christopher_barbieri“There’s no one way to select candidates for active surveillance,” says urologist and molecular biologist Chris Barbieri, M.D., Ph.D., of Weill Cornell Medical College/New York Presbyterian Hospital.  In addition to doing molecular research on prostate cancer, he treats men with all kinds of prostate cancer and works with several hundred patients currently on active surveillance.

Some hospitals have very specific criteria.  For example, at Johns Hopkins, men selected for the active surveillance program are considered “very low-risk.”  These men have Gleason score 6 cancer in no more than two biopsy cores; in each of these cores, cancer is present in half or less; their PSA density (PSA divided by prostate volume; this can be helpful if a man has benign prostate enlargement, or BPH, which is a separate prostate problem and is not cancer) is 0.15 or less; and they have no cancer that can be felt on a rectal exam.  Other men in the Hopkins program have “low-risk” cancer: no cancer that can be felt on a rectal exam, a PSA below 10, and Gleason 6 cancer on their biopsy.  All men are monitored faithfully, with regular follow-up visits and yearly biopsies, although recent studies suggest that some men can still be safely monitored with a longer interval between biopsies.

Other hospitals take it more on a case-by-case basis.  The truth, says Barbieri, is that “nobody knows the perfect way to do this.  There are many hospitals where physicians are taking very reasonable approaches,” even if they differ on the exact specifics.  “The principle is that it’s for men with a low volume of disease, and a low grade of cancer.  However, he adds, the National Comprehensive Cancer Network’s newest guidelines, unanimously developed by a panel of the country’s top urologists and scientists, has stated that selected patients with Gleason 3 plus 4 disease can also be considered for active surveillance.  “Age comes into play,” he says, as does the man’s general health.

medical labHow often should men on active surveillance get repeat biopsies?  “There’s no formal consensus,” says Barbieri.  “Quite frankly, we as a field are still trying to figure out how to do this perfectly, what’s working best and what’s not working.”  Although some men on active surveillance decide to have the cancer treated just because they’re anxious about it, “I think that’s improving, as we get the message out that some prostate cancers clearly are never going to threaten a man’s health during his natural lifetime.  The diagnosis itself becomes a little less threatening.”  There has been a major shift in attitude, he adds.  “More men are open to active surveillance, and are comfortable with the idea of watching the cancer instead of treating it right away.”

If there is going to be a “grade reclassification” – if a repeat biopsy finds a greater volume or a higher grade of cancer – it usually happens within the first two years.  “For most active surveillance protocols, the definition for when a cancer has progressed is based on a change in the grade,” says Barbieri.  “So if you had a Gleason 3 plus 3 cancer, and we find a higher grade of cancer with another biopsy, you are considered to have progressed on active surveillance, and most experts would suggest treatment.” 

Thus, a change in the grade of cancer can be a game-changer (meaning you go from being on active surveillance to needing treatment).  So is a change in the volume of disease.  “If a man has two cores of his initial biopsy positive for cancer, and the next time, 6 or 8 cores are positive, that’s a lot more cancer there,” and this likely needs to be treated.

What about the risks from having a lot of repeat biopsies?   “The major risk is the risk of infection,” Barbieri explains.  “The current data suggest the risk is between 2 and 5 percent per biopsy.  If you roll the dice enough times, you’re more likely to get an infection.”  The risk can be minimized in several ways, including prescribing different antibiotics after each biopsy (to help avoid resistance to the drugs), and doing a rectal culture to determine the presence of certain bacteria, and selecting antibiotics based on that.  Other risks, besides infection, include having trouble urinating after a biopsy and – this is a very small risk – the risk of excessive bleeding that requires a transfusion. 

doctor medicineWhat questions should you ask your urologist about active surveillance?

Here are a few that Barbieri suggests:

Does my cancer need to be treated now?

Given my age and general health, is this a good treatment for me?  If you are a young man, perhaps in your early fifties, you may decide to get your cancer treated, so you don’t have to think about it anymore, Barbieri says. 

Should I get a second opinion on my biopsy? Most likely yes, says Barbieri.  “In my experience, it is very rarely a bad idea to get a second opinion.”

You may also be wondering:  When can I safely stop active surveillance?  The answer there is, “We don’t know yet when it’s safe to stop active surveillance.”

What about red flags from the doctor’s perspective?  Even if a man seems to have low-grade, low-risk, low-volume cancer, are there reasons why active surveillance is not for him?  “I don’t think I would deny any man the opportunity to be on active surveillance if he understands the risks.” says Barbieri.

