Prostate Cancer, PSA, and Biopsies - A Critical Look
By Nurse Mark
Cancer is a terrifying word. It generates mental images of pain and suffering and disfigurement and disability. It seems almost everyone knows of someone who has died a hideous death from cancer. We instinctively recoil from cancer as we might from a venomous reptile or insect. We react with revulsion. The "ick factor."
For this reason the word "cancer" can be used by doctors to justify almost anything - no matter how risky, unproven, or nonsensical, if something is presented as being necessary to "fight this thing" or "catch it early" most people will meekly agree in order to purge themselves of the "ick factor" that the thought of cancer brings.
Prostate cancer is especially troublesome for men, because it hits us "where it hurts" - like a "kick in the…" - well, you know what I mean... It conjures up visions of emasculation, incontinence, and unpleasant medical and surgical procedures performed on our most sensitive parts.
But is prostate cancer really all that it is made up to be? Is it really a dread disease that strikes down virile men in their prime, killing all it touches? Or is that the "marketing angle" used to sell expensive tests, surgeries, drugs, and treatments?
Let's look at the whole issue a little more deeply.
What the heck is this prostate thing anyway?
In men the prostate is a walnut-sized lump of tissue that surrounds the urethra - the tube that carries urine out of the bladder - just below the urinary bladder. It normally weighs around 11 grams (just over 1/3 of an ounce) but can range from 7 to 11 grams and be considered normal. Its main purpose is to produce a fluid that aids in reproduction, transporting and protecting the sperm during the reproductive act.
Women have a similar organ, and female paraurethral glands called Skene's glands were officially renamed the female prostate by the Federative International Committee on Anatomical Terminology in 2002. But that is a whole different story, since the female prostate doesn't seem to encounter the same troubles as the male prostate does...
So what's the big deal about it?
For men, there are a couple of potential problems with the prostate.
First, and most commonly, like ears and noses the prostate just doesn't seem to know when to stop growing. In older men this leads to a condition known as Benign Prostatic Hypertrophy (or BPH) and can cause problems with urination since while it grows in size outwardly it also tends to tighten down on the urethra as it gets larger - with predictable results. Difficulty starting urination and difficulty emptying the bladder fully lead to a condition known as Urinary Frequency. This usually results in multiple trips to the bathroom through the day and more significantly through the night.
It is believed that this unnecessary growth of the prostate begins at around age 30 and that by age 50 at least 50% of men will have evidence of BPH. This number increases to include 75% of men who reach the age of 80, and some 40% to 50% of those men will experience symptoms from this otherwise benign growth.
The second and more serious problem occurs when some of those ever-increasing numbers of prostate cells become cancerous.
Most prostate cancers are what considered "indolent" (that's right - indolent means lazy, lethargic or idle) and more men than you might imagine actually have cancerous cells in their prostate but never, ever know it. One autopsy study of men who died of other causes found prostate cancer in 30% of men in their 50s, and in 80% of men in their 70s. It seems that any man who lives long enough will have prostate cancer eventually.
A few of those cancers however are of a more aggressive nature and can grow quickly, escaping the confines of the prostate gland and affecting other areas of the body in a process known as metastasis. These prostate cancers tend not to be without symptoms however, and are usually easy for an observant doctor to detect - a simple Digital Rectal Exam (the "dreaded DRE") where the doctor inserts a finger into the rectum and simply feels the surface of the prostate gland will quickly reveal any lumps or bumps or hardness that could indicate a cancer.
Well, how can a fellow know?
Good question - since most men go through life with nary an untoward symptom from their prostate.
Even though they may actually have an "enlarged" prostate, or even a cancerous prostate, chances are very good that most men will never know it and will go on to die from some other cause - things like a heart attack or stroke, an infection like pneumonia, an accident, old age, or even (as the joke goes) "shot by a jealous husband" are a far more likely end for most men.
When they do occur, symptoms of BPH that might send a man to his doctor include urinary hesitancy, frequent urination, urinary tract infections, urinary retention, or insomnia caused by frequent awakening to urinate through the night.
Cancer in the prostate, as mentioned, is often quite asymptomatic (without symptoms or complaints) for most men since it is usually "indolent" - slow growing and not aggressive. When the cancer is an aggressive kind the symptoms will often be fairly obvious: as in BPH they include frequent urination, nocturia (increased urination at night), and difficulty starting and maintaining a steady stream of urine.
