What Women (and Men) Need to Know About Prostate Cancer Screening: Part 3

PSA Numbers and How to Make Sense of Them

What should the PSA level be?  Before we look at some numbers, please note:  if a man’s PSA is higher than these numbers, that doesn’t necessarily mean that he has prostate cancer; there are other factors that can raise PSA, which we will cover briefly.  I have much more about PSA here, and of course, in the book. 

  • For men in their 40s and 50s: A PSA score greater than 2.5 ng/ml is considered abnormal. The median PSA for this age range is 0.6 to 0.7 ng/ml.
  • For men in their 60s: A PSA score greater than 4.0 ng/ml is considered abnormal. The normal range is between 1.0 and 1.5 ng/ml.
  • An abnormal rise (the rate and speed of change in PSA is called PSA velocity): A PSA score may also be considered abnormal if it rises a certain amount in a single year. For example, if a man’s PSA score rises more than 0.4 ng/ml in a single year, he needs to find out why.  If his PSA is going up and down but is still higher than it should be, he needs to find out why.

Men: If you are in your 40s and your PSA level is greater than 0.6 ng/ml, or if you are in your 50s and your PSA is greater than 0.7, you should have your PSA measured at least every two years.  If your PSA is below this, you may be able to wait as long as five years for the next test.

In older men, benign enlargement of the prostate (called BPH) can also raise the PSA number.  BPH is very common: it’s in 50 percent of men in their 50s, 60 percent of men in their 60s, 70 percent of men in their seventies, etc.  Note:  Drugs to treat BPH can artificially lower PSA by as much as half.  Taking a 5-alpha-reductase inhibitor, such as finasteride (Proscar) or dutasteride (Avodart) to treat BPH, or the drug Propecia, used to deter hair loss (a low-dose form of finasteride) can artificially lower PSA.  If a man has been taking one of these drugs for a short period of time, his PSA number should be doubled.  If he has been taking it for five years or longer, his PSA should be multiplied by 2.5.  Don’t just take that low score at face value.

Here are more PSA numbers from the book,, adapted from the Journal of the American Medical Association:

How many men my age have this PSA level?

2.5 or lower:  88 percent of men in their 50s, 75 percent of men in their 60s, and 61 percent of men age 70 or above.

2.6-4.0:  8 percent of men in their 50s. 14 percent of men in their 60s, and 18 percent of men age 70 or above.

4.1-9.8: 3 percent of men in their 50s.  9 percent of men in their 60s, and 16 percent of men age 70 or above.

10 or higher:  1 percent of men in their 50s.  2 percent of men in their 60s, and 5 percent of men age 70 or above.

All of this said, a PSA score on its own is not enough, because other things can raise PSA.  This is why getting that baseline and then watching what PSA does over time is so important.  This is PSA velocity:  watching what PSA does.

What else can raise PSA?

             Here’s a tip:  Get the PSA blood test done before the rectal exam at the annual physical.  The rectal exam, when the doctor pokes the prostate to check for any signs of hardness or lumps, can cause PSA to be released into the bloodstream – artificially raising the PSA number.  (Fun fact: what’s the prostate supposed to feel like?  Feel the pad at the base of your thumb.  The prostate should feel kind of squishy like that.)

            Similarly, so can having sex.  Therefore, a man should avoid sexual activity for three days before the blood test.  

Prostatitis can also raise PSA, sometimes to high levels.  This is not cancer; it’s inflammation in the prostate and it is treatable.  I have good information about prostatitis and pelvic pain syndrome here.

Second-Line Tests Shed Light in the Darkness!

Fortunately, there are “second-line” blood and urine tests that can help figure out if a raised PSA number is coming from BPH or prostate cancer.

I’ve got much more about these tests here, but briefly:  Nuanced tests such as the 4K score or Prostate Health Index (PHI) look at “free PSA.”  PSA comes in several different forms.  Free PSA measures whatever PSA in the blood that is not bound to proteins.  As Johns Hopkins urologist H. Ballentine Carter, M.D., was fond of saying, the higher percentage of PSA that is free, the more likely you are to be free from cancer.  This test provides context:  If the percentage of free PSA is higher than 25, then the elevated PSA is more likely to be caused by BPH, benign enlargement of the prostate.  If it’s lower than 25 percent, this doesn’t automatically mean that there’s cancer, but it does raise the likelihood that cancer may be present.  The 4K and PHI tests are even more helpful than the free PSA test, because they also look for biomarkers of aggressive cancer, and put it all together into a score.

What if these things point to cancer?  Is the next step biopsy?  No, it’s prostate MRI.

I’ve written about that here, but basically, the result of prostate MRI is called a PI-RADS score, ranging from 1 to 5.  A PI-RADS score of 3 or higher is the trigger for a biopsy.

