The Brief on PSA

PSA (prostate-specific antigen) is essential for prostate cancer screening and monitoring. This episode explores the PSA controversy, explains why annual PSA screening is crucial, and talks about the importance of PSA testing for monitoring prostate cancer treatment. Understand the benefits and drawbacks of PSA, and use this incredible tool to your advantage.

Dr. Scholz:  [00:03] We’re guiding you to treatment success and avoiding prostate cancer pitfalls.  I’m your host, Dr. Mark Scholz. 

Liz:  [00:10] And I’m your cohost, Liz Graves.

Dr. Scholz:  [00:13] Welcome to the PROSTATE PROS podcast.

Al Roker:  [00:16] I’ve been feeling great, but my doctor discovered I had an elevated PSA level in my blood work, PSA standing for prostate-specific antigen.  It’s the first line of defense when detecting possible prostate cancer.

Dr. John Torres:  [00:32] Today, an influential medical task force is changing those screening guidelines.  Now, urging all men ages fifty-five to sixty-nine to talk to their doctor about getting a PSA test.  Men ages seventy and older should not get screened.

Dr. Kirsten Bibbins-Domingo:  [00:46] This should really be a personal choice that a man makes together with his doctor, and the goal of these conversations is really to understand benefits and harms.

Dr. John Torres:  [00:57] Previously experts… 

Liz:  [00:58] There’s a lot of confusion and hesitation surrounding PSA screening.  What are the proper steps?  What do you do if the PSA test does come back abnormal?  This episode, Dr. Scholz and I are going to talk about the importance of PSA testing, what a high PSA actually means, and what the best steps to take are to further investigate.

Dr. Scholz:  [01:21] The PSA blood test has been around since 1987, about the time my career started it up.  I can’t tell you how revolutionary this blood test has been.  Really, we don’t have another blood test like this for other cancers.  In some ways, PSA makes prostate cancer a much easier cancer to treat.  In other ways, like any powerful tool, if it’s misused, it can create confusion and problems.  I hope we’ll be able to bring some clarity to why this blood test can be controversial. 

Liz:  [01:57] Everyone knows that PSA tests for prostate cancer.  PSA stands for prostate-specific antigen.  And when this is screened annually in men, it is to look for prostate cancer, but that is not all that PSA does.

Dr. Scholz:  [02:15] The problem with PSA as a screening tool and PSA is used for other things besides screening.  But, as a screening tool, men still have a prostate gland.  Typically if they have a small tumor in their prostate, the lion’s share of the PSA is actually coming from the gland, the benign prostate, not the cancer.  This is where the confusion comes.  Men will have inflammation of their prostates, and the PSA will be high.  Men will have enlarged prostates, and their PSA will be high.  Or, of course, they could have a low-grade, or a more consequential cancer, and their PSA could be high.  One savvy patient once told me, tell your patients to think of the PSA as a check engine light on the dashboard of your car.  Something’s going on in the prostate, it could be cancer, and it could be one of these other causes. 

Liz:  [03:12] When a PSA comes back elevated, taking time to understand what that means is crucial.  PSA can be a great tool to tell people they have prostate cancer, but it also has all of these other possible complications.  In 2011, the US Task Force advised against PSA testing.  Why was this Dr. Scholz?

Dr. Scholz:  [03:35] Small cancers that don’t spread are the root difficulty we have.  There have been active discussions about renaming certain types of prostate cancer as something non-cancerous.  That would be appropriate.  Of the 200,000 men diagnosed every year, about 100,000 have a condition that was named cancer back in the 1960s, that we now know never spreads.  But, that word cancer is so motivating that many people, to this day, are rushing into unnecessary surgery and radiation.  So the Task Force, realizing this problem of overtreatment, thought that quite possibly PSA screening was causing more harm than good.  Men were having treatments, making them impotent and incontinent for a condition that would never hurt them.  They later realized in 2016 that the men who have high-grade cancers were getting a short end of the stick.  People were coming in with more advanced cancers.  So they rescinded their recommendation to forgo PSA screening.  But you can imagine what confusion has ensued when you have a large task force arguing for, or against this powerful and useful test.

Liz:  [04:54] Low-grade cancers, which are also called Gleason 6, never spread.  So this PSA testing can lead to unnecessary treatment.  So there’s been a lot of controversy about the PSA testing.  What’s your policy, Dr. Scholz? 

Dr. Scholz:  [05:10] Well, I’m a big believer in doing PSA testing, at least in patients who are informed.  I get concerned about PSA testing just as the Task Force got concerned.  If you have uninformed patients that are like sheep, just doing what the industry tells them to do, those men are at risk of getting unnecessary surgery and radiation, which has all the consequences we mentioned. 