Because the cancerous cells are abnormal additional symptoms can include hematuria (blood in the urine), and dysuria (painful urination). Problems with sexual function and performance like difficulty achieving an erection or painful ejaculation can occur. And, should the cancer escape the prostate other areas of the body can be affected - the bone is a common site for these metastasis, with bone pain and weakness being common symptoms.
But my doctor - can he know?
Sure - if you help. Your doctor will do a number of things - but the most important thing will be to sit and talk with you. He (or she) will start out by just talking - asking about your family history, any symptoms you may be experiencing, your recent and past medical history, and so on. He will do a physical examination with DRE, and may order some lab tests - more on that in a moment.
For most men that's as far as it needs to go - if you are not having any symptoms and the doctor doesn't find anything on physical exam that rings his alarm bells then you can relax until next year's annual physical exam when he should be doing the same thing all over again for you.
Well, what about the PSA test - isn't that the best way to know?
Maybe, and no. There is a lot of controversy surrounding the PSA test and it's promoted use as a "screening tool" for prostate cancer. While the drug companies, laboratories, and urologists continue to support PSA testing as a universal screening tool for all men, most of the rest of conventional medicine is quietly turning away from the test except in specific circumstances.
Even the discoverer of PSA, researcher Richard J Ablin - whose father died of prostate cancer – concluded in a 2010 OpEd article in The New York Times:
"I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. The medical community must confront reality and stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments."
He says in his letter:
"American men have a 16 percent lifetime chance of receiving a diagnosis of prostate cancer, but only a 3 percent chance of dying from it. That's because the majority of prostate cancers grow slowly. In other words, men lucky enough to reach old age are much more likely to die with prostate cancer than to die of it."
And he continued:
"Even then, the [PSA] test is hardly more effective than a coin toss. As I've been trying to make clear for many years now, P.S.A. testing can't detect prostate cancer and, more important, it can't distinguish between the two types of prostate cancer — the one that will kill you and the one that won't."
More and more conventional medical governing bodies are moving away from PSA testing:
The American College of Preventive Medicine conducted a study that found:
"...no convincing evidence that early screening, detection, and treatment improves mortality. Limitations of prostate cancer screening include potential adverse health effects associated with false-positive and negative results, and treatment side effects."
They issued a statement to say that
"there is insufficient evidence to recommend routine population screening with DRE or PSA."
The American College of Physicians has taken a similar cautionary stance:
"...PSA is not just a blood test. It can open the door to more testing and treatment that a man may not want or that may harm him. Because chances of being harmed are greater than chances of benefiting, each man should have the opportunity to decide for himself whether to be screened."
The American Society of Clinical Oncology and the American College of Physicians together concluded that based on recent research:
"…it is uncertain whether the benefits associated with PSA testing for prostate cancer screening are worth the harms associated with screening and subsequent unnecessary treatment."
The U.S. Preventive Services Task Force says in their recommendation against the use of PSA testing:
"...many men are harmed as a result of prostate cancer screening and few, if any, benefit."
Even The American Urological Association - whose members obviously stand to profit handsomely from all things associated with the prostate - has issued a guideline that makes the following statements:
- PSA screening in men under age 40 years is not recommended.
- Routine screening in men between ages 40 to 54 years at average risk is not recommended.
- For men ages 55 to 69 years, the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, shared decision-making is recommended for men age 55 to 69 years that are considering PSA screening, and proceeding based on patients' values and preferences.
- To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce over diagnosis and false positives.
- Routine PSA screening is not recommended in men over age 70 or any man with less than a 10-15 year life expectancy.
Now, to be fair, there a number of medical experts (besides the drug and laboratory industry) that are still actively, even enthusiastically promoting universal PSA screening for men - the British Journal of Urology published a "consensus statement" created by a group of self-described "leading prostate cancer experts from around the world" who met at the 2013 Prostate Cancer World Congress in Melbourne, Australia and presented their recommendations for PSA testing.
Here are some highlights of their statement called The Melbourne Consensus Statement on Prostate Cancer Testing:
First, the authors emphasize that:
"For men aged 50–69, level 1 evidence demonstrates that PSA testing reduces prostate cancer-specific mortality and the incidence of metastatic prostate cancer."
BUT they go on to say...
"…the degree of over-diagnosis and over-treatment reduces considerably with longer follow-up.