That biopsy should be an MRI fusion biopsy, where the MRI image is combined with transrectal ultrasound to give the doctor the best view of any suspicious areas that really need to be checked.  In the biopsy, 12-14 hollow-core needles are used to get samples, or cores, of tissue.  Note:  a biopsy is not perfect; each needle only samples 1/10,000th of the prostate!  In the book I’ve said it’s like looking with a needle in a haystack.  That’s why the second-line tests can help paint a more complete picture of what’s going on in the prostate.

            There are two ways to have the biopsy done:  through the rectum (transrectal) and through the perineum, the area of skin between the rectum and the scrotum.  If you think of the prostate as about the size of a golf ball, the transrectal approach basically goes from south to north.  The transperineal approach goes from east to west, and it does a much better job of finding out-of-the-way cancer.  I’ve written about that here.  Not only is it more effective:  there is zero risk of infection.  No need for antibiotics!  It’s also better for diabetic men, who are at higher risk of getting an infection.  The transrectal approach, because it goes through the rectum, involves antibiotics.  There’s no getting around it; the rectum is chock full of bacteria.  Transperineal is the better way to go.

Since this series is about screening and detecting cancer, I’m going to leave it here and not get into treatment.  That is covered throughout this website, and if there’s interest, will be the subject of another series.  Very briefly, if cancer is found, you will be given a Gleason score, or Gleason grade group.  The cancer can range from very low, low, and favorable intermediate risk – which may not ever need treatment – to unfavorable intermediate, high, and very high risk.  You will also be given a clinical stage, which is the estimate of how much cancer there is – whether it is confined to the prostate (the most common scenario in the U.S. today because of screening); whether it has spread locally but does not appear to be present at distant sites (seen with imaging); or rarely, less than 10 percent of the time, whether the cancer has spread to either the lymph nodes or bone.  Whatever the finding, don’t become discouraged!  There is more hope now than ever before.

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years, 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.  Note: I am an Amazon affiliate, so if you do click the link and buy a book, I will theoretically make a small amount of money.  

© Janet Farrar Worthington

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What Women (and Men) Need to Know About Prostate Cancer Screening: Part 2

Why Don’t More Men Get Regular PSA Tests?  A Partial Deep Dive

           Why doesn’t every man just get a PSA test at the yearly physical, starting at age 40?  Well, for starters, a lot of men don’t get yearly physicals.  And a lot of family doctors don’t order a PSA test for men in their 40s and even 50s when they’re checking for cholesterol and all the other stuff on routine bloodwork.

PSA Testing: The Back Story

           Note:  This is the why, as in, why your doctor hasn’t checked your PSA, or maybe even why the doctor won’t order a second-line blood test to help rule out cancer.  If you’re already looking at numbers and want to make sense of them and know what to do next, go right to Part 3.  

There’s some bad blood here, metaphorically speaking.  Misunderstandings and issues with PSA go back to the 1990s.  I was there, Gandalf; I saw it play out.  It started with how awful a diagnosis of prostate cancer used to be and how ineffective the treatment was.  Until the 1980s, very few men who were diagnosed with prostate cancer survived it.  One major reason is that there was no early screening for this disease.  The only way it was diagnosed was when it got big enough to be felt during a rectal exam, often after symptoms of more advanced cancer developed, such as urinary problems or back pain from metastasis.  Although prostate cancer had the reputation of being an “old man’s disease,” one you could “die with, not of,” this was often not the case.  I can tell you, from painful personal observation, that death from metastatic prostate cancer can be awful.

            The treatment itself was rough, and few lives were saved by it.  Radiation wasn’t yet powerful or focused enough, and surgery was brutal.  Patrick Walsh, M.D., the great Johns Hopkins urologist and my longtime coauthor, told me the radical prostatectomy (operation to remove the prostate) used to be “performed in a sea of blood.”  Surgeons couldn’t see what they were doing.  Men didn’t want the surgery because it had two terrible side effects:  everyone who got it wound up with urinary incontinence and impotence.

The relatively few men who did get the surgery had to supply their own blood ahead of time, because everybody who had a radical prostatectomy needed a transfusion.  Walsh set out to make this operation safer, and the first thing he did was figure out how to control the terrible bleeding.  Once he did, surgeons could actually see what they were doing – a breakthrough – and it was possible to preserve urinary continence.  Then Walsh discovered the neurovascular bundles– tiny scaffolds of nerves, one on either side of the prostate like Mickey Mouse ears – that control erection.  Previously, everyone had assumed that these nerves were inside the penis.  Surgeons performing prostatectomy routinely sliced right through them.  In medical textbooks, these are now called the neurovascular bundles of Walsh.

