice is to ask your doctor\urologist about the decision to undergo prostate cancer screening.

Smelling Prostate Cancer

Prostate cancer is the most common cancer in older men with nearly one quarter of a million new cases discovered each year.  It is the second most cause of death in men with over 25,000 deaths each year.  Now there is a new diagnostic device that can detect prostate cancer in men’s urine.

A new device, Odoreader, was developed in the UK which can be helpful in disgnosing prostate cancer by identifying the unique odor in the urine of men with prostate cancer.

The researchers looked at a total of 155 men of which 58 had been diagnosed with prostate cancer by evaluating their urine with the Odoreader. The researchers found that Odoreader was able to successfully identify patterns of volatile compounds from urine samples, and detect those that indicate cancer.

Unfortunately at the present time there is no accurate test for prostate cancer. The standard used to day is the PSA blood test. The PSA test is not specific for prostate cancer and may also detect other prostate conditions such as benign enlargement of the prostate as well as prostate infections. The PSA test indicators can sometimes result in unnecessary biopsies, resulting in psychological toll, risk of infection from the procedure and even sometimes missing cancer cases. This new testing procedure can detect cancer in a non-invasive way by smelling the disease in men’s urine.

The Odoreader could pave the pathway for a new detection technique of prostate cancer, making invasive diagnostic procedures like a prostate biopsy less necessary and potentially saving the lives of many men who fight the disease.

Bottom Line: Prostate cancer is a prevalent medical problem affecting thousands of American men.  Now there is a new technique for the diagnosis of this disease which is non-invasive, accurate, and will help men avoid unnecessary diagnostic studies and perhaps unnecessary surgery.

PSA Testing-What Every Man Needs to Know

Prostate specific antigen is a simple blood test that can be a metric for prostate health.  It is a good screening test for prostate cancer.  This blog will discuss the PSA test and what you need to know to make a decision to obtain this common test.

Let’s start by reassuring men that having an elevated PSA level does not necessarily mean you have prostate cancer.

PSA is also likely to be increased with benign enlargement of the prostate gland as well as prostate infections or prostatitis.

It is important to emphasize that the PSA test is not a specific prostate cancer test, but it is a vital first step in screening for the potential presence of cancer.

The other factors that can cause PSA levels to rise:

• Age: PSA levels can increase gradually as you age
• Prostatitis: Inflammation of the prostate gland, due to infection or some unknown cause
• Benign prostatic hyperplasia (BPH): This condition refers to an enlarged prostate.  More prostate means more cells making prostate specific antigen, increasing the potential for an elevated PSA.
• Urinary tract infection: can irritate and inflame prostate cells and cause PSA to go up
• Medications: Some medications like Proscar, Avodart, or Propecia can falsely lower your PSA.  This too is important to remember.  If you are on any of these medications, talk to your doctor.  The general rule of thumb is to double your PSA for an accurate score.
• Sex/ejaculation:  This can cause a mild elevation in the PSA, but should return to normal after a few days. That is why I usually recommend that men refrain from sexual intimacy for 48 hours prior to PSA testing
• Prostate trauma: Anything that causes direct trauma to the prostate such as riding a bike, having a catheter inserted into the blader, a prostate biopsy, or a cystoscopy which is a look using a lighted tube through the urethra (tube in the penis that transports semen and urine) can increase the PSA temporarily.

A PSA level of less than 4.0 ng/mL is normal, while changes of more than 2.0 ng/mL over the course of a year could be an indicator of the presence of prostate cancer.

I point out that there is a familial or inherited basis of prostate cancer and also an increased risk of prostate cancer in African-American men.  In these men who are are at a greater risk of prostate cancer, I suggest annual testing with a digital rectal examination and a PSA test after age 40.  For all others, I suggest testing begin at age 50.

For men who have an elevated PSA test, then a discussion with the doctor about repeating the test in a few weeks or proceeding to an ultrasound examination and a prostate biopsy is in order.

Bottom Line: PSA testing is a non-specific test used to screen for prostate cancer.  Not all elevations of the PSA test indicate cancer.  Further testing and close monitoring as well as a prostate biopsy is in order.  For more information, speak to your doctor.

Prostate Biopsy Negative? What’s Next?

There are over 1 million men who have a prostate biopsy each year.  Many of the biopsies are negative.  What can a man do who has an elevated PSA level and a negative biopsy to be certain that he doesn’t have prostate cancer and avoid having a second biopsy?