While routine population-based screening is not recommended, healthy, well-informed men in this age group should be fully counseled about the positive and negative aspects of PSA testing to reduce their risk of metastases and death. This should be part of a shared decision-making process."
"Although screening is essential to diagnose high-risk cases within the window of curability, it is clear that many men with low-risk prostate cancer do not need aggressive treatment.
While it is accepted that active surveillance does not address the issue of over-diagnosis, it does provide a vehicle to avoid excessive intervention."
"PSA testing should not be considered on its own, but rather as part of a multivariable approach to early prostate cancer detection. PSA is a weak predictor of current risk and additional variables such as digital rectal examination, prostate volume, family history, ethnicity, risk prediction models, and new tools such as the phi test, can help to better risk stratify men."
"...a man in his 70s who has had a stable PSA at or below the median for a number of years previously is at low risk of developing a threatening prostate cancer and regular PSA screening should be discouraged."
In other words: With regular PSA testing a very narrowly defined group of men in a narrow age range might have an aggressive, treatable cancer detected but routine screening of all men is not recommended. They recognize that PSA testing frequently leads to over-diagnosis and over-treatment and that for many men there is no need for aggressive treatment. And finally, they admit that PSA testing "is a weak predictor of current risk" and should be considered only one part of an overall approach to men's prostate health.
But I did get tested, and my PSA is going up. The doctor said stuff like "PSA Velocity" and scared the heck out of me!
PSA Velocity is a fancy way of saying how quickly (or not) a PSA level has increased over a given amount of time. It's a fiddly, complicated mathematical exercise that looks really impressive to laypeople, but is being discredited by many authorities
In an article in the National Cancer Institute Cancer Bulletin we can find the following statement:
"A rapid increase in prostate-specific antigen (PSA) levels is not grounds for automatically recommending a prostate biopsy, according to a study published online February 24, 2011, in the Journal of the National Cancer Institute."
The study looked at over 5500 men to determine if using the "PSA Velocity" calculations could help doctors detect more prostate cancers. Here is what they found:
"Adding PSA velocity to the model would have identified 115 additional cancers (although not necessarily fatal cancers) but also resulted in 433 "unnecessary biopsies" that would have shown no cancer."
In other words, they might have found a few more cancers, but they would have had to do a lot of unnecessary biopsies to do it.
The researchers at the Memorial Sloan-Kettering Cancer Center in New York conclude:
"We found no evidence to support the recommendation that men with high PSA velocity should be biopsied in the absence of other indications; this measure should not be included in practice guidelines."
Well, my urologist says that the biopsy is "No Big Deal" and I shouldn't worry about it...
Again, conventional medical authorities are turning against that old party line, and so they should – because evidence of the dangers of prostate biopsies just keeps piling up.
A recent Bloomberg.com news article went into great detail on the risks, starting out with this statement:
"Doctors are changing their approach to prostate biopsies as evidence mounts that the danger of complications from the procedure may outweigh its usefulness identifying some cancers.
An increasing incidence of potentially lethal, difficult- to-treat bloodstream infections tied to prostate biopsies has become so serious that urologists are reassessing when, how and even if they do the procedure."
The problem is in the geographical location of the prostate in the body. It lives just under the bladder, and is most easily accessible to a doctor by way of the rectum - which is why the Digital Rectal Exam or DRE is such a convenient tool for your doctor.
Biopsies of the prostate are performed by stabbing a special needle into the prostate gland in a half-dozen or more places to pull out bits of tissue for the pathologist to inspect for cancerous cells
The most common way to get at the prostate for these needle pokes is, like the finger exam, up the rectum.
Since the lower bowel and rectum are a region of our body that is rich in bacteria and almost impossible to "sterilize" or even thoroughly clean, you can imagine the risks!
Just one errant bacterium dragged from the rectum into the prostate or bloodstream as the needle penetrates can result in potentially life-threatening sepsis or even septicemia (aka "blood poisoning"). Since we have been using antibiotics with such wild abandon over the past few decades and have created "superbugs", many of those bacteria are now antibiotic resistant and virtually untreatable.
But my urologist says he'll use a different procedure that avoids the rectum - that will be safer, right?
Your urologist is talking about using a trans-perineal approach and may even boast that it will allow him to access more of the prostate gland and take even more biopsy samples.
It is also a much bigger money-maker for your urologist - here is what that Bloomberg article had to say about it:
"The perineum, the skin between the bottom of the scrotum and the anus, is a safer entry point because it can be cleaned with antiseptic, unlike the rectum, said Lindsay Grayson, Austin Hospital's head of infectious diseases.