In 1984, Walsh did the first purposeful nerve-sparing radical prostatectomy.  That patient was potent immediately, his cancer was cured, and he lived nearly three decades longer.  Soon doctors from around the world were flocking to Johns Hopkins to learn the Walsh procedure.  Radiation got better, too – more powerful and less toxic to nearby tissue.  Deaths began to drop.  Since 1993, deaths from prostate cancer have fallen by half.  Of men diagnosed today, 99 percent can now expect to live more than five years, and the vast majority live much longer.  The key is early detection.   

 An Avalanche of New Cases 

             Yes, yes, you say, but what about the PSA test?  Well, in the late 1980s, when the PSA test first came out, there was a huge bubble of men being diagnosed with prostate cancer.  The number of new cases being diagnosed increased by 83 percent between 1988 and 1992.  As Northwestern urologist Hiten Patel, M.D., M.P.H., noted in the book, “This was no sudden epidemic of prostate cancer; the number of men with the disease was the same then as it is now.  It’s just that, for the first time, widespread PSA testing was picking up all cancers – early cancers destined to be lethal, and early cancers that were indolent and never at risk of harming the patient.”

            After that avalanche, (this often happens when a new diagnostic tool comes out), the number of new cases has slowed down.  The good news is that, because of PSA screening and with more effective treatment, the death rate from prostate cancer dropped by over 30 percent from 1992 to 2003.  In 2019, the death rate from prostate cancer was 53 percent lower than before PSA.

            What the PSA test did was, it bought time – allowing men to be diagnosed about five years earlier than they would otherwise have been.

 Doctors didn’t know what to do with PSA at first.  In the past, so many men with prostate cancer died terrible deaths that doctors went overboard the other way.  They treated a lot of men who didn’t need to be treated – but they didn’t know that yet.  Doctors were just so excited to have a way to prevent the horrible death from metastatic prostate cancer.  Also, there was a learning curve with the nerve-sparing operation.  Because it is so technically difficult, and few achieved Walsh’s results with open surgery, prostatectomy actually is done most commonly these days as a laparoscopic procedure, using a robot. In the 1990s and early 2000s, a lot of men had lingering side effects from surgery that was not done as well as it could have been.  Surgery that not all of them even needed.

            And then came the USPSTF.  In 2012, on a dark day for men’s health, the brain trust that is the Congressionally funded, policy-setting U.S. Preventive Services Task Force (USPSTF) recommended against screening “average risk” men for prostate cancer.  They remembered all the men who had been overtreated, the men with slow-growing prostate cancer who didn’t need curative treatment, and the men who were still dealing with incontinence and impotence from surgery, and impotence and bowel problems after radiation.

They did not seem to take into account that both surgery and radiation have gotten a lot more precise.  They didn’t take into account that some men don’t know their family history, and they didn’t take into account that not all men are the same: factors such as obesity, diet, cigarette smoking, and other environmental factors all can raise a man’s risk of getting prostate cancer.

Not only that: because of second-line blood tests, better MRI and other factors like PSA density (the PSA score divided by the volume of the prostate, as determined by MRI or ultrasound; this is another way to help tell if it’s likely to be cancer or BPH), and PSA velocity (watching what PSA does, and if it rises, how fast), doctors are a lot better now at figuring out who really needs to be treated.

The USPSTF’s 2012 guidelines did a huge disservice to doctors and their patients.  Millions of American men stopped getting PSA screening.  By the way, there was not a single urologist on that panel of geniuses.

            Unfortunately, there was a rise in men diagnosed with aggressive and advanced prostate cancer.  This created such an uproar in the prostate cancer community that this bad decision was walked back in 2018.  The USPSTF now says, “The decision about whether to be screened for prostate cancer should be an individual one.  The USPSTF recommends that clinicians inform men ages 55 to 69 years about the potential benefits and harms of prostate-specific antigen (PSA)-based screening for prostate cancer.”

This is a major change in language and policy, and a major step back in the right direction, although age 55 is too late for many men to start this discussion.

Also, men diagnosed at age 75 or older account for 48 percent of metastatic cancers and 53 percent of prostate cancer deaths, despite representing only 26 percent of the population.  So, most older men still need to be screened.  However: If a man is 75 and his PSA is less than 3, it is extremely unlikely that he will be diagnosed with prostate cancer.  If he’s 65 and his PSA is below 1.0, it is also unlikely that prostate cancer will be missed later in life, and he may be able to stop screening, as well.

Thus, if your doctor says something like, “There’s really no evidence that screening for prostate cancer extends life, and we want to avoid a lot of side effects of treatment,” that is wrong, it’s outdated, and it’s dangerous.

            So, to recap:  Men should start PSA screening in their 40s, ideally with a baseline PSA at age 40, because of the younger age of people being diagnosed with cancer these days.  Do not wait until your 50s to start.  Men with a family history of prostate cancer or other cancers should start at age 40.  Some men, if they have a strong family history of cancer, are diagnosed with prostate cancer in their 30s.  Who’s at highest risk?  Men with a family history of prostate cancer or other cancer, and Black men.