However:  If you are a man of African descent, you are at a higher risk to have prostate cancer, a higher risk to have more aggressive prostate cancer, and at a higher risk to die of prostate cancer if you do have it.  Even if it seems to be the “good” kind. You can still be on active surveillance, but careful urologists such as Barbieri will keep an especially close eye on you.  “I’m more likely to order additional tests for African American men,” including an MRI and genetic tests.  “Most small or even medium-sized cancers really can’t be seen on transrectal ultrasound.  MRI can show this.  It can give you a lot of information about the location of a possible tumor, and whether the tumor is higher-grade.”  However, MRI is more expensive; it also can generate false positives and lead to additional biopsies.

Another red flag for Barbieri is the man’s family history.   “If somebody looks like he should be fine on active surveillance and has a bunch of prostate cancer in his family, that’s reasonable as long as you’re keeping a close eye on him.”  However, he is concerned “if a man’s family members died of prostate cancer, especially at a fairly young age.  I always ask that question: what happened with the prostate cancer?  If your dad had it and died at age 60, that’s a different situation than, say, your dad got it at age 78 and got hit by a bus at age 97.”  When the family history has men dying of prostate cancer, this suggests that a different kind of cancer – the opposite of indolent; in fact, aggressive enough to kill – may be a possibility. 

And the presence of Gleason 4 disease makes Barbieri wary.  “Gleason 4 plus 3 disease and above, or any young man with any Gleason pattern 4.”  The presence of Gleason 4, especially in a younger man, suggests that the cancer may be more aggressive than it seems and that it probably needs treatment.

Finally, what about red flags from the patient’s perspective?  What should a doctor not be doing?  Beware of over-frequent biopsies, says Barbieri.  “If a doctor is doing biopsies more often than in the range of consensus, after a first confirmatory biopsy to know there wasn’t high-grade cancer missed – doing it more than yearly is hard to justify.”  Also, beware of a doctor who orders lots of tests and can’t really give you a good explanation for why you need them.  For example, “frequent transrectal ultrasound on active surveillance doesn’t really help” do anything except pad the doctor’s bottom line, rather than serve the patient’s best interests. 

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington

What You Need to Know

Is active surveillance right for you?  The answer to this question varies, depending on a bunch of factors: your particular form of prostate cancer, your age, and general health, and also on the criteria used to select men for active surveillance programs from hospital to hospital; some are stricter than others.

Men who are eligible for active surveillance have cancer that shows all signs of being the “good” kind:  slow-growing, low-volume (meaning, there’s not very much of it in all the tissue samples from your prostate biopsy), not aggressive. 

men thinkingCan men live with slow-growing, low-volume prostate cancer?  Absolutely.  The proof of this is found every day, in many thousands of autopsies done around the world, of men in their eighties and older who died of something else – a heart attack, for instance.  Then, in the autopsy, the pathologist looks at the man’s prostate and sees cancer in there.   This cancer is what doctors call “indolent.”  It’s low-risk.  Slow-growing, low-volume. It sits there.  It doesn’t cause any harm, and clearly never needed to be treated, because the guy never knew he had it and died of something else.  When urologist Christopher Barbieri, M.D., Ph.D., on the faculty at Weill Cornell Medicine at New York Presbyterian, talks to his patients who are candidates for active surveillance, he tells them, “You’re more likely to get hit by a bus when you’re 100 years old than for this cancer to kill you.”

Let us digress for a moment and think of prostate cancer in the form of an animal.  The most aggressive cancer is like a bird; it grows quickly and is very likely to fly away from the prostate to other places in the body, making it more difficult to kill.  The least aggressive cancer moves like – well, something slow, a turtle, or a sloth.  And then there are men with the cancers in between – let’s think of them as rabbits — cancers that do need to be treated with surgery or radiation.

Indolent prostate cancer is the pet rock of cancers; it doesn’t do much, but the upside of that is that it doesn’t need to be treated, either. 

Important point:  Cancer may not stay indolent.  Or, from the initial biopsy and test results it might appear to be low-risk and or low-volume, but actually more cancer is there and the biopsy needle just missed it.   So, men who choose active surveillance may not stay on it forever if their cancer undergoes “grade reclassification” – if that is, you have another biopsy and it suggests that more cancer is present, or that it may not be so slothlike in personality.  So if you choose active surveillance, know that at some point, you may need to have surgery or radiation.   If you are an African American man, talk to your doctor about getting an MRI to make sure that you don’t have cancer that was missed on the biopsy.

