Several years ago, I received a diagnosis no one wants to hear. Cancer! Prostate cancer to be specific. Thanks to two skilled urologists, I’ve been cancer free for three years.
But it might not have had a happy ending. Please indulge me and let me tell you my story. I think it will be worth your time.
It starts with the PSA. The prostate specific antigen. This is something every man over 40 should know about and every man over 50 should be getting checked.
So, what is the PSA? It is a protein that is produced by both cancerous and normal cells in the prostate gland. It can be elevated by prostate cancer but it can also be elevated by prostatitis (an infection of the prostate) or an enlarged prostate (benign prostatic hypertrophy). It is checked through a simple blood test. Your family doctor can order as part of your annual work up.
What are the recommendations for the PSA? The US Preventive Services Task Force (USPSTF), the group chartered by the federal government to develop recommendations for effective screening of health conditions of the American public has the following three recommendations: (1) consideration of annual screening for men aged 55 to 69 with no family history of prostate cancer; this should be a shared, informed decision between the patient and his physician; (2) for men who have a significant family history of prostate cancer consideration should be given to screening beginning at age 40; (3) for men over 70 years old they recommend against screening for prostate cancer. Please note the phrase “consideration of screening”. This is not a firm recommendation. Unfortunately, some have interpreted that as meaning screening is not necessary.
Their concern about large-scale screening is that it may lead to over diagnosis or over treatment. A PSA test can have false positives that may lead to unnecessary biopsies or surgery. Only about 25% of men who have a prostate biopsy are found to have cancer. Although, it is important to recognize that a prostate biopsy does not test the entire gland. It takes samples from several areas of the gland. It is possible, though unusual, that a cancer could be missed in the biopsy process
Additionally, most prostate cancer is very slow growing. Most men who have prostate cancer later in life will generally die of something else before they would die of prostate cancer. However, a small percentage of men will have a high-grade prostate cancer that can progress rapidly and cause their death.
A prostate biopsy is graded on what is called a Gleason score. This is a complicated process that involves evaluating the highest grade and lowest grade areas sampled by the biopsy. I won’t go into detail because even medical professionals frequently have to look up the scoring process. The simplified version is that a 6 is a low-grade risk, a 7 is an intermediate risk and an 8 to 10 is a high-grade risk. Originally the Gleason scale was rated 2 to 10. With 2 to 5 being considered no risk. Currently only 6 to 10 is used with 6 being the lowest score.
I’m going to use my personal experience as a way of explaining why I disagree with the current recommendations for PSA screening. The week before my 70th birthday I went in to get my annual physical. In our clinic we have a “birthday panel”, a blood test that we draw for people annually for their physical exam. I had not planned to have my PSA checked since it was not recommended by either the USPSTF or the American Academy of Family Physicians for 70-year-olds. However, it had slipped my mind that a PSA was part of our “birthday panel”.
My PSA came back slightly elevated. Since it was a very minor elevation, I followed the guidelines and waited six months and repeated it. At that time, it increased only a small amount. The guidelines suggested repeating it again in six months. I have to admit though, I have never been a wait-and-see kind of guy. I scheduled an appointment with a urologist.
The urologist and I discussed the options. He told me that the elevation was slight and we could wait and repeat it in 6 months or if I wished we could do a biopsy. Again, not being a wait-and-see kind of guy I opted for the biopsy. After the biopsy my Gleason score was 7 and the pathology report said specifically that it was favorable-intermediate. The guidelines suggested repeating the biopsy again in six months.
As I said, I don’t like to wait. I opted for surgery. I had my prostate removed. I should mention that my family are not wait and see people either and they insisted I choose surgery.
The post-operative report said that there was a high-grade carcinoma that apparently had been missed by the biopsy. It had begun to extend beyond the capsule of the gland. Fortunately for me it had not metastasized and had not spread to the lymph nodes. Had I followed the guidelines and waited another year or even six months for a repeat biopsy, it is possible that the cancer would have metastasized and it could have been fatal.
It is important to recognize that all screening and treatment guidelines are developed on what is considered cost effective medicine for the population as a whole. They are not necessarily what is best for you as an individual. If you have any concerns, you should discuss them with your physician. Never be shy about requesting treatment beyond what guidelines suggest. Just remember, they are guidelines, not hard and fast rules. Take responsibility for your own health and don’t let anyone talk you out of what you think is best for you.
That is the opinion of the Grumpy Doc. If you have any questions, please leave comments on the blog or email me at grumpydocWV@gmail.com.
