Repeating The Psa Test
A mans blood PSA level can vary over time , so some doctors recommend repeating the test after a month or so if the initial PSA result is abnormal. This is most likely to be a reasonable option if the PSA level is on the lower end of the borderline range . For higher PSA levels, doctors are more likely to recommend getting other tests, or going straight to a prostate biopsy.
Screening Indications And Controversies
Digital rectal examination and prostate-specific antigen measurement are the two components necessary for a modern screening program.
The indications for screening are controversial. Advocates of screening believe that early detection is crucial to finding organ-confined disease and to reducing the likelihood of mortality. When symptoms develop or when DRE results become positive, most cases have already advanced beyond organ-confined disease. Those who do not advocate screening note that screening can detect cancers that are not biologically significant , and subject patients to the risks of unnecessary intervention.
The American Cancer Society recommends that asymptomatic men with at least a 10-year life expectancy should be given an opportunity to make an informed decision with their health care provider after receiving information on the uncertainties, risks, and benefits of screening PSA evaluation. The recommended age at which men should receive this information varies by prostate cancer risk, as follows :
- Age 50 for those at average risk of developing prostate cancer
- Age 45 for those at high risk, including African Americans and men with a first-degree relative diagnosed with prostate cancer before age 65
- Age 40 for those at higher risk
Men who decide to be screened should be tested with a PSA test. A DRE may also be done as a part of screening. If screening does not detect cancer, the time between subsequent screenings depends on the PSA results, as follows :
New Prostate Cancer Blood Test
If you have an abnormal PSA score, your doctor may recommend another newertest that gives a better sense of yourprostate cancer risk. The prostate health index is one such test that is a more accurateblood test and measures your risk for having prostate cancer. Its approvedby the FDA for men who have PSA scores between 4 and 10.
What are the benefits of the PHI test?
- Fewer unnecessary biopsies: Some men who have elevated PSA scores are unsure about getting an invasive biopsy. This tool can be used to better determine whether your risk is high enough to warrant a biopsy.
- More accurate: This test is better at detecting prostate cancer. It can also detect whether you have a more aggressive type of cancer. This information can guide doctors to a more targeted treatment plan for you.
If you score low on the PHI test, your doctor may recommend monitoring youover time to see if your levels rise enough to cause concern.
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Tests To Diagnose And Stage Prostate Cancer
Most prostate cancers are first found as a result of screening. Early prostate cancers usually dont cause symptoms, but more advanced cancers are sometimes first found because of symptoms they cause.
If prostate cancer is suspected based on results of screening tests or symptoms, tests will be needed to be sure. If youre seeing your primary care doctor, you might be referred to a urologist, a doctor who treats cancers of the genital and urinary tract, including the prostate.
The actual diagnosis of prostate cancer can only be made with a prostate biopsy .
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Metastatic Signs And Symptoms
Metastatic symptoms include weight loss and loss of appetite bone pain, with or without pathologic fracture and lower extremity pain and edema due to obstruction of venous and lymphatic tributaries by nodal metastasis. Uremic symptoms can occur from ureteral obstruction caused by local prostate growth or retroperitoneal adenopathy secondary to nodal metastasis.
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When Psa Is 4
Nick Mulcahy
The Prostate Health Index significantly changes urologists’ opinions about whether men with certain results on prostate-specific antigen screening should or should not undergo a prostate biopsy to assess for cancer, according to new observational research.
Use of the test affected the physician’s management plan in 73% of the cases in the study, report the authors, led by Jay White, MD, a urologist at Carolina Urology Partners in Huntersville, North Carolina.
The changes included biopsy deferrals when the phi test score was low and biopsy referrals when the score indicated an intermediate or high probability of prostate cancer.
In the study, the most common change in management was to avoid a biopsy.
The study was November 20 in Prostate Cancer and Prostatic Diseases.
For their study, Dr White and colleagues compared 506 men who were prospectively enrolled and who received the phi test, and 683 historical control patients, who did not receive the phi test. Notably, the prospectively enrolled participants and the control patients were from the same four large urology groups and were managed by the same physicians.
The men who received the phi test underwent significantly fewer biopsy procedures compared to the historical control group .
“Physicians were less inclined to do a biopsy on patients receiving a low phi score,” said Dr White in a press statement.
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Use In Men Who Might Have Prostate Cancer
The PSA blood test is used mainly to screen for prostate cancer in men without symptoms. Its also one of the first tests done in men who have symptoms that might be caused by prostate cancer.