Choosing active surveillance – remember the keyword is “active” – means that you will need to keep getting your cancer checked out.  You will need to get follow-up PSA tests, exams, and biopsies, maybe once a year, for many years.  If you are a young man, say age 50, and you could reasonably expect to live another 40 years, this could mean that you get your prostate stuck with needles many, many more times in your life.  (Not until you’re 90, but at least another 15 years or so.)  Biopsies have their own risks, which I’ve written about here.  You may not want to subject yourself to this.

restaurant manYou will also have to live your life knowing you have cancer.  Can you handle this?  Some men can’t.  Thinking about the cancer in there makes them anxious.  To them, it’s like a time bomb – when actually, it may not be a time bomb at all, but more of a clock just happily ticking away, not causing harm – and they end up having surgery or radiation just for the peace of mind.

On the other hand, if you can live with it — trusting that the follow-up monitoring will detect any change if it happens and that if you need to get treatment, you won’t miss that window of treatment when the cancer is still confined to the prostate, and you will have plenty of time to make that decision — then active surveillance may be a good option for you. 

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington

You’ve Got Prostate Cancer. Now what?

You’ve had the PSA test – or more likely, several of them – plus the digital rectal exam, and one or both of these suggested that you needed a biopsy.  The biopsy was not fun, but you did it, and then you waited for a pathologist to look at the tiny, needle-sized cores of tissue removed from your prostate.  Maybe you managed to forget about it while you were waiting – maybe you feel perfectly healthy, and this all seemed surreal.  Or maybe you let some dark thoughts creep in, and you started thinking about cancer and remembering everyone you ever know who has had cancer and not done very well.  The waiting’s over now.  Your doctor has just given you the news:  there’s cancer in there.   What are you going to do?

The very first thing you should do is, don’t panic. 

christopher_barbieriIf you have cancer in your prostate, it didn’t just spring up like a mushroom.  It has been there for years, maybe even a decade, growing very slowly, taking a long time just to get big enough to be discovered.   “Even in a fairly aggressive form, prostate cancer grows slowly compared to other cancers,” says urologist and molecular biologist Christopher E. Barbieri, M.D., Ph.D., on the faculty Weill Cornell Medicine at New York Presbyterian.  I recently interviewed him for the Prostate Cancer Foundation’s website.

What this means for you is: brush the dark thoughts away.  Nobody wants to have cancer, but if you have to have it, there has never been a time of more hope.  There have never been better treatments.  There have never been so many men not dying of prostate cancer, and not having bad side effects from treatment. 

You are going to get through this. 

If your cancer was diagnosed through regular screening, that’s an extra reason to be upbeat:  Just a couple of decades ago, before the PSA test and regular screening became widespread, most men didn’t know they had prostate cancer until it was often too late.  Either it had gotten advanced enough to cause symptoms like back pain or urinary problems, or it was big enough for a doctor to feel it during a rectal exam.  Many men used to be diagnosed when cancer was no longer confined to the prostate and was more difficult to treat. 

That’s no longer the case.  Thanks to regular screening, most men are diagnosed at least five years earlier than they used to be.  Most men are diagnosed with cancer that is very curable.  In fact, many men are diagnosed with cancer that maybe shouldn’t even have been found – cancer that doctors call “incidental,” which means it’s just there, but it doesn’t do anything.  It just sits there in your prostate, just a few very slow-growing, not aggressive cancer cells, and you could have lived your whole life never knowing they were in there.  Many men die with prostate cancer, not of it.   

So the second thing you need to do – the first, remember, is do not panic – is figure out just what kind of prostate cancer you have

If you were diagnosed at a smaller medical center, doctor’s office, or hospital, it’s a good idea to have your biopsy results sent out to another pathologist at a large medical center, where they see a lot of men with prostate cancer, for a second opinion.  Prostate cancer can be tricky to interpret, and it’s a good idea to get a second opinion from somebody who specializes in looking at it – not breast cancer, not ovarian cancer, not colon cancer, just prostate cancer. 