You and Your PSA
By John Turley
On May 19, 2022
In Commentary, Medicine
Several years ago, I received a diagnosis no one wants to hear. Cancer! Prostate cancer to be specific. Thanks to two skilled urologists, I’ve been cancer free for three years.
But it might not have had a happy ending. Please indulge me and let me tell you my story. I think it will be worth your time.
It starts with the PSA. The prostate specific antigen. This is something every man over 40 should know about and every man over 50 should be getting checked.
So, what is the PSA? It is a protein that is produced by both cancerous and normal cells in the prostate gland. It can be elevated by prostate cancer but it can also be elevated by prostatitis (an infection of the prostate) or an enlarged prostate (benign prostatic hypertrophy). It is checked through a simple blood test. Your family doctor can order as part of your annual work up.
What are the recommendations for the PSA? The US Preventive Services Task Force (USPSTF), the group chartered by the federal government to develop recommendations for effective screening of health conditions of the American public has the following three recommendations: (1) consideration of annual screening for men aged 55 to 69 with no family history of prostate cancer; this should be a shared, informed decision between the patient and his physician; (2) for men who have a significant family history of prostate cancer consideration should be given to screening beginning at age 40; (3) for men over 70 years old they recommend against screening for prostate cancer. Please note the phrase “consideration of screening”. This is not a firm recommendation. Unfortunately, some have interpreted that as meaning screening is not necessary.
Their concern about large-scale screening is that it may lead to over diagnosis or over treatment. A PSA test can have false positives that may lead to unnecessary biopsies or surgery. Only about 25% of men who have a prostate biopsy are found to have cancer. Although, it is important to recognize that a prostate biopsy does not test the entire gland. It takes samples from several areas of the gland. It is possible, though unusual, that a cancer could be missed in the biopsy process
Additionally, most prostate cancer is very slow growing. Most men who have prostate cancer later in life will generally die of something else before they would die of prostate cancer. However, a small percentage of men will have a high-grade prostate cancer that can progress rapidly and cause their death.
A prostate biopsy is graded on what is called a Gleason score. This is a complicated process that involves evaluating the highest grade and lowest grade areas sampled by the biopsy. I won’t go into detail because even medical professionals frequently have to look up the scoring process. The simplified version is that a 6 is a low-grade risk, a 7 is an intermediate risk and an 8 to 10 is a high-grade risk. Originally the Gleason scale was rated 2 to 10. With 2 to 5 being considered no risk. Currently only 6 to 10 is used with 6 being the lowest score.
I’m going to use my personal experience as a way of explaining why I disagree with the current recommendations for PSA screening. The week before my 70th birthday I went in to get my annual physical. In our clinic we have a “birthday panel”, a blood test that we draw for people annually for their physical exam. I had not planned to have my PSA checked since it was not recommended by either the USPSTF or the American Academy of Family Physicians for 70-year-olds. However, it had slipped my mind that a PSA was part of our “birthday panel”.
My PSA came back slightly elevated. Since it was a very minor elevation, I followed the guidelines and waited six months and repeated it. At that time, it increased only a small amount. The guidelines suggested repeating it again in six months. I have to admit though, I have never been a wait-and-see kind of guy. I scheduled an appointment with a urologist.
The urologist and I discussed the options. He told me that the elevation was slight and we could wait and repeat it in 6 months or if I wished we could do a biopsy. Again, not being a wait-and-see kind of guy I opted for the biopsy. After the biopsy my Gleason score was 7 and the pathology report said specifically that it was favorable-intermediate. The guidelines suggested repeating the biopsy again in six months.
As I said, I don’t like to wait. I opted for surgery. I had my prostate removed. I should mention that my family are not wait and see people either and they insisted I choose surgery.
The post-operative report said that there was a high-grade carcinoma that apparently had been missed by the biopsy. It had begun to extend beyond the capsule of the gland. Fortunately for me it had not metastasized and had not spread to the lymph nodes. Had I followed the guidelines and waited another year or even six months for a repeat biopsy, it is possible that the cancer would have metastasized and it could have been fatal.
It is important to recognize that all screening and treatment guidelines are developed on what is considered cost effective medicine for the population as a whole. They are not necessarily what is best for you as an individual. If you have any concerns, you should discuss them with your physician. Never be shy about requesting treatment beyond what guidelines suggest. Just remember, they are guidelines, not hard and fast rules. Take responsibility for your own health and don’t let anyone talk you out of what you think is best for you.
That is the opinion of the Grumpy Doc. If you have any questions, please leave comments on the blog or email me at grumpydocWV@gmail.com.