PSA in the blood is measured in units called nanograms per milliliter . The chance of having prostate cancer goes up as the PSA level goes up, but there is no set cutoff point that can tell for sure if a man does or doesnt have prostate cancer. Many doctors use a PSA cutoff point of 4 ng/mL or higher when deciding if a man might need further testing, while others might recommend it starting at a lower level, such as 2.5 or 3.
- Most men without prostate cancer have PSA levels under 4 ng/mL of blood. Still, a level below 4 is not a guarantee that a man doesnt have cancer.
- Men with a PSA level between 4 and 10 have about a 1 in 4 chance of having prostate cancer.
- If the PSA is more than 10, the chance of having prostate cancer is over 50%.
If your PSA level is high, you might need further tests to look for prostate cancer.
To learn more about how the PSA test is used to look for cancer, including factors that can affect PSA levels, special types of PSA tests, and what the next steps might be if you have an abnormal PSA level, see Screening Tests for Prostate Cancer.
The Prostate Health Index And The Need For Biopsy
It will come as no great surprise to regular readers that your Sitemaster has been less than enthusiastic to date about the potential of the Prostate Health Index or phi test as a tool for assessment of risk for prostate cancer. However, new data is starting to give him slightly greater hope regarding the value of this test.
In a paper by de la Calle et al. just published in the Journal of Urology, the authors used prospective data from two independent patient cohorts in an attempt to assess the ability of the phi test to differentiate between risk for aggressive prostate cancer and risk for indolent or no cancer in a biopsy-naive population. We shall be blunt in saying that the involvement of two highly respected researchers in the development and implementation of this study gives it a stature that has not been quite so evident in some of the earlier research.
The authors used a primary cohort of 561 biopsy-naive patients from one clinical trial site and another 395 biopsy-naive patients from a secondary trial site to build and validate their hypothesis. Specifically, they then set out to compare the diagnostic specificity of the phi test to the specificity of total and %free PSA data by using prostate biopsy results, where aggressive prostate cancers were classified as those with a Gleason score of 7 or higher as opposed to indolent prostate cancers or no prostate cancer on biopsy.
Here are the core study findings from Cohort A:
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Getting The Results Of The Biopsy
Your biopsy samples will be sent to a lab, where they will be looked at with a microscope to see if they contain cancer cells. Getting the results usually takes at least 1 to 3 days, but it can sometimes take longer. The results might be reported as:
- Positive for cancer: Cancer cells were seen in the biopsy samples.
- Negative for cancer: No cancer cells were seen in the biopsy samples.
- Suspicious: Something abnormal was seen, but it might not be cancer.
If the biopsy is negative
If the prostate biopsy results are negative , and the chance that you have prostate cancer isnt very high based on your PSA level and other tests, you might not need any more tests, other than repeat PSA tests sometime later.
But even if many samples are taken, biopsies can still sometimes miss a cancer if none of the biopsy needles pass through it. This is known as a false-negative result. If your doctor still strongly suspects you have prostate cancer , your doctor might suggest:
- Getting other lab tests to help get a better idea of whether or not you might have prostate cancer. Examples of such tests include the Prostate Health Index , 4Kscore test, PCA3 tests , and ConfirmMDx. These tests are discussed in Whats New in Prostate Cancer Research?
- Getting a repeat prostate biopsy. This might include getting additional samples of parts of the prostate not biopsied the first time, or using imaging tests such as MRI to look more closely for abnormal areas to target.
Prostate cancer grade
Gleason score
What Other Test Are Available For Men At Risk For Prostate Cancer
While traditionally, the options available to men at risk for prostate cancer were limited to PSA blood test and a prostate exam , a number of exciting innovative options are now available.
PSA is still a useful test but is being supplanted by more informative tests such as 4KScore and PHI , both of which incorporate the traditional PSA test as well. Thus, the report will list both the traditional PSA test and the 4KScore or PHI score respectively.
PHI is a new test that provides an incremental improvement over the PSA test alone when it comes to predicting the risk of prostate cancer. It can be used to reduce the need for unnecessary biopsies in some men.
If you have any questions, to schedule a consultation or if you need a second opinion, pleasecontact us or call:
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Lymph Node Biopsy As A Separate Procedure
A lymph node biopsy is rarely done as a separate procedure. Its sometimes used when a radical prostatectomy isnt planned , but when its still important to know if the lymph nodes contain cancer.