The third thing:  Take your time

pexels-photo-53918Once you know what you’re dealing with, your first reaction should not be, “Oh, my God! I’ve got to get this out of here!” or other words to that effect.  Do not feel rushed to get treatment right away.  First of all, your body needs several weeks to heal from the biopsy.  Second, now is the time – for you to figure out which treatment is right for you

Remember, that cancer has been in there for a long time.  It’s not going to grow very much over the next few weeks; in fact, it may not grow at all.  If you and your doctor decide you need surgery or radiation to kill the cancer you then need to find the best place – it may be nearby, or in another city in your state, or even further away – for you to have this done.  It is far better to take a little while – not much time at all in the greater picture of your life – and make a decision that is right for you than to rush into treatment and later regret being so hasty. 

Do not despair.  Take heart, take a deep breath, and figure this thing out. You are not alone.  There are millions of us here in the “reluctant brotherhood” of prostate cancer (and plenty of sisters, too – wives, daughters, sisters, girlfriends, mothers – who have shared this journey).  Reach out to us.  We have been where you are now, and come through it.  You will, too.

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington

sand_sun_beachIn 2002, when I ghostwrote the first edition of The Paleo Diet for Loren Cordain, I thought we were writing sacrilege when he said people need sunlight.  That’s because our view of what’s normal and natural has gotten skewed.  “Oh, no!” I thought.  “Must have sunscreen.  Sunscreen good, sun bad!”  Just a few steps away from Frankenstein being terrified of fire.

I’ve lightened up, so to speak, since then.  Cordain was right:  Yes, excessive sunlight exposure is linked to skin cancers, including squamous cell cancers, which form on the top layers of the skin; basal cell cancers, which form on the bottom layers of the skin; and melanomas, which form within the skin’s pigment-producing cells, the melanocytes.  However, avoiding sunlight is not the way to prevent disease.

“The experience of our hunter-gatherer ancestors proves helpful,” Cordain wrote.  “Many studies have shown that people with high lifetime sunlight exposure, similar to that of hunter-gatherers, have lower rates of melanoma than those with low sunlight exposure.  Also, indoor workers have a greater risk of melanoma than outdoor workers.  Even more puzzling, melanomas often arise in body areas that are infrequently or intermittently exposed to sun.”  Many scientists believe that severe sunburn during childhood — like that time where you went to the beach and came home red as a lobster, and maybe your mom (as mine did) treated it with baking soda and/or aloe, apple cider vinegar, or other home remedies — or intense burns in areas that usually don’t see the sun are bigger risk factors for the development of melanoma.

“When your exposure to sunlight is gradual, moderate and continuous,” Cordain explained, your body responds “in a manner guided by evolutionary wisdom.”  Your skin begins to get tan, because your body is ramping up its production of melanin.  The darkened skin helps protect you from the sunlight’s most damaging ultraviolet rays.  Also important: Vitamin D levels in the blood start to increase, too, as the UV light hits the skin and your body starts to convert cholesterol into Vitamin D.

Vitamin D is a really good thing.  It’s actually a hormone, which is mostly formed in the skin.  As an aside, jumping to other books I’ve co-written: In Dr. Patrick Walsh’s Guide to Preventing Prostate Cancer, Walsh, the noted Johns Hopkins urologist, points out that “over the last 25 years, the death rates from prostate cancer in America have been the highest in the regions of the country that get the least sunshine” (north of 40 degrees latitude).  However, Walsh cautions, taking too much Vitamin D is not a great approach, either.  If you’re going to take a Vitamin D supplement, he advises not taking more than 4000 IU per day.

Cordain cited evidence from population studies confirming that people with the greatest lifetime sun exposures have the lowest rates of prostate, breast, and colon cancers.  But most important to Cordain, from years of study of our Stone Age ancestors, is this: “Exposure to sunlight is natural for humans.  It is part of our evolutionary heritage.  Without sunlight, it is virtually impossible to achieve an adequate intake of vitamin D from the natural foods that were available to our hunter-gatherer ancestors.  Our food supply has been a significant source of vitamin D for a very short time — less than a century, when dairy producers began adding it to the milk and later, to margarine.  Sunlight exposure is healthy as long as it occurs in a slow, gradual, and limited dose over the course of a lifetime.”

©Janet Farrar Worthington

Prostate Exam“Hey, buddy!  It’s me, your prostate.  How’s it going?  I know you’re busy, but … I’m just going to put it out there.  You’re ignoring me.  You never call, you don’t even text — and you don’t get me checked.”

Okay, that wasn’t actually your prostate, but let’s face it, for most men the prostate is not a top health priority.  It falls in the category of “obscure body parts” that includes the spleen, the medulla oblongata, and the little thing that hangs at the back of your throat.