Lots of controversy surrounds the standard PSA (prostate-specific antigen) screening test for prostate cancer, which is unreliable and not specific for the disease. This uncertainty has prompted many men to ask, “Is there a better test for PSA?” Fortunately, there are options which, while they don’t replace the current PSA test, can provide significantly more reliable, actionable information.

The PSA test involves a blood draw and measuring the level of the blood protein, prostate specific antigen. Currently, men whose PSA test levels are between 4 ng/mL and 10 ng/mL typically are told they should consider getting a prostate biopsy. However, an elevated PSA can be caused by many different benign conditions such as benign enlargement of the prostate gland, a prostate infection or simply lifestyle habits, which means a biopsy would be an unnecessary invasive procedure.

Why we need more accurate testing?

Approximately 1.3 million prostate biopsies are performed annually, and less than one third of them reveal cancer. While that sounds like good news on one hand, on the other hand it means that two thirds of those biopsies may not have been necessary and/or these men have negative biopsy results but other clinical risk factors for prostate cancer such as a family member who has prostate cancer or being an African-American man who have a slightly greater risk for prostate cancer than a Caucasian man.

If you have been in this situation, you probably know how frustrating and confusing it can be. What should you do? Have a repeat biopsy or choose to have more tests? The uncertainty of having a hidden prostate cancer can lead men to get repeat biopsies, which can be associated with an increased risk of infection, hospitalization, emotional trauma, and significant costs.

Fortunately, some progress is being made in the realm of better testing for prostate cancer and in determining whether a prostate biopsy is necessary. In this blog I will discuss the PCA3 test that may be helpful and prevent additional biopsies and additional psychological anxiety.

PCA3 Test

PCA3 is an acronym for Prostate CAncer gene 3. Prostate cells have PCA3 genes that are responsible for making this prostate cancer-specific protein. Prostate cancer cells produce higher levels of PCA3 than do healthy cells, and when the level of PCA3 protein is high, it leaks into the urine, where it can be measured. Unlike the PSA test, PCA3 is not affected by benign prostatic hyperplasia (enlarged prostate) or other noncancerous prostate conditions such as prostatitis.

To take the PCA3 test, you must first have a digital rectal examination (DRE), which stimulates the PCA3 to enter the urine. Then you must immediately provide a urine sample. Typically, it takes 1 to 2 weeks to obtain the results of the PCA3 test. For diagnostic purposes, the higher the PCA3 score, the more likely a man has prostate cancer. When the PCA3 score is used to help with treatment, the higher the score, the more aggressive the prostate cancer is likely to be.

The Food and Drug Administration approved the PCA3 test in 2012. Physicians can use the PCA3 score, in addition to DRE and PSA test, to help them make treatment decisions. For example, knowing a man’s PCA3 score can be helpful when:

• Men have a family history of prostate cancer
• Men have a positive biopsy, because their PCA3 score can provide additional information about how aggressive the cancer may be and therefore, be helpful in determining which treatment approach is best
• Men have an elevated PSA or a suspicious DRE and are considering a prostate biopsy
• Men have a negative result on their biopsy but the doctor is still uncertain about the presence of cancer
• Men have a positive result on their biopsy and they and their doctor want to better understand how aggressive the cancer is
• Men who have early, nonaggressive prostate cancer and have chosen active surveillance want to monitor any possible cancer progression

How effective is the PCA3 score in detecting prostate cancer? This question was addressed in a study involving 859 men who were scheduled to undergo a prostate biopsy. The authors found that use of the PCA3 test improved over-detection of low-grade prostate cancer and under-detection of high-grade cancer. Cost of the PCA3 test is about $450. The test is paid by most insurance companies including Medicare.

Bottom Line:  Prostate cancer is the most common cancer in men and the second most common cause of death in men.  The PSA test is a good screening test for men between the ages of 50 and 70.  However, there are false positive results with consequences of unnecessary prostate biopsies or may result in unnecessary repeat prostate biopsies.  The PCA3 test is helpful in identifying prostate cancer or helpful in reassuring a man that he doesn’t have prostate cancer and can avoid a repeat biopsy.  For more information, speak to your urologist.

