Prostate Cancer
Prostate cancer, PSA’s, MRI’s and Ex-Presidents – what’s the story?
Hi all, as a 56-year-old male GP, naturally I see a lot of patients who are of a similar demographic to me, and a very common topic of conversation is the PSA test for prostate issues.
There has been a lot in the press recently about prostate cancer, especially with sad news that ex-President Joe Biden has been diagnosed with an aggressive form which has already spread to his bones. If this can happen to one of the most closely watched and observed people in the world, what about the rest of us?
As you may know, the prostate is a small gland that sits at the base of the bladder. Two main things can happen as we get older – benign enlargement, which causes urinary problems, and prostate cancer. Prostate cancer itself can take many forms, from very benign slow-growing variants (that might be found if you did postmortems on elderly men dying of other causes) to the types that can spread rapidly, for example to bone or brain, and might already be incurable by the time they are detected.
One of the big problems we’ve always had is that the PSA blood test is far from perfect. Here are some problems with it:
- Many cases of a mildly raised PSA will not be prostate cancer. So, as a screening test, it’s not very specific. Other causes of a raised PSA include benign prostatic enlargement, infections such as UTI’s, and even mechanical trauma such as cycling. But, getting to the end of this puzzle can be very traumatic, especially in the days before MRI was so readily available, often requiring invasive biopsies and procedures (which have their own potential complications) and long periods of stressful waiting.
- Not all prostate cancers cause a rise in the PSA. So, a “normal” PSA is not 100% reliable in ruling out the disease.
- It’s not just about the absolute value of the PSA, it’s about change. A subtly rising PSA can be a danger sign, even if it’s still in the “normal range” for age. Unless you’ve been checking your PSA regularly over a period of time, and you’re seeing the same GP who has access to your previous results, that’s going to be very, very easy to miss.
Hence the medical profession has always been very wary about whole-heartedly backing the PSA for many men unless you fall within certain criteria, which are currently:
- Age 50-69: Consider PSA testing every two years if you are interested in early detection of prostate cancer.
- Family History: If you have a strong family history (father or brother diagnosed with prostate cancer, especially at a young age), discuss earlier and more frequent testing with your doctor, potentially starting at age 40.
- Informed Decision: Discuss the potential benefits and risks of PSA testing with your doctor to make an informed decision about whether or not to get tested.
- Symptoms: If you experience any symptoms that could indicate a problem, such as urinary issues, blood in semen or urine, or pain on urination, discuss PSA testing with your doctor.
Factors Affecting Testing Frequency:
- PSA Levels:
If your PSA level is low, you may only need to be retested every two years. If your PSA level is higher, more frequent testing (e.g., yearly) may be recommended.
- Individual Risk Factors:
Your doctor will consider your individual risk factors, such as family history, age, and other risk factors, when determining the appropriate testing frequency.
- Clinical Assessment:
In some cases, particularly for men over 70, testing may be recommended based on clinical assessment rather than strict age-based guidelines (the “cure” may be worse than the condition depending on other health issues, general state of health, etc.)
So, that leaves a lot of grey area for interpretation, a lot of confusion, and therefore many men falling through the net and missing the opportunity for early detection and treatment. That can particularly be the case these days where medical care has become more fragmented, and often there is not that strong doctor / patient relationship that has been built up over years.
In more recent years, the situation has changed, and continues to evolve, as we now have access to more sophisticated methods of dealing with a raised PSA. This includes Prostate MRI – but’s vital to realise that even that test is not 100% reliable and tends to give a result which is based on scoring, for example using the Gleason score, that an absolute yes or no answer. For this reason, the vast majority of GP’s would not order an MRI themselves but would refer to a urologist for advice and expert interpretation – plus of course onward management. Furthermore, if the MRI is ordered by a urologist, Medicare rebates apply and it is quite inexpensive, whereas if ordered a GP full private fees apply.
There have now been suggestions that PSA testing guidelines should be overhauled, with the test being offered to all men at the age of 40, but this has not been finalised as yet. Watch this space.
At Remede we are fortunate to be able to offer longer appointments with both male and female GP’s to discuss these types of serious matters in detail and answer your questions fully, before making informed decisions. We look forward to seeing you next time in our clinic.
Keep well,
Dr Richard Newton
Specialist GP