Most men reckon that the prostate is best dealt with on a need-to-know basis.  Unfortunately, you will need to know about the prostate sometime, because this troublesome gland is the source of three of the major health problems that affect men:  Prostate cancer, the most common major cancer in men; benign enlargement of the prostate (BPH, for benign prostatic hyperplasia), one of the most common benign tumors and a source of urinary symptoms for most men as they age; and prostatitis, painful inflammation of the prostate, the most common cause of urinary tract infections in men.  Some men are unlucky enough to deal with more than one of these over the course of their lifetime.

Today, I want to talk to you about prostate cancer.  Because when it’s caught early, it is usually curable.  Equally important:  In its earliest, most curable stages, prostate cancer produces no symptoms and you feel perfectly fine.  The best way to not die of prostate cancer is to find it when it’s still curable.  As Patrick Walsh, M.D., the great Johns Hopkins urologist and my longtime co-author, puts it, “If you can expect to live at least 10 to 20 more years and don’t want to die from prostate cancer, you should be screened.” 

Start When You’re 40

Screening involves two things:  A blood test for PSA (prostate-specific antigen) and a digital rectal exam that takes about a minute.  You should start when you’re 40, and depending on your results, you may not even need to get screened every year.  The PSA test is like a barometer for the prostate – but it’s best served up as a continuum, not a cut-and-dried, one-shot reading.  Another Johns Hopkins urologist, H. Ballentine (Bal) Carter, M.D., came up with a concept called PSA velocity.   Years ago, using an excellent database called the Baltimore Longitudinal Study of Aging (BLSA), he was able to look at the blood of men over a period of many years.  He looked at their PSA levels, and watched as they changed, or didn’t change, over time.   He has published many articles on this, and Patrick Walsh and I have written about it in several books (most recently, the Third Edition of Dr. Patrick Walsh’s Guide to Surviving Prostate Cancer, which has everything you could possibly want to know about PSA and the many ways to test it.)

Here’s the most basic information you need to know:

Get the Test

If you are in your forties, and you have a PSA level greater than 0.6 ng/ml (nanograms per milliliter), you should get your PSA measured every year. 

If you are in your fifties, and your PSA is greater than 0.7, you should get your PSA measured every year.  (These numbers come from Carter’s research. In another study, urologists Stacy Loeb, now at New York University, and William Catalona of Northwestern University, found the numbers to be slightly higher; 0.7 for men in their forties and 0.9 for men in their fifties.) 

This first PSA test is your baseline.  From this, your doctor will watch your PSA to see if it changes.  If you have a low PSA level (between 1 and 4 ng/ml), any increase is alarming.  In a study using data from the BLSA, Bal Carter and colleagues found that if PSA climbs more than 0.2-0.4 ng/ml per year, this is a predictor of death from prostate cancer.  This is really important:  No matter what your number is, if it keeps going up, you need to have it checked out.  Especially if you are in a high-risk group for prostate cancer — if you have a family history of the disease, or if you are an African American.  The number shouldn’t be changing very much.  If it is changing, and you don’t have a good reason for it (like a urinary tract or prostate infection; see below) you need to get a biopsy.  If no cancer is found and it’s still going up, you need to get a repeat biopsy in several months.  (There are other reasons why PSA can go up, including BPH, but this is more common in men in their sixties and older.  For men with a PSA greater than 4, an average, consistent increase of more than 0.75 ng/ml over the course of three tests is significant.)

Now, as I write this, I have a friend with a family history of prostate cancer; his father, uncle, and grandfather have all had it.  He is 51.  His PSA has gone up more than 0.2 ng/ml each year over the last two years.  His urologist has not recommended a biopsy.  In my opinion, his urologist is an idiot.  A lot of doctors are still lulled by low numbers; it used to be that any PSA below 4 was considered “safe.”  That’s not true. 

[Tweet “The key is, is your PSA going up, and if so, how fast? #prostatecancer”]

What if You Don’t Have a Baseline? 

What if this is your first PSA test?  Says Walsh:  “If you are in your 40s, 50s, or 60s and you have never had a PSA test, if you get one and your level is greater than 2.5 ng/ml and you can expect to live at least another 15 to 20 years, you should have a biopsy.  If your biopsy finds no cancer, you should continue to have your PSA level rechecked at regular intervals, using both the total PSA level and the speed at which it rises over time to determine whether and when you need to have a repeat biopsy.” 

When Can You Stop Screening? 