            Family history is key: In 2016, a cancer Dream Team funded by the Prostate Cancer Foundation published an article in the New England Journal of Medicine that was a stunner:  They showed that prostate cancer is a lot more of an inherited disease than anybody thought.  They found 16 bad genes that we now know to look for, including BRCA1 and BRCA2, which for years were only linked to breast, ovarian and other cancers, but not prostate cancer.  It turns out that 25 percent of prostate cancer runs in families.  And this is not just about the men in the family:  if a man has a known mutation in one of these genes, his sons and daughters and their children are more likely to develop breast, ovarian, or other cancer, too.

            Black men, please get PSA screening:  I wrote a story about one of the nicest men I ever met, diagnosed with metastatic prostate cancer at age 45.  He should have been diagnosed five years sooner.  He was a Veteran and a Black man, and had been in the hospital for several issues (including back pain) that should have raised a red flag.  But he never got a PSA test.  The VA does many things well with prostate cancer: they are pouring many millions into treatment for metastatic prostate cancer, which is to be commended.  But if they had an aggressive screening program, metastatic prostate cancer wouldn’t be such an issue.

I have talked to many Veterans since I started writing about prostate cancer in 1992.  All of them were diagnosed with metastatic cancer.  One is an exceptional responder and is now in remission.

Next, Part 3:  PSA Numbers and How to Make Sense of Them

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years, 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.  Note: I am an Amazon affiliate, so if you do click the link and buy a book, I will theoretically make a small amount of money.  

© Janet Farrar Worthington

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What Women (and Men) Need to Know About Prostate Cancer Screening: Part 1  

Recently, I gave a talk on what women need to know about prostate cancer.  It was supposed to be for 20 minutes, but it went on for well over an hour because the ladies, ranging from their 30s to 70s, had so many questions.  So…Ladies, this one is for you.  Actually, it is for men in their 40s and 50s, but they probably won’t read it. 

I can attest that this is true.  My own dad, diagnosed in his early 60s with prostate cancer and cured by Johns Hopkins urologist Patrick Walsh, M.D. (my longtime co-author of now seven books on the subject) never read our book. Instead, my mom read it to him, passages she had previously highlighted, as they drove up I-95 from South Carolina to Baltimore for the surgery that saved his life and enabled him to live 20 more years.  In fact, my mom and I were the ones who made him start getting his prostate checked in the first place, something he definitely did not want to do.

When my husband, Mark, at age 59 found out that his PSA went up from a 2.0 – which I had thought was high and was watching it – to a 3.0, and his local doctor said it was “still low and in the normal range” (this was garbage; we disproved this in our books in the early 2000s), I recommended a second-line blood test (see Part 3) for clarification.  When that suggested cancer, I said:  “You need an MRI and a biopsy.”  He wasn’t convinced, and his local doctor said he could wait a while and see (really bad advice).  I called Pat Walsh, who not only told Mark the same thing, but told him which doctors he had picked out to do the biopsy and the surgery.  Thank God we got it when we did, and Mark is now cancer-free.  You can read Mark’s story here.

I have several key points for you to consider:  One, the younger men who are most likely to be cured of prostate cancer or, if it is slow-growing, followed carefully in active surveillance, are the least likely to be checking for it. ***Note***If a man is already getting PSA testing and wants to know more about the numbers, jump right to Part 3.***

Two, for whatever reason, more people are being diagnosed with cancer at a younger age.  You can take your pick on the reasons, and I have some thoughts, but the point is simply that it’s happening, and younger men need to start getting checked.  Because prostate cancer, when caught early, is 100 percent curable.

Three, despite what your family doctor may say, men need a baseline PSA blood test starting at age 40.

It’s just a simple blood test.  We will talk more about this in Parts 2 and 3.  (Personal note, because we have a high-risk family with six men affected so far on both Mark’s and my sides, I am going to make my sons get a baseline test at age 35.)  Also, we will talk about what the PSA numbers should be, and about more specific, second-line blood tests that can help determine if it’s cancer.  Please keep reading!

Four, treatment for prostate cancer is better than ever.  And, a diagnosis of prostate cancer doesn’t always mean that a man needs to be treated right away.  Many men can be treated for years or even indefinitely with active surveillance: they are followed carefully, and then treated only if and when the cancer starts to progress.  If a man does need treatment, surgery and external-beam radiation therapy are better than ever.  And: new advances suggest that in the next few years, we will see more and more focal therapy (treating only the cancer within the prostate, not removing the whole prostate), and even partial prostatectomies (like a lumpectomy for breast cancer).  We’re not there yet, but with better imaging and with in-surgery use of tracers such as the PSMA-targeting radionuclides, which can light up tiny spots of cancer invisible to the naked eye in PET imaging, it will be possible during surgery to know which tissue can safely be spared.  This should help minimize side effects of temporary urinary incontinence and ED.  Where surgery goes, radiation goes, as well, and I predict more nerve-sparing forms of radiation therapy and even more highly targeted therapy that will minimize side effects, too.