Liz:  [05:34] This is something we come back to again and again, it’s how important it is to advocate for yourself.  This means educating yourself, this means having conversations with doctors.  PSA screening should begin at forty for people who have family history and at forty-five for people who do not.  

Dr. Scholz:  [05:54] Be aware that when you go in for an annual physical, many of you are assuming that your doctor’s simply going to add a PSA to the blood test section that isn’t always happening.  Some doctors still are following the 2011 Task Force recommendations, and it doesn’t come up in conversation.  I have seen patients come in with high PSA, say from an insurance exam, and when they look back at their annual physicals, their doctor wasn’t doing PSA.  So you need to make sure that PSA is part of the blood screening during the annual physical. 

Liz:  [06:31] What happens if someone isn’t getting annual PSA tests? 

Dr. Scholz:  [06:35] Well, hopefully they don’t have a bad prostate cancer, in which case they’ll be fine.  But the incidence of prostate cancer is somewhere around one in seven men.  This means that a significant number of men could end up with advanced cancers that could have been prevented. 

Liz:  [06:52] When most people think about PSA, they attribute it with screening.  Men with prostate cancer know that PSA is used for more than just screening. 

Dr. Scholz:  [07:03] So when we were naming our clinic, Prostate Oncology Specialists, we actually considered calling ourselves the PSA clinic.  PSA for men who have already been diagnosed with prostate cancers is a very accurate test.  Why is this?  Well, as I stated before, one of the problems we have with screening is that men’s prostate glands are intact.  The prostate gland makes a lot of PSA, which is unrelated to cancer.  Most men that have been treated for prostate cancer have had their prostates, either surgically removed or they’ve undergone radiation, which dramatically reduces the amount of PSA production from the gland.  So, if we are monitoring someone going forward who’s been previously treated, if the PSA starts going up, we know that it’s almost certainly coming directly from the cancer.  It gives us a speedometer to tell us how much cancer is present and how fast it’s growing, which we can tell by how quickly it rises. 

Liz:  [08:03] So, men with prostate cancer will get very familiar with their PSA numbers because they’re being monitored, they’re being discussed in terms of treatment options and staging. 

Dr. Scholz:  [08:14] Many of my medical oncology colleagues are very jealous when I tell them that I specialize just in prostate cancer because of the accuracy of the PSA test.  We don’t have as much ambiguity about the status of the cancer.  We can tell so much about how the cancer is behaving just by checking a PSA. 

Liz:  [08:35] How often are men with prostate cancer having their PSA’s checked during monitoring? 

Dr. Scholz:  [08:41] Well, they’re certainly different situations.  The men who’ve had surgery or radiation typically will get their PSA checked every three months for a couple of years after the treatment, then maybe every six months out to about five years after treatment, then annually thereafter.  Men with advanced cancers, who are undergoing hormone treatments or chemo treatments, will often have their PSA checked every month to determine how effective the treatment is.  Is it working and whatnot, because we want to know if we need to switch treatment or strengthen or reduce the intensity of the treatment. 

Liz:  [09:18] PSA is a great tool for men with prostate cancer, whether it be for screening or for gauging treatment success.  There is so much to learn about PSA screening, DREs, OPKO 4K.  We’ve discussed this in past podcasts, but we’ll always keep you updated on what the latest is on these topics.  For those of you who love to learn about prostate cancer, the Mid-Year Moyad and Scholz Update with the PCRI is on Saturday, March 27th.  It’s free registration and it’s virtual this year.  So we’re really looking forward to joining in on that.  You can register at pcri.org and submit any questions to the experts.  This year Dr. Tia Higano will be joining, she is a brilliant oncologist from the University of Washington.  She will be talking about hormone therapy and its side effects.  The new PSMA scan will also be talked about by Thomas Hope.   Dr. Scholz, what are you looking forward to with the PCRI Mid-Year Conference? 

Dr. Scholz:  [10:28] Both the topics are so relevant, but the new PSMA PET scans, which we’ve talked about extensively really can’t be talked about enough.  They’re going to have relevance for men with advanced disease and men who are dealing with early stage disease.  This information is going to be very helpful, but it is so new, I don’t even know all the things that are going to be coming. 

Liz:  [10:52] My personal favorite part is always when you and Dr. Moyad talk.  So I’m looking forward to hearing some great questions and seeing what you have to say.  Thank you for listening.  You can email any questions or topics to [email protected].