That’s a good question.  Again, your PSA track record determines a lot.  In his research, Bal Carter showed that if PSA testing were discontinued at age 65 in men who had PSA levels below 0.5-1.0 ng/ml, it would be unlikely that prostate cancer would be missed later in life.  A more recent study suggested that it is safe to discontinue PSA testing for men aged 75-80 with PSA levels lower than 3 ng/ml.  However, the men aged 75-80 who had PSA levels greater than 3 remained at risk of developing life-threatening disease.   This also depends on your general health.  If you are in your seventies, you don’t have any other health problems and can expect to live a good long life, for your own peace of mind you may prefer to keep on getting tested.  

In the Case of PSA, Numbers Really Matter

If PSA is so important, why do you need the rectal exam?  Because the PSA test is not foolproof.  About 25 percent of men who turn out to have prostate cancer have a low PSA level — say it’s 1.2, and it goes up a little over time, maybe to 1.8 — one that, despite an increase, doesn’t get flagged as suspicious.  For several reasons, including the way some tumors make PSA, you need a “back-up” plan (I admit, pun intended).   Conversely, the rectal exam is not perfect, either.  In many men with prostate cancer, the tumor may be in an inopportune spot, just out of finger’s reach, where it simply can’t be felt by a doctor.  In other men, cancer is “multifocal”– there are several patches of cancer, not just one – and the prostate feels uniform in consistency.  It’s deceptive, but the doctor’s finger doesn’t have a microscope on it and doesn’t always know when it’s being fooled.  Most normal prostates feel soft.  Cancer feels hard.  But if it’s in several places, or too small to feel yet – even though it’s growing and dangerous – a doctor could touch it and not know. 

This is why you need both tests, instead of an either-or approach for early detection.  It’s like using the breast exam and mammogram together to find breast cancer in women.  In one study of 2,634 men, investigators found that the PSA test and the digital rectal exam were nearly equal in cancer-detecting ability – but they didn’t always find the same tumors.  So if only one technique had been used, some cancers would have been missed.  Together, these two tests make a formidable team.

Really Important Things You Need to Know Before the PSA Test That Your Doctor Might Not Tell You

Don’t ejaculate for at least two days before you have your blood drawn.  This can raise your PSA level, throw off the test, and scare everyone unnecessarily.

Whatever you do, make sure to have the test before the rectal exam.  (The rectal exam can stimulate the prostate and cause more PSA to show up in the bloodstream and again, make your PSA level seem higher.)  I tell you this because my husband once had the test before the exam, it made his PSA number higher, and we got scared.  His doctor should have known better.

If you are taking Proscar or Avodart for BPH, or Propecia for hair loss, all of these drugs lower PSA.   They can make it seem artificially low, and if you have cancer, it might be missed.  (To correct for this, if you have recently started taking one of these drugs, your PSA level should be multiplied by 2.0.  If you have been taking it for five years or longer, your level should be multiplied by 2.5.)

If you have had surgery or a laser procedure to treat BPH, this can make your PSA much lower.  Don’t focus on the number; watch what it does.  If your PSA begins to increase steadily, you should see a urologist.

If your PSA test shows a significant increase, repeat the test in the same lab.  In 25 percent of these cases, the reading will be back down to its former level.  Says Walsh:  “If there is a clear-cut elevation, ask your doctor about prescribing antibiotics to rule out a possible infection.  Often, men receive ciprofloxacin or levofloxacin for three to four weeks and have the PSA measured again.  If it is elevated again, you should have a biopsy, using a different antibiotic when you have this procedure, to avoid infection from resistant bacteria.”

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington


antique spittoon on floorIf you use smokeless tobacco, or know a guy who does and want to help him, this is for you.  Obviously, the best thing you can do is quit.  But if you can’t do that, these three words may save your life:  Move your chaw!

I’ll explain, with help from Jason Campbell, D.D.S., a Prescott, Arizona, dental surgeon who specializes in complex reconstructions.  (Note: Campbell is also a very nice guy, and he says if you have any questions about what we’re talking about in this story, contact him at and he will answer them.)

When you stick a plug of tobacco in your mouth, it begins to break down, or denature, the tissue it touches.  It doesn’t just alter the tissue but the genetic code, as well, and this can lead to cancer.  By habit, says Campbell, “guys typically tend to keep the tobacco in the same spot all the time. “ The repeated chemical attack, of denaturant leaking out of a chaw of tobacco day after day, causes the body’s immune system to launch defensive countermeasures.   “The body’s way of protecting the tissue is, it toughens it up and thickens it, like when you get callouses on your hands from shoveling or lifting weights.  We see that wherever that tobacco goes.”  The official diagnosis of this phenomenon is called “tobacco pouch keratosis.”  (It’s gross.  Google it.)

