PSA Remains the Best Test

Scientists are looking hard for a better "biomarker" of prostate cancer than the prostate-specific antigen ( PSA ) test. Having been through this one personally and with my special training in public health I feel obliged to add my opinion.

Much of the antagonism toward this test has been raised by governmental "bean counters" focusing only on costs. I do not want these people to have any control over the health care of mature men. Decision making should come only from doctors specially trained in public health and preventive medicine.

The PSA test by itself is not expensive - a simple blood test. It is what comes after a positive test value that makes the costs escalate.

I was 65 years of age when my PSA results first crossed the magic 4 reading. Knowing how frequent and silent chronic prostatitis can be and suspecting one of those ubiquitous organisms had set up house in my prostate, I took a course of appropriate antibiotics, resulting in a very satisfying drop in my PSA to less than 4.

Likely, I did have an infectious component but that was not all I had. Six months later it was back up to 5, then 7, climbing to 8 within a year or so - time for biopsy. Of the six biopsy specimens, only one was positive with a mid-range aggressiveness score. I thought then, "What if my biopsy had been negative?" I wondered how many are missed?

My surgeon asked me what my thoughts were on treatment. I responded that I wanted to be "seeded". Brachytherapy ( radiotherapy by the implantation of radioactive seeds ) appealed to me.

"How much longer do you expect to live, he questioned? Close to 15 more years," I replied, wondering what that had to do with anything. "Then at 74 or 75 you are going to have to tolerate the inevitable effects of radiation proctitis and cystitis?" he countered. "It is physically impossible to place those seeds so that you cover 100% of the prostate without irradiating adjacent bowel and bladder."

The space between your prostate and bowel or bladder is no thicker than a sheet of paper and it takes some 8 to 10 years after radiation before the symptoms of radiation burning starts. He reminded me of my medical school anatomy.

I wound up with robotic laparoscopy where they delivered my prostate through my navel and sent me home within 18 hours with five band-aids on my abdomen.

Catheter out in one week. Piece of cake. My last ten annual PSAs undetectable. I consider this the ultimate in preventive medicine. Needless to say I am critical of this growing criticism about prostate cancer screening by periodic PSA testing. I believe I would be dead now if they were in charge.

Yes, there are ways this test can be improved. First of all it has to start earlier because prostate cancer therapies are most effective and sparing of function when the cancer is at an early stage.

Additionally we have to do more with the various types of PSA in the blood. Noncancerous prostates usually release "free" PSA that circulates through the body, while PSA produced by cancer cells tends to attach itself to various proteins in the blood. By considering the ratio of the types of PSA we likely can derive more specificity to this test.     

Your first PSA test is but a marker and most urologists now consider it as such. The magic number 4 for everyone no longer applies. Your second test is far more important than the first. Much depends upon your age and how fast your numbers increase. Some researchers say an increase in your PSA of more than 0.25 in one year for a 40-year-old man should prompt concern.

I hope my thoughts will allow you to make a rational judgment when you read of these negative views about PSA testing. Prostate cancer is one of our most common killers and prevention will not be gained by ignoring the problem.

Duane Graveline MD MPH
Former USAF Flight Surgeon
Former NASA Astronaut
Retired Family Doctor
March 2010

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