The lower risk of infections means urologists can take more core samples of the prostate, especially of the part of the gland that's difficult to reach from the rectum, Frydenberg said.
On the downside, the procedure takes at least twice as long to perform, requires heavier patient sedation, six people in an operating theater, and equipment costing about $100,000, he said."
And still not without risk...
Though the transperineal approach may carry less risk of infection, it still exposes men to the same risk as the rectal approach - the risk of spreading an indolent cancer from inside the confines of the prostate where it was sleeping peacefully to the blood and other areas of the body as those cells are dragged out through the surrounding tissues.
In an article in Medical News Today titled Prostate Biopsy Spreads Prostate Cancer Cells, the Diagnostic Center For Disease in Sarasota Florida discussed the phenomenon called "tracking" that occurs:
"A more important issue that is often not discussed between physician and patient involves the possibility of "needle tracking", the very real possibility of spreading cancer cells beyond the prostate when a biopsy is performed. An extensive review of the literature confirms that once a needle penetrates the capsule of an organ, a phenomenon called "needle tracking" takes place. When the needle is withdrawn from the targeted organ, the chance of spreading cancer cells (when encountered) establishes itself, and every puncture of the prostate adds to this risk.
Despite the significance of this risk to the patient, physicians generally fail to acknowledge a process that allows cells to lie dormant or incubate for up to 10 years or more regardless of the treatment rendered. In a 2 billion dollar prostate biopsy industry, the phenomenon of "needle tracking" takes place approximately 20-30 percent of the time."
This same article also discusses some of the other risks of prostate biopsy:
"...all men suffer the potential risk for bleeding, scarring, infection or sepsis and needless intrusion that has reportedly resulted in impotency and/or incontinence in some patients."
But, my PSA is up and my doctor says he's worried...
There are more reasons than just prostate cancer that might account for a rising PSA - and most of those reasons are quite benign.
Once again let's see what the discoverer of PSA, Richard J Ablin, has to say:
"Even then, the test is hardly more effective than a coin toss. As I've been trying to make clear for many years now, P.S.A. testing can't detect prostate cancer and, more important, it can't distinguish between the two types of prostate cancer — the one that will kill you and the one that won't.
Instead, the test simply reveals how much of the prostate antigen a man has in his blood. Infections, over-the-counter drugs like ibuprofen, and benign swelling of the prostate can all elevate a man's P.S.A. levels, but none of these factors signals cancer."
PSA naturally rises as a man ages and the prostate continues growing, but that's not all:
- A urinary tract infection or prostatitis can elevate PSA.
- A healthy activity like a vigorous bicycle (or horseback) ride can elevate PSA.
- PSA can also be falsely and transiently elevated from something as innocent as having sex with your wife within a day or two of the test.
- Even the DRE that the doctor performed can cause an elevation of the PSA.
Yes that's right; an unscrupulous doctor could conceivably perform a "vigorous" or "thorough" DRE "prostate exam" knowing that an elevated PSA would be the result and then use that PSA result to sell his patient a completely unnecessary biopsy procedure!
So, it looks like the PSA is a Bust and shouldn't ever be used?
Not at all! There are some specific situations where the PSA is a useful tool for the wise doctor to have at his disposal. The following are some of those men who may be wise to follow their PSA:
- Men with a family history of aggressive prostate cancer, early onset prostate cancer, or death from prostate cancer.
- Men, especially younger men, (under age 50 or so) who have symptoms of prostate enlargement or disease or unusual findings on DRE.
- Men of African ethnicity, who tend to develop more aggressive prostate cancers, earlier in life.
- Men who have been treated for prostate cancer or who has had a prostatectomy performed.
And those biopsies - are there any alternatives?
There may be times when you and your doctor just really need to know – because of symptoms, an unusual finding on DRE, or a rapidly rising PSA over several tests... but biopsy may not be the only option.
Recently, an imaging technology called a "3.0 Tesla Magnetic Resonance Imaging Spectroscopy" scan (MRI -S) is being used to predict and confirm the presence of prostate cancer. This technology is claimed to be the most sensitive and specific diagnostic tool for prostate evaluation in the world, and is said to be able to replace less accurate scanning procedures like the PET scan, CAT scan and Prostascint scans. This is certainly something to discuss with your urologist.
