My Cancer: How It All Began, or, 'To PSA Or Not To PSA?'

When I first posted news about my prostate cancer (here, with the later update here), several people asked how I found out about it. It's odd that I didn't include that in my original post; but I'm going to rectify that now.

In December 2010, I went to a general practitioner for a small, totally unrelated medical matter. As part of the general check-up, he thought I should have some blood tests done, as well as a digital rectal exam (known everywhere to men as the "finger up the butt" exam). Due to my age - 47 at the time - I was more at risk for prostate cancer and/or, more likely, benign prostatic hyperplasia (BPH), an enlargement of the prostate that can lead to urinary difficulties. According to Wikipedia, "Adenomatous prostatic growth is believed to begin at approximately age 30 years. An estimated 50% of men have histologic evidence of BPH by age 50 years and 75% by age 80 years. In 40-50% of these patients, BPH becomes clinically significant."

The digital rectal exam revealed nothing unusual; but the blood tests revealed elevated PSA levels. PSA stands for prostate-specific antigen, a protein produced by the normal function of the prostate. In the case of prostate cancer, PSA levels in the blood may rise above normal levels. However, non-cancerous events, like having sex or riding a bike, can also lead to temporarily elevated PSA levels.

My PSA value was 4.1, when the recommended level is less than 2.5. My general practitioner referred me to an urologist (the same one that will be doing my surgery on 8 December). He repeated the digital rectal exam with the same results (nothing), and then recommended I take anti-inflammatory drugs for a couple of weeks and repeat the PSA blood screen in February 2011.

MY PSA level was 2.7 in February. Definitely lower, but still not quite where we would like it. We decided to look at it again in a couple of months.

In April, the level was 3.3. The urologist recommended we do a biopsy. I was hesitant, as that involved an invasive procedure. So we decided to wait a few more months.

In July my PSA level was 2.7 again. The doctor said that was about twice what it should be and, while it was not going up, it also was not going down. He again suggested the biopsy and I agreed. That was conducted later that month and, as I reported earlier, 14 of the 16 samples taken contained cancer.

This history is interesting to me in light of recent developments in the healthcare arena. The United States Preventive Services Task Force recently recommended that doctors no longer use the PSA test to screen for prostate cancer. (You can read about it here and here.) Also, a book was recently released that takes the position that most men with prostate cancer should not seek surgery or radiation treatments.

I understand the perspectives presented by those sources, and I'm even a bit sympathetic to them. However, I still believe that surgery is definitely the best option for my situation. Prostate cancer tends to grow/spread slowly. So, for many men, something else will kill them before the cancer does. However, I'm not even 50 yet and I plan to spend quite a few more years alive. I figure the longer I wait, the more likely it is that the cancer metastasizes and I'm in serious trouble. I'm not willing to bet that the cancer will not spread in the next 20 years. Even 10 years would seem like a risky bet to me.

If that makes sense, then it follows that the PSA test was a good thing for me. Without it, I probably never would have known I had cancer until it spread and affected some other organ.

I'm just one case, though. It's entirely possible that the vast majority of men who are tested and found to have elevated PSA levels are better off not knowing and not seeking treatment. If so, that's a lot of unnecessary treatments and post-treatment difficulties. The statistics from one of the studies suggest that 47 out of 48 men fall into that category. So I can see why the panel would recommend not using the test. But for that one guy (and his family and friends), it's a very different story!

Unfortunately, life doesn't come with a control group; so we'll never know what would happen if I don't have the surgery. "You roll the dice and you take the chance."

I did ask my second urologist (the robotic surgery expert) about the no-PSA recommendation. He believes that U.S. doctors tend to over-treat prostate cancer, rushing to surgery or radiation when a wait-and-see approach may be more reasonable.

Ultimately, I come down on the same side I always do: knowledge. Or, as I like to say: "knowledge over sanity". I think it's good to know things, including how some of the things you "know" can be wrong or misleading. So I support the PSA test, but think that conclusions have to be reached in context, and that it's useful to not blindly accept what a doctor tells you (though it's hard not to, given the average person's ignorance about these issues; I include myself in that category!). It wasn't the PSA result that led me to choose surgery. It was the trend of multiple PSA results that led me to the biopsy, and it was the biopsy results - interpreted in the context of my age, overall health, etc. - that has led to the surgery.