Most often, this is done as a needle biopsy. To do this, the doctor uses an image to guide a long, hollow needle through the skin in the lower abdomen and into an enlarged node. The skin is numbed with local anesthesia before the needle is inserted to take a small tissue sample. The sample is then sent to the lab and looked at for cancer cells.
Factors That Might Affect Psa Levels
One reason its hard to use a set cutoff point with the PSA test when looking for prostate cancer is that a number of factors other than cancer can also affect PSA levels.
Factors that might raise PSA levels include:
- An enlarged prostate: Conditions such as benign prostatic hyperplasia, a non-cancerous enlargement of the prostate that affects many men as they grow older, can raise PSA levels.
- Older age: PSA levels normally go up slowly as you get older, even if you have no prostate abnormality.
- Prostatitis: This is an infection or inflammation of the prostate gland, which can raise PSA levels.
- Ejaculation: Thiscan make the PSA go up for a short time. This is why some doctors suggest that men abstain from ejaculation for a day or two before testing.
- Riding a bicycle: Some studies have suggested that cycling may raise PSA levels for a short time , although not all studies have found this.
- Certain urologic procedures: Some procedures done in a doctors office that affect the prostate, such as a prostate biopsy or cystoscopy, can raise PSA levels for a short time. Some studies have suggested that a digital rectal exam might raise PSA levels slightly, although other studies have not found this. Still, if both a PSA test and a DRE are being done during a doctor visit, some doctors advise having the blood drawn for the PSA before having the DRE, just in case.
- Certain medicines: Taking male hormones like testosterone may cause a rise in PSA.
Some things might lower PSA levels :
Recommended Reading: Testosterone Therapy And Prostate Cancer
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The Role Of The Phi Test Prior To Decisions About Prostate Biopsies
Yesterday morning, a newly published paper was brought to my attention. It reports that use of the Prostate Health Index or phi test in a partially prospective study can and did change urologists opinions about whether selected patients really do or dont need to have a prostate biopsy.
The phi test was designed to help urologists and their patients make better decisions about who really did and who really did not need a biopsy if the patient had an elevated PSA level of 4 to 10 ng/ml but no other significant indicator of risk for prostate cancer.
While this study by White et al. is not a perfect study , it may still be a very important one.
What the study did was to enroll 506 men who appeared to have some degree of risk for prostate cancer and give them a phi test. These men were individually selected by urologists practicing at one of four large, US-based, urology practice groups, if they met the following citeria:
- They had to
- Be 50 years of age
- Have a non-suspicious rectal exam
- Have a total serum PSA level of 4 to 10 ng/ml within 6 months of the DRE
And here is what the study found:
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Better Detection Can Reduce Unnecessary Biopsies
Physicians typically advise men with increased PSA levels in the range of 4-10 ng/ml to have a prostate biopsy. However, the PSA could be elevated for benign reasons. Approximately 75% of prostate biopsies are negative for cancer and thus may not be necessary.
If a patient has an elevated PSA test, the phi test can be used to more specifically screen for prostate cancer and better guide the decision to obtain a biopsy. The FDA has approved phi for men ages 50 years and older with PSA in the 4-10 ng/ml range and negative digital rectal examination findings.
Dr. Catalona conducted several feasibility studies on the development of the phi blood test over 12 years. He also led the pivotal study that gained its approval by the US Food and Drug Administration .
Psa Test: The Current Prostate Screening Standard
Before recommending when you should be screened for prostate cancer, yourdoctor will consider many factors, such as:
- Age
- Family history, particularly whether any of your family members have had prostate cancer
- Race, as African-American men have a higher risk of developing prostate cancer
If your doctor determines you should undergo screening, he or she will mostlikely recommend the PSA test. For more than 30 years, the PSA test hasbeen the gold standard in prostate cancer screening. This simple blood testmeasures how much prostate-specific antigen is in your blood.
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What Does Phi Score Mean
Table 1 represents clinical study data analyzed to estimate an individual patient’s probability of having detectable prostate cancer based on Beckman Coulter phi results when that patient has a PSA in the diagnostic gray zone between 4 and 10 ng/mL.3 At phi cutoffs between 27 to 55, the probability of cancer ranged from 16.8 to 50.1%. For example, a patient with a phi result below 27 has a 90% chance that his prostate biopsy will be negative.
Table 1. Probability of Prostate Cancer Based on phi Results Between 4 and 10 ng/mL1
| phi Range* |