Step one: Get the baseline PSA.  Ideally, at age 40, but in the 40s is better than waiting until age 50.  (However, if a man is in his 50s and hasn’t had a PSA test, he needs to get one!)

            Note:  This is not a “one and done” thing.  What happens next depends on the number.  If a man’s PSA is lower than 1 ng/ml, the doctor may say he can wait two to four years for the next one.  However, if the man is at high risk for prostate cancer – if he has a family history of cancer and/or prostate cancer, or if he is of African descent – he should just get on the PSA train and get screened every year.

            Here’s something to think about:  A lot of men don’t know their family history.  So how do they know if they are at higher risk of getting prostate cancer?  Also, for many people, including our family, the family history changes in real time.  When Mark and I got married, we didn’t have any prostate cancer in the family.  Then his dad died of it at age 53, his maternal grandfather died in his 80s of complications from radiation that he probably didn’t need, my grandfather died in his 80s of complications from estrogen (they don’t even use that now) that he probably didn’t need, either.  Then my dad got it.  Then Mark, and then his paternal uncle.  So we’re six and counting.  But again, we weren’t a prostate family… until we were.

Next:  Part 2:  Why is PSA Screening Such an Issue?

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years, 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.  Note: I am an Amazon affiliate, so if you do click the link and buy a book, I will theoretically make a small amount of money.  

© Janet Farrar Worthington

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Testosterone After Surgery or Radiation for Prostate Cancer

When it comes to testosterone, think of Goldilocks and the Three Bears:  You don’t want too much, and you don’t want too little.  There are health risks at either extreme.  You want it to be just right, in the normal range.

            “After radical prostatectomy, if you have an undetectable PSA and your testosterone is low, it’s okay to take some supplemental testosterone to restore it to normal range,” says Weill Cornell Medicine urologist Jim C. Hu, M.D., M.P.H.  I recently interviewed him for the Prostate Cancer Foundation’s website, and Jim’s expert opinion also was featured in our book.  What is the normal range?  In our book, my co-author Edward “Ted” Schaeffer, M.D., Ph.D., Chair of Urology at Northwestern University, says it is between 300 and 800 ng/dL.  (If you look on the internet, you can see the normal range as high as 1,000 to 1,200 ng/dL, but I trust and respect Ted Schaeffer’s advice.)

Restoring normal levels of testosterone has become a more common practice in recent years, Hu notes.  “People used to worry that you’re pouring gas on a fire,” adding testosterone to prostate cancer – but if there is no prostate tissue, and the supplement only brings testosterone back to where it should be, it is safe.  Look at it this way:  It’s not like you’re re-introducing testosterone to your body, like bringing wolves back to some wilderness area where they had become extinct.  You’ve already got testosterone; you’re just bringing it up to the normal level.  “There is no evidence that restoring testosterone levels to the normal range makes you more likely to have a recurrence of prostate cancer if you have an undetectable PSA after surgery.”

At the American Urological Association’s 2024 meeting in San Antonio, Hu and colleagues presented results from a population-based study looking at data from SEER (the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program) and Medicare.  “We found that men who got testosterone supplementation to the normal level after surgery were not at a higher risk of prostate cancer-specific mortality.”  More recently, they looked at SEER and Medicare data for men with lower-risk prostate cancer on active surveillance who got testosterone replacement therapy.  “These men were not at any increased risk from developing aggressive disease or dying of prostate cancer.”

“There are health risks from having testosterone below the range where it should be,” says Hu, “including a higher risk of heart attack, loss of muscle mass and bone density, a higher risk of cognitive impairment, and a higher risk of developing metabolic syndrome, which can lead to diabetes.”

            Because of the benefits of having testosterone restored to the normal range, “in men diagnosed with low-risk prostate cancer who are on active surveillance, men with an undetectable PSA after surgery, or men with a low, stable PSA after a successful response to radiation therapy, testosterone supplementation is becoming a more accepted practice.”

For men who have undergone radiation therapy, Hu recommends waiting two years before considering testosterone supplementation, “to make sure the PSA has trended down in an appropriate way.”  Note:  If you choose to start testosterone supplementation (after radiation or surgery), it is vital that you do this in conjunction with a physician and continue to monitor your PSA closely, along with regular bloodwork to monitor liver function and blood counts.