Tobacco pouch keratosis is a precancerous condition.  “When the body starts laying excessive tissue down in order to protect itself, when those immune system cells get turned on, the body is automatically activating a system for cell formation.”  Cancer, Campbell points out, “is the continuous growth of tissue.  If the chemicals in tobacco alter the normal process, this system can get turned on and never turned off, and that’s when cancer can form.”  Usually, Campbell sees this keratosis on the lip and gum, but it’s kind of a tip-of-the-iceberg situation.  “Some of the fallout is, it creates inflammation in the area.  Periodontal bone loss is a process of inflammation, and that inflammation can cause a receding gum line, because it damages the bone, and then the gum follows the bone.  So periodontal defects are also very common in people who hold their tobacco in the same place over and over. “

If you smoke instead of chew, don’t feel too smug: The heat from a cigarette or cigar damages tissue, as well, and hampers the immune system in that area.  “So the heat is a problem, but the chemicals in smoked tobacco also inhibit the immune system,” says Campbell.  “Consider that the mouth is a pretty dirty environment.  A lot of different bacteria live there, and if the immune system is suppressed, it’s going to increase someone’s risk for bacteria-induced gum disease, as well as bacteria-caused tooth decay.”  (Another downside of smoking tobacco is that it messes up the taste buds; food doesn’t taste as good, and this suppresses the appetite – which is why you might see super-thin models and actresses puffing on cigarettes.  When people quit smoking, food starts to taste better.)

[Tweet “The damage to your lip and gum are reversible when you quit smokeless tobacco”]

Good news: the damage to the lip and gum is “100 percent reversible when tobacco products are discontinued.”  In the mouth, there is “a constant turnover rate of tissue replacement,” Campbell says.  “When the tissue detects that it doesn’t need to protect itself, that over-reactive thickening stops.  Usually that tissue can rebound.”  Periodontal damage, and damage from bone loss, can be corrected with surgery.

If you can’t quit chewing tobacco, there is still good news:  “I encourage our patients, if they are unwilling to quit, to move it.  My job as their dentist is to help them avoid big problems.  I’d much rather have them move it than increase their risk for cancer.”  For example:  If you generally keep your chaw tucked away on the right side of your mouth, put it on the left.

Campbell knows that for a lot of people, this means, “I just reduced my risk for cancer.  It’s okay for me to continue to chew!”  So, just because you can minimize your risk of cancer by moving your chaw, don’t think that’s one more reason why you shouldn’t quit.  “But one upside is, seeing that tissue heal does bring peace of mind for people.” It doesn’t happen right away, but “in six to eight months, we usually see that kind of leathery tissue start to dissipate.  In the tissue where there is receding of the gum, almost instantly we see the inflammation go down.  The gum is usually red and inflamed there, and that will heal very quickly.”

Keep in mind, Campbell notes, that tooth decay and gum disease are bigger oral health worries than the risks of cancer when it comes to smoking or chewing tobacco – and quitting reduces your risk for having to get cavities fixed, having your teeth go bad and needing crowns, or needing to have gum surgery.  “People need to understand that their risk of developing oral cancer is low.  But their chance of survival is very low.”  The mouth has a lot of blood flow – blood that can take cancer elsewhere, allowing it to metastasize.  People who get oral cancer from tobacco may need to have part of their face removed, or may risk having that cancer spread to other parts of the body.   I wouldn’t wish that on anyone.

Rinse Tests for Oral Cancer:  “We’re getting better at detecting oral cancer,” says Campbell.  Most dentists now check your mouth and throat very carefully for tissue changes, and at many practices, you can request a diagnostic test for oral cancer – a fluorescent rinse that bonds with precancerous cells, causing them to glow or stand out when the dentist shines a light on them.  These tests look for abnormal tissue, and aren’t just limited to changes caused by tobacco.  They can also detect other oral cancers, such as those caused by HPV.

©Janet Farrar Worthington

I lied in the headline.

strawberriesA prostate biopsy is not actually fun. But if you need one – if your PSA has gone up more than 0.4 ng/ml a year, or if your doctor has felt something suspicious, like a hard spot on the prostate during the rectal exam – then you need one, so here are a few things you should know.