Ultrasound, while not as accurate, may also be employed and is frequently used to guide needle biopsy procedures, either by itself or in combination with MRI imaging.
So, what's the bottom line?
- Most men as they age will have an increase in the size of their prostate. This is normal.
- Most men as they age will have increased PSA levels. This is normal.
- Most men, if they live long enough, will have cancer in their prostate.
- Most prostate cancers are very slow growing and cause no problems.
- Most men with prostate cancer will never know it and will die from something else.
- PSA testing by itself cannot detect cancer.
- PSA testing is unreliable in many cases and often leads to unnecessary biopsies and treatments.
- Prostate biopsy procedures are risky for many reasons.
- Treatments for prostate cancer can cause more harm than good in many cases.
It is clear that for every aggressive prostate cancer found, treated, and "life saved", there are many more lives made into a misery of impotence and incontinence through aggressive and unnecessary diagnostics and treatments.
We must do better.
References and Resources:
Epidemiology of BPH: http://emedicine.medscape.com/article/1950546-overview#aw2aab6b5
Latent carcinoma of prostate at autopsy in seven areas. Collaborative study organized by the International Agency for Research on Cancer, Lyons, France: http://onlinelibrary.wiley.com/doi/10.1002/ijc.2910200506/abstract
Richard J Ablin - The Great Prostate Mistake: Published: March 9, 2010 New York Times - http://www.nytimes.com/2010/03/10/opinion/10Ablin.html?_r=0
Screening for prostate cancer in U.S. men ACPM position statement on preventive practice.: http://www.ncbi.nlm.nih.gov/pubmed/18201648
Screening for Prostate Cancer: A Guidance Statement From the Clinical Guidelines Committee of the American College of Physicians: http://annals.org/article.aspx?articleid=1676184
The USPSTF recommends against PSA-based screening for prostate cancer.: http://www.uspreventiveservicestaskforce.org/prostatecancerscreening.htm
AUA RELEASES NEW CLINICAL GUIDELINE ON PROSTATE CANCER SCREENING - http://www.auanet.org/advnews/press_releases/article.cfm?articleNo=290
PSA Screening Does More Harm Than Good, Says New Analysis: http://www.medscape.com/viewarticle/811846
The Melbourne Consensus Statement on Prostate Cancer Testing: http://www.bjuinternational.com/bjui-blog/the-melbourne-consensus-statement-on-prostate-cancer-testing/
PSA Velocity Does Not Improve Prostate Cancer Detection: http://www.cancer.gov/clinicaltrials/results/summary/2011/psa-velocity2011
An empirical evaluation of guidelines on prostate-specific antigen velocity in prostate cancer detection.: http://www.ncbi.nlm.nih.gov/pubmed/21350221
Prostate Cancer Test Causing Sepsis Spurs Biopsy Concerns. Bloomberg, Apr 24, 2013: http://www.bloomberg.com/news/2013-04-24/prostate-cancer-test-causing-sepsis-spurs-biopsy-concerns.html
The Impact of Repeat Biopsies on Infectious Complications in Men with Prostate Cancer on Active Surveillance.: http://www.ncbi.nlm.nih.gov/pubmed/24018237
Diagnostic Center For Disease: Prostate Biopsy Spreads Prostate Cancer Cells - http://www.medicalnewstoday.com/releases/97872.php
Mortality Results from a Randomized Prostate-Cancer Screening Trial: http://www.nejm.org/doi/full/10.1056/NEJMoa0810696
Screening and Prostate-Cancer Mortality in a Randomized European Study: http://www.nejm.org/doi/full/10.1056/NEJMoa0810084
Harvard School of Public Health - Men with prostate cancer more likely to die from other causes: http://ki.se/ki/jsp/polopoly.jsp?d=130&a=146954&l=en&newsdep=130
Accurate Use of Prostate-specific Antigen in Determining Risk of Prostate Cancer: http://www.medscape.com/viewarticle/718972_1
ECC 2013 Press Release: Organised Screening for Prostate Cancer using the Prostate-Specific Antigen Test, Does more Harm than Good - Prostate cancer screening using the prostate-specific antigen (PSA) test is widely used in France despite a lack of evidence showing that it reduces cancer deaths.: http://www.esmo.org/Conferences/European-Cancer-Congress-2013/News/ECC-2013-Press-Release-Organised-Screening-for-Prostate-Cancer-using-the-Prostate-Specific-Antigen-Test-Does-more-Harm-than-Good