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years, 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

 

 

 

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Understanding PSA after Radiation Therapy

In interviews I did for the Prostate Cancer Foundation’s website, Weill Cornell Medicine urologist Jim C. Hu, M.D., M.P.H. (whose expert opinion also was featured in our book), breaks down what rising or persistent PSA means after treatment for localized prostate cancer, and what you should do next.  Remember the first lesson from Part 1:  Don’t panic!

             How do you know if localized prostate cancer is cured?  That answer to that question is straightforward for men who undergo radical prostatectomy:  in the weeks after surgery, the PSA should become undetectable, falling to less than 0.1.

But for men who undergo radiation therapy, it’s more complicated: there is no definitive PSA cutoff point that signals success or failure of treatment.  That’s because radiation therapy – external-beam or radiation seeds (brachytherapy) – is designed to kill prostate cancer, not normal prostate tissue.  It doesn’t kill the entire prostate – and thus, PSA does not go away completely.

Instead, PSA drops, eventually reaching a rock-bottom level called the PSA nadir.  Note:  there may be a little bump along the way, called the PSA “bounce.”  This doesn’t happen to everyone; it’s more common in younger men.  The PSA bounce does not mean that you are not headed for a low, stable PSA.  It’s just a weird thing that may be related to inflammation of the prostate; it’s temporary and usually happens within the first two years after treatment. Then PSA usually settles down, remaining at a very low level.

It can take anywhere from two to five years after radiation for PSA to bottom out.  If it starts to climb back up, further tests are not indicated until the PSA reaches the nadir value + 2 ng/ml.  “The very term, ‘nadir +2,’ tells you that whole-gland radiation is not expected to kill all the cells within the prostate,” says Jim Hu.  “There are some benign cells left behind that can still make PSA.  But if there are also some remaining cancer cells, those cells will grow over time, and finally produce enough PSA to exceed that nadir + 2 cutoff.”  Thus, if cancer is still present after radiation therapy, it may take months or even years to find out about it.

If Some Cancer is Still There, Where is it?

There are several possibilities as to where the cancer might be lurking, says Hu.  “The cancer could be just within the prostate.  It could be within and outside the prostate, but still in the nearby area.”  Or, it might be further afield – in a lymph node, perhaps.  “It may be that the radiation killed the cancer within the prostate, but there were some microscopic metastases outside the prostate that were not touched by the radiation.”

The first place to look for recurrent cancer after radiation therapy is within the prostate – with an MRI and a biopsy.  What happens next?  Let’s say the cancer is still in the prostate.  “Typically, you can’t do more radiation to the prostate because that part of the body has already tolerated the maximal dosage of radiation,” says Hu.  “But at some centers, they will put some radioactive seeds (this is called brachytherapy) in the area where the cancer is, or within the prostate.”

What about surgery?  Many centers do not offer “salvage” prostatectomy, “because the delay in diagnosing the recurrence means the cancer might have spread.  Some salvage radical prostatectomy series [studies] showed that the likelihood of cure (with surgery after the radiation) was only 20 to 30 percent.”  Hu has performed 20 salvage robotic prostatectomies, but he makes sure his patients know that complications are much more likely when surgery is performed on an area that has undergone radiation therapy.  That’s because the tissue is already damage to start with.  “The incontinence risk, instead of being 1 to 2 percent, is now 50 to 80 percent for stress urinary incontinence (when urine leaks during certain activities, such as exercise), and there is a higher risk of the rectal tissue – which becomes fragile after being irradiated – developing a hole or tear (called a fistula).

Other options:  High-intensity focused ultrasound (HIFU) of the entire prostate is another option, and so is cryotherapy (freezing the tissue inside the prostate).  Both of these options, currently being offered at some centers as focal therapy, have a lower risk of incontinence and ED than salvage prostatectomy, Hu explains – but notes that here again, PSA will most likely not become undetectable after treatment.  Instead, it’s back to waiting for the PSA to reach its nadir.  And if you have a PSMA PET scan or other imaging showing that cancer has spread outside the prostate area, such as to bones, you and your doctor will need to discuss starting ADT, by itself or along with an androgen receptor-targeting drug such as enzalutamide or abiraterone plus prednisone for a combined punch.  These medicines lower testosterone, cutting off the cancer’s “fuel supply,” and can be effective for many years.

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. 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

 

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What if PSA Never Becomes Undetectable after Prostatectomy? 

In interviews I did for the Prostate Cancer Foundation’s website, Weill Cornell Medicine urologist Jim C. Hu, M.D., M.P.H. (whose expert opinion also was featured in our book), breaks down what rising or persistent PSA means after treatment for localized prostate cancer, and what you should do next.  Remember the first lesson from Part 1:  Don’t panic!  

If PSA does not go away after prostatectomy, this is called “PSA persistence,” and there are three things that could be causing it, says Jim Hu.