The way doctors look for cancer in the prostate is much like looking with a needle in a haystack. The needle in this case is a spring-loaded biopsy gun, a tiny device that’s attached to an ultrasound machine. It’s not like a sewing needle; this one has a hollow center, so that it can capture at least 10 to 12 tiny cores of tissue, each one about a millimeter thick. Those cores go to a pathologist, who studies them under the microscope.

The Seeds in the Strawberry

What are they looking for? Johns Hopkins urologist Patrick Walsh, my co-author of Dr. Patrick Walsh‘s Guide to Surviving Prostate Cancer, uses this image with his patients: Imagine the prostate as a large strawberry.

Prostate cancer is multifocal. It causes what scientists call a field change. Multiple tumors pop up like dandelions, all at about the same time.

These seeds are tumors, and three to seven is the average number of separate cancers found in a radical prostatectomy (the operation to remove the entire prostate) specimen. How can a man develop several different spots of cancer? Prostate cancer is multifocal. It causes what scientists call a “field change” – basically, the entire prostate undergoes a transformation. Multiple tumors pop up like dandelions, all at about the same time. Each spot can be millimeters in size.

So this is what the urologist is looking for with the biopsy needle. But it’s not easy to hit a tiny seed inside a strawberry, especially one you can’t always see.

Why Cancer Can be Missed in African American Men

In another post, I mentioned the important work that another urologist, Ted Schaeffer, M.D., Ph.D., chairman of urology at Northwestern, is doing in understanding how prostate cancer is different in African American men. One reason it may be more aggressive when it’s diagnosed is that black men with prostate cancer make less PSA per gram of cancerous tissue, “So their PSA score could be misleading,” says Schaeffer. “There are fewer early warning signs.”

But even when an African American man does get a biopsy, his cancer can be missed. This is because his cancer, for some ornery reason, picks the hardest-to-get-to, easiest-to-miss-on-a-biopsy region of the prostate. “The way I explain it to patients,” says Schaeffer, “is, think about your prostate like a house.

“You have a basement. Just under that basement, the sub-basement, is the rectum, where we do the biopsies. You have a first floor, and an attic. Tumors in most Caucasians occur in the basement. If you’re taking tissue samples of the prostate from the sub-basement, you can get a good sampling of that area and are more likely to pick up a cancer. But if you’re African American, you have a high chance of having what we call an anterior tumor, in the attic of the house. It’s just harder, frankly, to be able to sample that area on a standard biopsy.”

This is why Schaeffer and colleagues get MRI images of their patients at highest risk, including African American men. “If we see something suspicious, we do an MRI-guided biopsy. We’re not the only place in the world doing this, but we’re doing it for reasons that were discovered at Hopkins.”

So, this is what I hope will be the take-home message:

If you are a black man, you need to be checked for prostate cancer starting at age 40. Get a baseline PSA test and have a rectal exam. If your PSA goes up more than 0.4 ng/ml a year – even if the number itself is low – you need a biopsy. Ideally, you need an MRI-guided biopsy. If no cancer is found, and that PSA keeps going up, you need another biopsy. If your doctor does not feel this way, find another one – a doctor who understands that prostate cancer is different in African American men in several important ways.

And Now, a Word About the Bacteria in Your Rear End

No offense, but you have bacteria in your bottom. We all do, so it’s nothing personal here. But it becomes an issue, so to speak, when you need a prostate biopsy. You’ve probably heard of nasty bugs known as multi-drug-resistant bacteria. When the biopsy needle goes into the prostate, it goes “transrectally” – through the rectum. To minimize the risk of infection, the standard protocol is for men to have an enema and to take antibiotics.

But this is not always enough. It turns out that one out of every five men has this multi-drug-resistant bacteria. If you have it, and you get an infection, “you can get very sick,” says Ted Schaeffer. The men most at risk? “Diabetics and health care providers. He made this observation in a study of a huge Medicare database of patients. His father, noted urologist Anthony J. Schaeffer, Urologist-in-Chief at Northwestern, is an expert on infection. Together, they came up with a protocol to lower the risk of a bad infection. “Before any biopsy, we sample the rectal flora” – the butt bacteria, if you will – with a simple swab test. “If we detect resistant bacteria, we then appropriately modify the antibiotic we give before the biopsy. That’s very important, because we’re preventing infectious complications that could be life-threatening.”

Before your biopsy, talk to your doctor about the risk of infection, and whether it would be possible to get a simple swab test ahead of time.

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington