UNDIAGNOSED

Most men over age 40 are already host to some type of prostate cancer but don’t know it.

Autopsy studies of men dying from unrelated causes show that the likelihood of harboring prostate cancer is the same as putting a percentage sign after his age. Over a million men undergo a prostate biopsy every year. Approximately 200,000 are diagnosed with cancer. Of these 200,000, more than 100,000 are diagnosed with a “latent” type of prostate cancer, a form of the disease that is not life-threatening and will never require treatment.

Prostate cancer is confusing because of the variety of different forms (see “Prostate Cancer is Not One Illness”). The fact that some types of prostate cancer remain dormant for a lifetime is unique compared to other cancers. Unfortunately, society in general, including many primary care physicians, is uninformed about this latent type of prostate cancer. Patients are unaware that latent prostate cancer can be safely observed without immediate treatment. So when a biopsy discloses prostate cancer, an emotional chain reaction occurs. The word CANCER triggers powerful feelings and a rush to aggressive treatment. The strength of the emotional reaction has such a blinding effect that many people fail to realize that treatment was unnecessary until after the damage. In men with the latent form of prostate cancer, common treatments like surgery, radiation and hormonal therapy destroy quality-of-life without prolonging it.

While latent prostate cancer is incredibly common, aggressive prostate cancer is also a reality-- 30,000 men die from prostate cancer every year. Therefore, precautions like annual PSA testing and digital rectal examination are prudent. However, the information derived from PSA testing has to be used wisely. It’s dangerous to rush into a biopsy before all the ramifications of being diagnosed with latent prostate cancer has been thoroughly researched and comprehended. See the No Previous Biopsy section for information about the pros and cons of having a biopsy.

Normal PSA

PSA is termed normal or abnormal if it is above 4.0, or more recently, 2.5. Biopsy is recommended whenever PSA is above this threshold. Due to the flood of men being diagnosed with latent prostate cancer, we no longer have the luxury of such a mindless approach. Too many men are being swept up in unnecessary surgery or radiation.

A number of factors should be considered before doing an immediate biopsy:

1. Recent sexual activity, lab error or benign prostate enlargement (BPH) could be elevating the PSA.
2. Advanced age reduces the risk of dying of prostate cancer because the chance of dying from the disease in less than ten years is extremely small.
3. The psychological impact of hearing you have CANCER must be considered. For many of us, it doesn’t matter how many times we are told that our prostate cancer is Low-Risk, Chronic, non-life-threatening, latent or doesn’t require treatment. Once we hear we have cancer, our self image is forever transformed for the worse.

PSA Density

As men get older, almost all develop enlargement of the prostate gland. Invariably, PSA rises as a result. When checking PSA the question should not be, “Is it above 2.5 or 4.0?” The question should be, “Is the PSA excessive considering the size of my prostate?” Prostate size can be measured with ultrasound or MRI. A normal PSA is one point for each 10 cc of prostate volume. Abnormal is greater than 1.5 points per 10 cc.

PSA Velocity

As noted in the PSA Density section, the prostate expands as we age. But this expansion occurs slowly. If the PSA rises more than 0.35 points per year when the PSA is less than 4 or more than 0.75 points a year when the PSA is between 4 and 10 the possibility of underlying prostate cancer should be considered. This sequential monitoring approach over time is only accurate when PSA tests come from the same lab.

Free PSA

Think of the free PSA blood test as a shortcut to determining PSA density, but without an ultrasound. Free PSA is reported as a percentage. Values above 28% indicate that benign prostate enlargement (BPH) is present. When Free PSA is less than 10%, BPH is likely absent. Therefore, if PSA is higher than expected, cancer is more likely. With Free PSA, percentages between 10% and 28% don’t tell you anything. Free PSA is an indirect (and therefore less accurate) method for detecting BPH rather than measuring the prostate size with ultrasound. Also, prostate infections can drop the free PSA percentage.

Abnormal PSA

An abnormal PSA may need further evaluation, possibly a biopsy since it may be a sign of underlying aggressive prostate cancer.

However, PSA should only be considered “abnormal” when:

1. It is consistently elevated upon repeat testing after abstaining from sex for 48 hours.
2. A prostate infection has been ruled out by rechecking the PSA after a trial of antibiotics.
3. PSA is higher than what is expected in relation to the size of the prostate as determined by ultrasound scanning. The normal ratio is one point of PSA for each 10 cc of prostate volume.Greater than 1.5 points of PSA per 10 cc of prostate is abnormal.
4. PSA is rising faster than what would be expected due to the normal increase from aging. The normal rate of rise due to aging is less than 0.4 points per year. (Accurate comparisons require year to year PSA comparisons from the same lab).
5. Free-PSA is less than 10% and no underlying infection is suspected.

No Previous Biopsy

The following pros and cons need to be discussed and weighed before having a biopsy:

Biopsy Pros:

1. It is the most accurate way to diagnose and stage aggressive prostate cancer.
2. It is a fairly effective way to exclude the presence of aggressive prostate cancer.

Biopsy Cons:

1. Biopsy may diagnose latent prostate cancer, a condition that frequently frightens men into unnecessary treatment that can destroy sex life, normal urinary function and rectal function.
2. One-percent of biopsies cause serious bleeding requiring transfusion and serious infection requiring hospitalization.
3. Biopsy causes erectile dysfunction about one-third of the time. This is presently believed to be a temporary phenomena, resolving within a few months.

Consider counseling from a prostate cancer center experienced in Active Surveillance prior to doing a biopsy. Sometimes after further investigations with Color Doppler ultrasound, Endorectal MRI and urinary PCA-3, continued watching with sequential scans and PSA testing will be preferable to undergoing immediate biopsy.

Previous Negative Biopsy

Experts know that a well-performed random prostate biopsy misses underling prostate cancer 15% of the time. Missing low-grade disease is probably a good thing, while missing aggressive prostate cancer is not. Many of the same factors (Color Doppler Ultrasound, Endorectal MRI, PCA-3) that were discussed in the No Previous Biopsy section should be considered prior to embarking on further random biopsies.

In cases where underlying aggressive prostate cancer is strongly suspected, additional measures to be considered are:

1. Lesion-directed biopsy using Color Doppler Ultrasound
2. Endorectal MRI directed biopsy
3. Biopsy with ultrasound/ MRI fusion images
4. Saturation biopsy under anesthesia