Geoff McLennan, Prostate Cancer Survivor and Advocate

PSA was not developed for diagnosing new prostate cancer cases

Richard J. Ablin, Ph.D. discovered prostate-specific antigen, an enzyme made by the prostate, in 1970. He originally developed the PSA test as a tracking tool for men who had already been treated for prostate cancer (PCa). Once the prostate is removed, PSA production should become nil, and thus the PSA test to confirm the treatment’s success.

Since then, Dr. Ablin has been skeptical of PSA test use as a cancer screening tool because he intended it to be used only to track increases in PSA production after treatment of the prostate. Nonetheless, after the test’s approval by the FDA in 1994, widespread use of it became common as an initial harbinger of PCa. The rate of false positives for the test is high, so men should be aware of other, more accurate means of predicting PCa with new blood and urine tests such as the 4K, PCA3, PHI and many more. I will discuss those tests in another post.

How and why is the PSA test still used for new cases?

As Dr. Ablin describes, an off-label, or unintended use, of the PSA test became more typical by doctors after the FDA approval. Over time, this led to what many medical practitioners and journalists deemed “overtreatment” by rushing patients into treatment of what was thought to be PCa by some urologists and other clinicians, such as oncologists.

That led the United States Preventive Services Task Force (USPSTF) to issue a caution about use of the test in 2017, which created controversy both within and outside of the medical community. It was recognized that the PSA test alone often led to unnecessary treatment that had serious quality-of-life effects on treated men who did not need treatment. Back then, we did not know for sure.

Follow-up studies of the USPSTF caution determined that many men were later diagnosed with a more advanced PCa than would have developed had they been tested sooner. As a result, the USPSTF reduced its caution shortly thereafter, just as a referee can pick up the flag. This controversy about the PSA remains, but newer blood and urine-based tests, such as the 4K, PCA3 and additional tests, serve as more accurate (“sensitive”) predictors of PCa. Nonetheless, the PSA test remains the usual first step for a man’s prostate testing and care. In your medical care, doctor-patient shared decision-making is the critical component for you to comprehend and express your understanding and need for this test.

When should I begin having PSA blood tests?

A family history may influence when you should begin PSA testing. Ancestry or known history of PCa in male relatives is a critical risk factor. A genetic test such as Myriad’s MyRisk® Hereditary Cancer Testing is a good hedge against knowing if your family genes or germline carries a risk for cancers.. PSA testing can begin as early as age 40 for men with a family history or studies of ancestry that indicate higher risk. Some doctors begin testing around age 55.

It’s a good idea to think about the timing and ask your doctor’s opinion on the PSA testing. I began in my late fifties, as there was no known history of PCa in my parents’ families, and I had no urinary complications or problems. My attentive primary care doctor just asked unexpectedly one day, and I said, “Sure, let’s do it.” But give some thought to your genetic test, not just for you, but for your family –  including brothers, uncles, aunts and sisters.

What not to do before a PSA test and other things that increase PSA scores

As with most bodies, certain activities leave traces. Recent sex, strenuous exercise and even some foods may increase your PSA score. Any kind of ejaculation will raise your PSA score. Even riding a bike may do so, as some types of bicycle seats put stress on the prostate (there are special bicycle seats to protect men). Even heredity may increase your PSA, or preexisting and diagnosed infections and illness of the prostate, including BPH (Benign Prostatic Hyperplasia) , chronic inflammation, age, and prostatitis will increase your score.  Be sure to tell your doctor if you have any of these factors or conditions before the PSA blood draw, as he or she may want to delay or not do the test.

What about the PSA test results?

Prepare for a discussion with your doctor, knowing that some behaviors may affect your PSA score. As provided above, many other factors beside your prostate can affect the PSA score. Try to be mindful before you take the PSA test to avoid food, activities or exercise that may impact your score.

How many PSA tests are there?

Active surveillance (AS) protocol, depending on your doctor and institution, requires PSA tests at least biannually. Sometimes the Rx is more frequent based on your prostate and overall health, age and treatments. Two types of PSA tests are the “standard” and the “ultrasensitive.” The standard PSA test is used prior to treatment of the prostate, whereas the ultrasensitive PSA test is more precise and records smaller measures. Ask your doctor which test you need and why. Again, it is good to communicate and share your care management.

I’ve been on AS for over 10 years and have some nice graphs of my PSA tests by date, location and variances. It’s fun to chart you own test history, hopefully nothing like a rocket trajectory, and it’s a good idea to know your test numbers. You can know about fast cars, but can you drive one? Drive your own health.

PSA velocity biomarker

The Veloster is a fast Hyundai car driven by the adventurous and has an impressive 0-60 time. PSA velocity or kinetics is the rate at which your PSA score increases over time. Research indicates this measure is controversial, i.e., not very reliable. In my case, I’ve been fortunate to have a slow rising PSA that graphs kind of like a rolling hill versus a peak. Despite being controversial, PSA velocity can be more than a caution depending on how quickly your PSA increases, your age and other health indicators. Again, educate yourself about PSA velocity, make up your own mind and you will be better armed to deal with a possibly important biomarker term if and when it arises.

Summary: The PSA test is not the end-all-be-all

Rest assured that the PSA score is only one measure of many used to determine prostate health. Be prepared and read our future post about other liquid tests (blood or urine) that are more accurate in assessing your risk of PCa, because they are based on more current science and research. As always, we aim to provide knowledge in order to conquer the unknown.

Until our golf carts cross paths again, BE WELL.

Looking for more information on prostate cancer? Read What is a Gleason Score?

Geoff is dedicated to helping families and friends support a prostate cancer patient. He joined the board of Active Surveillance Patients International (ASPI) in 2018 and is an 11-year PCa patient. As a PCa patient advocate, he envisions providing a broad understanding of how patients can collaborate with clinicians for realistic medical care. He enjoys meeting and learning from his clinicians, cancer researchers, providing free online programs for patients, and reminds us that “to live, learn and thrive with PCa” is the motto of ASPI. He is glad he took science courses for understanding a healthy lifestyle that includes exercise and diet.

Geoff also volunteers as a board member and past chairman of the Placer County Mental Health Advisory Board where his interest includes therapy and resources for AS men, and a broad oversight of community mental health programs and innovations. He is married to Constance McLennan, a fine artist, has a grown son, and lives in Northern California.