Fixated on PSA? – why chasing numbers don’t work
My 53-year-old male patient is in the waiting room. Sweating a little. Blood pressure 143/90 – moderately elevated (it’s usually 125/80). This great guy, a patient of mine, father of 3, is anxiously waiting to have his PSA blood drawn.
What is PSA?
Among physician’s, it’s jokingly short for “Patient Stimulated Anxiety. “ It stands for Prostate Specific Antigen – a misnomer. It turns out that PSA is found in many other tissues and fluids other than the prostate. In males, there are PSA molecules in semen, for example.
In women, PSA molecules are found in the female ejaculate (that’s right, females ejaculate too – I know you did not know that), in breast milk and amniotic fluid.
Here’s the kicker; PSA is found in a women’s blood who have cervical, uterine and breast cancer (Pummer et al. 1992, Mohajeri et al. 2011).
Ok, sorry to digress a little. I have not answered the questions – what is PSA?
PSA is a sugar molecule combined with a protein (referred to a glycoprotein in the scientific community). Its main role is to liquefy semen. You may have noticed that semen clumps up initially after ejaculation. Within a few minutes, it liquefies due to the function of the molecule PSA. This “anti-clumping” aspect is important for procreation. Sperm cells swim better when they are loose and free.
PSA and men before Prostate Cancer diagnosis
Anything under 4ml/ng does not mean you don’t have prostate cancer. 15% of men with a PSA under 4 develop prostate cancer (Thompson et al. 2004)
Generally speaking, PSA is age-related. For example, a 40-year-old should have a PSA well under 1.0ml/ng (exception to the rule, this individual may have an infection of his prostate causing his PSA to be above 4).
A 60-year-old with a PSA of 2 may indicate no malignant disease.
A steady trend upward, even if the number is under 4, after three or four PSA tests may be more connected to prostate cancer once prostatitis or other benign conditions are ruled out.
FYI – prostate enlargement or BPH may also cause the PSA to increase.
Other causes of false PSA alarms
1. The finger before the blood draw. That’s right, a digital prostate exam before the blood draw will cause the PSA number to be higher (Collins et al. 1997).
You’d be surprised how many physicians’ do this >:-(.
Take charge. If you’re going to get the finger, get it after the blood draw, not before.
2. Ejaculating 48 hours before the blood draw (Herschman et al. 1997). I usually make my patients suffer and have them hold out 72 hours before a blood draw – just playing it safe gents.
Two things cause a false lower PSA
The meds Finasteride (Proscar) and Dutasteride (Avodart) – falsely lowers PSA up to 50% (spelling may be off, and trademark symbol was not applied – apologies to Pfizer and GlaxoSmithKline – no disrespect)
Obesity: estrogen activity (which big men have more of) causes a decrease in PSA.
FYI: Obese men typically have worse cases of prostate cancer and a higher change of prostate cancer relapse after treatment. (Cao , 2011) Yet another motive for overweight men to get on the program and get in shape.
PSA in men after Prostate Cancer treatment
What’s most frustrating to me about men who have had their prostates either removed or radiated is that they think they’re home-free – nothing to worry about. No need to follow an anti-cancer CaPLESS methodology anymore. “For what? My cancer is out.”
This is a case of what I call foolish denial.
If you’re “home-free” why is your physician still taking your PSA every 3 to 12 months for the next 10 years or so?
Answer: Because of up to 40% of men treated for prostate cancer witness biochemical recurrence within 10 years (Ward et al 2005).
Now, not all rising PSA after “curative” treatment is due to cancer returning. But most are. Sometimes there’s benign prostate tissue left behind.
Bottom line: Be proactive. Stop chasing numbers and start living life to the fullest. Live a lifestyle conducive to wellness and one that can significantly diminish the chances for prostate cancer recurrence – a CaPLESS lifestyle. Everything else will take care of itself.
As always, thank you for sharing with your friends and family on facebook and twitter.
More sources to read on this:
Six things to do before PSA test
Pummer K, Wirnsberger G, Pürstner P, Stettner H, Wandschneider G. False positive prostate specific antigen values in the sera of women with renal cell carcinoma. J Urol. 1992 Jul;148(1):21-3.
Mohajeri A, Zarghami N, Pourhasan Moghadam M, Alani B, Montazeri V, Baiat A, Fekhrjou A.Prostate-specific antigen gene expression and telomerase activity in breast cancer patients: possible relationship to steroid hormone receptors. Oncol Res. 2011;19(8-9):375-80.
I. Thompson, D.K. Pauler, P.J. Goodman,P revalence of prostate cancer among men with a prostate-specific antigen level ≤4.0 ng per milliliter. N Engl J Med, 350 (2004), pp. 2239–2246
Collins GN, Martin PJ, Wynn-Davies A, Brooman PJ, O’Reilly PH (May 1997). “The effect of digital rectal examination, flexible cystoscopy and prostatic biopsy on free and total prostate specific antigen, and the free-to-total prostate specific antigen ratio in clinical practice”. J. Urol. 157 (5): 1744–7.
Herschman JD, Smith DS, Catalona WJ (August 1997). “Effect of ejaculation on serum total and free prostate-specific antigen concentrations”. Urology 50 (2): 239–43.
Cao Y, Ma J (2011 Apr). “Body mass index, prostate cancer-specific mortality, and biochemical recurrence: a systematic review and meta-analysis”. Cancer Prev Res (Phila) 4 (4): 486–501.
Ward JF, Moul JW. Rising prostate-specific antigen after primary prostate cancer therapy. Nat Clin Pract Urol. 2005;2(4):17182