            There could be some normal prostate tissue left behind.  “This was more common when we first started doing robotic prostatectomy,” instead of the open surgical procedure, “but it still does happen.”

            There could be some prostate cancer that has left the prostate, but is still in the local area, and can be treated with “salvage” radiation therapy.  Even if you had a PSMA-PET scan, and/or a bone scan or CT scan before treatment, this is a possibility, particularly if you had high-volume unfavorable risk cancer (Grade Group 3, or Gleason 4+3=7) or higher-grade cancer (Grade Group 4 or 5, or Gleason 4+4=8 or higher).  It could be that this cancer was too small to be seen on imaging, and now has gotten bigger.  “This can happen, even if the lymph node dissection during surgery showed no cancer,” says Hu. “There could be one area or several areas producing enough PSA to be above 0.2 ng/ml.”

Depending on the results of imaging – PSMA-PET, a bone scan, and/or CT scan – salvage radiation could cover just the prostate bed or the entire pelvis.  Or, it could just target highly specific areas, because:

            There could be oligometastasis.  Here again, it’s possible that a few micrometastases – too small to be seen even by PSMA-PET – escaped the prostate before surgery, and now have gotten big enough to be seen.  If there are just a few isolated spots, this is called oligometastasis.  It’s not full-blown metastasis, and most important to know: “You can still go for a cure,” says Hu, “with targeted stereotactic radiation therapy to those areas, and a salvage lymph node dissection.”  There is a chance that further micrometastases will reveal themselves after this treatment, Hu says.  But University of Maryland radiation oncologist Phuoc Tran, M.D., Ph.D., who has pioneered research and treatment in prostate cancer oligometastasis, says those new spots can be “zapped,” as well – still with a chance of a cure.   He likens this approach to “whack-a-mole.”

            What about androgen deprivation therapy (ADT) with radiation?  “There’s still shared decision-making,” Hu notes, where you and your doctor discuss the risks and benefits of a short-term course of ADT along with radiation therapy.  However, he advises that patients seriously consider it.  “The new guidelines say you should add ADT to salvage radiation if someone has high-risk features, such as positive surgical margins, cancer in the seminal vesicles, or Grade Group 4 or 5 cancer,” and this, in Hu’s opinion, is the smartest thing to do.  “There’s not a conclusive, randomized trial that says you absolutely should have it – but if you want to have the highest chance of cure, I think you should do ADT along with the radiation.  If I have prostate cancer and primary therapy has not worked, I don’t want to miss the window of curability again; I want to maximize my chance of cure with radiation therapy and temporary ADT.”

Next: Understanding PSA after Radiation Therapy

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. 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

 

 

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PSA After Surgery: What Number Should Sound the Call to Action?

In interviews I did for the Prostate Cancer Foundation’s website, Weill Cornell Medicine urologist Jim C. Hu, M.D., M.P.H. (whose expert opinion also was featured in our book), breaks down what rising or persistent PSA means after treatment for localized prostate cancer, and what you should do next.  Remember the first lesson from Part 1:  Don’t panic!  

            Let’s say a prostatectomy patient’s first PSA after surgery was less than 0.02 at three months, but at one year is 0.1.  “If that patient is high-risk (see below) to begin with, that’s a pretty clear signal that this particular patient is probably going to have a recurrence,” says Jim Hu.  “On the other hand, if that patient were Grade Group 2 (Gleason 3+4=7), had negative margins, had low-volume disease confined to the prostate, and then had a 0.1 PSA, there’s more of a comfort level in having a higher threshold, in waiting to let it declare itself further.”  The advice here would be to wait another three or six months, and check it again.  “You want to give it long enough to see if anything has changed.”

—

Do You Have High-Risk Cancer?

Features that indicate aggressive cancer and higher risk of recurrence:

*Positive surgical margins

OR

*Seminal vesicle invasion

OR

*N1 lymph node involvement

OR

*High-grade (Grade Group 4 or 5; Gleason 8, 9, or 10) cancer

OR

*Pathologic stage of T3b

—

            Is there a magic number that signals further action is needed?  The American Urological Association and the Society of Urologic Oncology recommend a cutoff of 0.2.  “Some literature and research have suggested you could even hold off until 0.4,” notes Hu.  “The new guidelines say that for detectable PSA after radical prostatectomy, when radiation therapy is considered, clinicians should provide salvage radiation when PSA is less than or equal to 0.5.  At 0.4, there is still debate among radical prostatectomy surgeons that you could wait longer to let the cancer declare itself.”  (A genomic test may help; see below.)

