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, 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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