Prostate Cancer –Management of Low Risk Disease*

Prostate cancer remains one of the most common cancers in men with 250,000 new cases each year and causes nearly 40,000 deaths each year. Like most other cancers there are shades of gray and not all cancers need to have treatment. This blog will discuss the use of androgen deprivation therapy and when it might used in men with advanced prostate cancer.

There’s nothing like an elevated prostate specific antigen (PSA) test result to strike fear into even the most unflappable and courageous of men. That’s because elevations in PSA in the blood can point to the presence of prostate cancer. On the other hand, elevated PSA can also indicate prostatic enlargement or inflammation of the prostate. However, an elevated PSA test result, combined with a digital rectal exam and a 12-core prostate biopsy to remove small pieces of prostate tissue from the gland, will provide a very good idea as to whether a man has cancer or not.

About 40 to 50 percent of the 241,000 men expected to be diagnosed with prostate cancer this year will have a suspicious PSA score and a Gleason score of 6 out of 10, which is based on the prostate biopsy. A Gleason score of 6 is an indicator of a very favorable or low-risk disease, a disease that is treatable and curable — if, in fact, a man chooses to treat it.

Facing treatment decisions. Once a man has a prostate cancer diagnosis, he then has to choose what type of treatment he wants, which can include surgery or radiation therapy; men with low-risk cancer can also opt for active surveillance, or close monitoring without any immediate treatment. However, these men have to have a digital rectal exam and PSA test and possibly a repeat biopsy on a regular basis.

The good news is that low-risk prostate cancer — meaning low grade and low stage with a PSA below 10 ng/mL — grows slowly, if at all. Therefore, a man should be sure to discuss with his doctor whether he really needs to undergo any therapy to treat his cancer. That’s because in the majority of cases the answer will be “not now.”

What we have learned over the years with low-grade cancer is that sometimes the best option is no treatment whatsoever. And that includes treatment with androgen deprivation therapy, or ADT.
Earlier this summer, I came across a study in JAMA Internal Medicine that reminded me that many men with low-risk prostate cancer are still being offered primary ADT to treat their cancer, something that we would not recommend at Johns Hopkins. The reason: ADT offers no survival benefit for men with low-risk cancer and it causes significant side effects, including osteoporosis, diabetes and decreased libido.

Androgen deprivation therapy (ADT)–also called hormone deprivation, or hormonal or androgen ablation–is effective at turning off the body’s supply of male hormones, which prostate cells need to grow and develop. When the supply is shut off by drugs or by removing the testes, a portion of the cancer dies, tumors generally shrink, and PSA levels drop.

It’s androgens, or male hormones, that stimulate the growth of prostate tumors. The two most common androgens are testosterone and dihydrotestosterone (DHT). Since the Nobel Prize-winning discovery by Dr. Charles Huggins of the University of Chicago that prostate tumors depend on these hormones to grow, reducing androgen levels or blocking the action of androgen (androgen suppression) has become the standard of care for men with cancer that has spread beyond the prostate (metastasized) to the bones and other organs. There has also been increasing interest in using it in men whose PSA level has begun to rise after treatment with surgery or radiation (“biochemical recurrence,” an early sign that the cancer has not been eradicated).

Most urologists typically wait until there is evidence of metastatic disease before starting with ADT. There is an exception, however, and that is when we see a rapid PSA doubling time (less than six months) — because this provides indirect evidence of micrometastic disease that will develop in the next few years.

While ADT plays a significant role in the treatment of advanced prostate cancer, it has no role in the treatment of older men with low-risk cancer. Yet primary ADT is nevertheless being prescribed for one in eight men over age 65 diagnosed with localized prostate cancer.

The JAMA article. In the JAMA Internal Medicine study conducted by Grace L. Lu-Yao, Ph.D., a cancer epidemiologist at the Rutgers Cancer Institute of New Jersey and professor of medicine at Rutgers Robert Wood Johnson Medical School, more than 66,000 older men with low-risk prostate cancer were followed for up to 15 years. Dr. Lu-Yao reported that those men who received ADT lived no longer on average when compared with men who did not receive the therapy.

Prescribing ADT for these low-risk patients may decrease the high anxiety level that a patient may have due to his cancer diagnosis, however, it is necessary to note that such treatment may carry more risk than benefit. ADT helps reduce anxiety by quickly dropping PSA levels into the undetectable range, so the doctors may feel that they are doing something positive for their patients. However, ADT may not really be in the patient’s best interest due to complex side effects. The doctor should really be talking to patients with low-risk disease about pursuing active surveillance, not ADT.