Here’s a big question:  is it actual prostate cancer causing the rise in PSA, or just some leftover prostate cells?  “Everyone does this surgery a little differently,” says Hu.  “It could be that a little bit of benign prostate tissue was left behind, especially if the surgeon did aggressive nerve sparing.”  The nerves responsible for erection sit in two neurovascular bundles outside the prostate, and are left intact in the “nerve-sparing” prostatectomy – if there is no cancer nearby.  (If cancer is too close, one or both neurovascular bundles may be removed.)  But it is possible, if a surgeon is really trying to stay away from those nerves, that some prostate cancer cells may be missed.

Thus, this prostate tissue could very well be benign – but because these are prostate cells, and prostate cells make PSA, that PSA could become detectable over time.  Or, there could be cancer in this prostate tissue.  “This comes back to the risk,” says Hu, “and there needs to be shared decision-making, or patient involvement, in the decision of what to do next.”

Can PSMA-PET imaging help?  Yes, but not when the PSA is very low.  “PSMA-PET is unlikely to show anything until the PSA gets to 0.4 or higher,” Hu explains.  “Many patients get a PSMA-PET scan before surgery if they have high-risk disease, but we often do a repeat PSMA-PET if their insurance allows it,” because their next step is salvage radiation.  “The radiation oncologist may want that imaging study, as well, to determine whether to extend the radiation field.  But at PSA below 0.4, it’s unlikely that anything is going to light up” to show whether there is residual cancer, and where it is.

What Happens Next?

Let’s say a man has a prostatectomy and one of his PSA follow-up tests shows the PSA has gone from being undetectable to being 0.1 ng/ml.  What should he do?  Wait until the next test, and see what happens.  “To be concordant with guidelines, you wait until the PSA reaches 0.2 before you see a radiation oncologist.”

Could a genomic test provide helpful information here?  Decipher and other genomic tests examine prostate tissue (either from a biopsy or from the prostate specimen after prostatectomy), looking look for genes that are known to be involved in aggressive prostate cancer.  If you did not get a genomic test at diagnosis, getting one now may help determine your next steps.  For example, using the Decipher score, cancer that is less aggressive shows up as less than 0.45; intermediate risk cancer is less than 0.6, and high-risk cancer is from 0.6 to 1.0.

            How might this help you and your doctor decide what to do next?  Do you need “salvage” radiation (radiation given after prostatectomy)?  And do you need a temporary course of ADT, as well?  Hu gives an example:  “’The PSA is 0.2 or higher.  Let’s send off the Decipher, see if it is favorable, and then we can just do the radiation without androgen deprivation therapy (ADT).’  That’s where shared decision-making comes into play, because of the undesirable side effects of ADT.   There are many reasons, ranging from masculinity concerns to worries about bone fracture, why the individual may want to avoid ADT – and a low or intermediate Decipher score may reinforce their desire to avoid it.”  But the stakes are higher this time, he cautions.  “If it were me, I would take the short course, four to six months of ADT, along with the radiation to make sure that we get the cancer.   We’ve already missed one chance to get a cure.”

Treatment Options

The standard of care treatment for a rising PSA after prostatectomy is salvage radiation therapy to the prostate bed(where the prostate was) and potentially to the entire pelvis.   The National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA) guidelines recommend that if a patient has high-risk features (see above) after prostatectomy, and if there is a short PSA doubling time (if it doubles in less than 6 months), he should also get four to six months of ADT in addition to salvage radiation therapy.  “This maximizes your chance at a cure,” says Hu.

Note:  If salvage radiation therapy is the next step for you, sooner is better than later, and this is why early PSA monitoring is so important.  “There is strong evidence that for a detectable PSA after radical prostatectomy, salvage radiation is more effective when the PSA is at 0.5 or lower,” says Hu.  However, if you are at high risk for clinical progression, and you have a detectable PSA, your doctor may recommend starting salvage radiation when the PSA is at 0.2.  “Here again, shared decision-making is really important,” because salvage radiation is going to an area that has already gone through the upheaval of surgery.  This means that the risk of side effects, including problems with urinary control, ED, and bowel function, is inherently higher.

To Recap:  

If this feels confusing….that’s understandable.  These decisions are complex, and because each patient’s situation is unique, there’s no one-size-fits-all answer.  In general, consider the following thresholds, and consult your doctor:

  • Do not skip your PSA monitoring appointments.
  • PSA rises to 0.1: Recheck in 3 months. Patients who had high-risk disease features at surgery may need to act sooner
  • PSA rises to 0.2: See a radiation oncologist and consider a genomic test of prostate tissue to better understand your risk of aggressive, recurrent prostate cancer
  • PSA rises to 0.4: Consider a PSMA PET scan to look for small amounts of cancer in the pelvic region or elsewhere in the body.  Consider starting salvage radiation therapy with or without ADT

Next: Part 3:  What if PSA never becomes undetectable after prostatectomy?

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. 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

 

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