The New Skinny On Prostate Cancer Screening With the PSA Test

Prostate cancer remains one of the most common cancers in men and is the second most common cause of death from cancer in men.  (Lung cancer is still leading the list)  The American Cancer Society projects more than 161,000 new cases this year in the U.S., with about 26,730 deaths each year.  Prostate cancer accounted for 4.4% of all cancer deaths in the United States last year.

The U.S. Preventive Services Task Force, an independent and influential panel of experts, published new guidelines in early April 2017 for screening for prostate cancer for the first time in five years.

The new recommendations: Men ages 55 to 69 should “make an individualized decision about prostate cancer screening with their clinician.” That’s updated from a blanket recommendation in 2012 for no routine screening at any age.

The task force also recommends that those men older than 70 shouldn’t undergo PSA screening.

Now doctors are saying that the older recommendation in 2012, i.e., not to screen for prostate cancer likely resulted in deaths that could have been avoided..

The PSA test is a simple blood test that determines levels of the prostate-specific antigen protein, and elevated PSA can be a sign of prostate cancer. But elevated PSA can also be caused by other conditions, like inflammation of the prostate or benign enlargement of the prostate gland.

The risk of potential harm of over-diagnosis has led to confusing recommendations for screening. Treatment for prostate cancer, including removal of the prostate and radiation, is associated with the side effects of incontinence and erectile dysfunction.

False positives can lead to unnecessary further testing or treatment, and many cases of prostate cancer are slow-moving and require watchful waiting rather than immediate treatment.  This means that the men with slow growing, non-aggressive cancer can be followed with a digital rectal exam, frequent PSA testing, and perhaps additional prostate biopsies.

So how useful is PSA screening? According to the New England Journal of Medicine, studies imply that 1 prostate cancer death is averted per 1,000 men screened several times each, and followed for 10 to 15 years.

On the flip side, the authors reported, data show about 35 over-diagnosed cases per 1,000 men screened.

Some groups are at higher risk for prostate cancer, including African-American men and those with a family history of the disease.

Bottom Line: It is my recommendation to my patients 55-69 they have a discussion with their physician and weigh the benefits vs. the harms of PSA testing.  With that discussion the men can make the best choice for themselves, together with their doctor.

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.

The Skinny On Screening for Prostate Cancer

Prostate cancer is the second most common cancer among men (after skin cancer), according to the American Cancer Society. It is the second most common cause of death in following lung cancer and causes nearly 30,000 deaths annually in the United States.  The good news is that often prostate cancer can be treated successfully, especially when caught in its early stages.   More than 2 million men in America count themselves as prostate cancer survivors, according to the American Cancer Society.

At the present time screening for prostate cancer is controversial in the medical profession.  There are physicians who believe that testing all men for prostate cancer outweighs the benefit because it may find some very slow growing cancers in some men that could be left alone without any negative consequences. My personal opinion is that prostate cancer screening should be done but requires education and a decision made between doctor and patient.

My belief is that if prostate cancer is detected early, it has a favorable  prognosis. If men ask me what are the early signs of prostate cancer, the answer is that there are NO early signs of prostate cancer when it is confined to the prostate gland.  That is why men need to have an examination or the digital rectal examination and a PSA test.

Risk factors help determine who should be screened when

The protocol starts by evaluating men for their risk factors for developing prostate cancer. Risk factors include: age (after age 50 risk of prostate cancer rises rapidly); race (men of African-American and Caribbean descent are at higher risk); and family history (men who have a father, brother, or uncle with prostate cancer are at a higher risk of developing prostate cancer and should be screened on a regular basis) Men should be screened every year until they reach age 70 or 75. For most men who reach age 70 and all their screening tests are normal, the chances of their developing a cancer that would impact their well-being or their longevity is really low.

Managing the elevated PSA test

If your screening detects a possible cancer, your doctor will order a biopsy. This is done in the office under a local anesthesia and takes 10-15 minutes.  If the biopsy detects prostate cancer, then the next step is to determine the aggressiveness of the cancer or how likely it is to spread or grow.  For men with low-risk tumors that are not going to put their health or longevity at risk, I will often recommend surveillance, which means regular testing of the PSA and a follow up biopsy in 12-18 months.  As long as the PSA remains stable and there is no evidence of escalation of the cancer, then these men can be safely followed and only treated if the cancer appears to be growing or the PSA is steadily increasing.  Men with more aggressive tumors may need surgery and\or radiation. You and your doctor will make the best treatment decisions for you together.

Bottom Line:  Prostate cancer is a common cancer and can easily be diagnosed with prostate cancer screening.  Not all men need to be screened, but if you are between 50 and 70 years of age, speak to your doctor about the benefits of screening and make an informed decision if screening is right for you.

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.

Men Start Your Engines But First Check Under the Hood!

Men Start Your Engines But First Check Under the Hood!
This article appeared in the recent Baton Rouge Advocate on men’s health.

Celebrate Father’s Day with your health. Men need to let doctors look under the hood.

We have an attitude in our south Louisiana culture — if it ain’t broke, don’t fix it! In reality, men do more preventative maintenance on their cars and lawns than on their bodies. But, this attitude should never be applied to health.

Many men don’t receive checkups because they feel that they have a big “S” (for Superman) tattooed on their chests — but no one is Superman. On average, women live 5 to 7 years longer than men. That gap could close if men practiced preventive health as often as women. Fortunately, men’s attitude and behavior is slowly changing.

Not surprisingly, impotence drugs have lured men into the doctor’s office, which is half the battle and usually leads to a prostate screening. Over the years, public awareness campaigns, at-work health screenings and overall understanding of the male patient have aided in improving men’s health.

Before the 1990s, there were no male equivalents to the Pap test or mammogram. But now, the prostate-specific antigen (PSA) — the screening test for prostate cancer — is detecting problems early, giving men a myriad of treatment options and, more importantly, saving lives.
This means more time to enjoy their golden years, more time to walk their daughters down the aisle and more time to watch their grandchildren grow. Don’t wait for prostate cancer or other diseases to hit close to home; don’t wait for symptoms.
The only waiting should be done in your doctor’s waiting room.
Neil Baum
Professor of Clinical Urology At Tulane Medical School
New Orleans