There are serious potential risks associated with ADT, including coronary heart disease, and the associated high costs of the medications, the use of primary ADT should be limited to patients in the high-risk cancer group who are not suitable for, or opt not to receive, primary therapy — surgery or radiation — that has the potential to cure.
The side effects associated with ADT. In general, hormonal therapy will cause significant side effects after several months of treatment. Long-term side effects of ADT may include one, some or all of the following:
• Anemia
• Coronary heart disease
• Decreased energy
• Decrease in mental acuity
• Depression
• Diabetes
• Erectile dysfunction
• Hot flashes
• Loss of muscle mass
• Osteopenia
• Osteoporosis

Bottom Line: Many men with prostate cancer who have low risk disease or who have recurrence after treatment with radiation or surgery. This is usually detected by a rising PSA after treatment for prostate cancer that is confined to the prostate gland. These men should have a discussion with their urologists and discuss if androgen deprivation therapy is really in their best interests and that the benefits vs. the side effects are worth the treatment with androgen deprivation therapy.

*This blog was modified from the Johns Hopkins Newsletter, July 2014

PSA Elevation After Treatment For Prostate Cancer

Prostate cancer represents the second most common cancer in men following lung cancer. Prostate cancer will be diagnosed in nearly 250,000 men annually and causes nearly 40,000 deaths each year. If you already have had prostate cancer treatment, changes in PSA levels can tell whether treatment is working.

After surgical removal of your prostate, your PSA levels should be undetectable. After radiation therapy, the PSA levels should drop and remain at low levels.
Signs that your cancer has returned may include one of these:
Three consecutive PSA rises above the lowest level over time
Confirmed rise of more than 2 ng/mL from your lowest level

The key is monitoring your PSA levels over time. A rapid rise suggests rapid cancer growth and the need for treatment. A very slow rise of the PSA can often be watched.
But PSA levels can also be somewhat confusing. For example, they can go up and down a bit for no reason. The PSA test is not precise, and minor changes from test to test are to be expected.
Low rises of PSA levels can’t predict your longevity or symptoms when you have cancer. But high or rapidly rising PSA levels can suggest future problems.
That’s why doctors take other factors into account when evaluating your situation. Talk with your doctor to get a better idea of what to expect, so the numbers don’t add to your anxiety.

Advanced Prostate Cancer and PSA Levels Over Time
If you have advanced prostate cancer that has spread outside the prostate, your doctor will be looking less at your actual PSA levels than at whether and how quickly PSA levels change.
Doctors use changes in PSA levels over time (called PSA velocity) to tell how extensive and aggressive your cancer is.

Your doctor won’t just look at one PSA reading at a time. He or she will confirm it with multiple tests over many months, especially after any radiation therapy. That’s because you can have a temporary bump in PSA levels for about one to two years after radiation treatment.
To determine how aggressive your cancer is and whether further treatment makes sense, your doctor may also consider your:
PSA levels before cancer
Grade of cancer or the Gleason score. The higher the Gleason score, the more aggressive the cancer.
Overall health and life expectancy
PSA Levels and Treatment for Advanced Prostate Cancer
Your symptoms and how long it takes for your PSA levels to double (PSA doubling time) affect decisions about how soon to try treatment such as hormone therapy.
Your doctor will look at how quickly or slowly PSA rises before deciding on which treatment to suggest. You may need continued monitoring before moving to a new treatment. Your doctor may suggest waiting for a while to delay the appearance of treatment-related side effects. Discuss with your doctor how to weigh these considerations.

PSA levels may also be useful in checking if your treatment for advanced prostate cancer is working after you have had:
Hormone therapy
Chemotherapy
Vaccine therapy
Treatment should lower PSA levels, keep them from rising, or slow the rise, at least for a while.
Doctors monitor PSA regularly based on the type of treatment you had first. For example, after hormone therapy, PSA should drop to a lower level quickly, i.e., within weeks. It may fall further over time as you continue hormone therapy.

Combined with symptoms and other tests, PSA tests can also show if it’s time to try another type of treatment.

Bottom Line: PSA is an imprecise test for diagnosing and monitoring prostate cancer. If the PSA rises quickly after treatment, whether it is surgery, radiation, or hormone treatment, this is of concern and you may need to have additional treatment. Speak to your doctor if you have any questions.