Frequently Asked Questions
The following questions are those most often asked this month.
Q-1: What is cancer of the prostate (CaP)?
A: Normal prostate cells live and die according to their natural schedule. After a cell lives its allotted time, it reproduces itself exactly, then dies. Cell-death on schedule is called apoptosis (app-op-toe-siss).
For some reason not yet clear, a prostate cell does not die when it should. Instead, it divides into more cells as uncontrolled and death-defying as the original. Uncontrolled divisions from that single cell continue until the cells clump to form a malignant tumor.
If nothing stops the growth of malignant cells, they can break off the parent tumor, travel within the body and lodge elsewhere. This process is called metastasis (meh-taas--tuh--siss). A favorite site for CaP cells is the bones. They can also locate in other parts of the body where they grow until they kill the man or he dies from other causes.
CaP, like ALL cancers, starts with a single "death-defying"cell.
Q-2: What are the symptoms of CaP?
A: CaP is called the "silent assassin" for good reason. In its initial stages, there is no warning pain, no blood, no discharge. There is nothing!
It's only in CaP's advanced stage that symptoms finally occur. Then it's too late; the disease has advanced beyond cure. In this stage, there are plenty of symptoms felt 24 hours a day and so painful some men pray to die. The best that can be done is to slow down the cancer and relieve pain. Incredibly, we find some well-meaning individuals actually listing symptoms of CaP, encouraging men to wait for them rather than get regular prostate exams -- a wrong-headed, mis-guided notion if we ever saw one!
Q-3: How old should a man be to start PSA exams?
A: Most urologists' recommend that Caucasian/Asian men begin PSA testing by age 50. African-American men should start by age 45.
However, these general standards apply to men at large. Each individual should determine his own minimum-age in line with possibly increased risks. For example, men with CaP found in a father or brother should begin PSA exams at least 5 years earlier than shown in the PSA tables describing how CaP is found. Men with two grandfathers who developed CaP should also start 5 years earlier than shown. These are some of the variables to be discussed with your physician.
Q- 4: How do they know what's a safe PSA for my age -- they've never talked to me! And why don't PSA charts show my PSA which is 13.5?
A: Thousands of research hours have been used to calculate a "normal" amount of PSA in a man's blood according to his age and race, and therefore no reason to put him through cancer tests.
Thousands of cases over a number of years have shown that any level of PSA higher than "normal" is a "red flag" suggesting that cancer may be the cause of the high PSA. What happens when a "red flag" starts flying?
As a general rule, doctors do not order a biopsy when the PSA is below 4.0. This is true although roughly 20-25% of CaP occurs in men with PSA levels below 4, and the PSA exceeds the "normal" level for younger men.
Why? A basic reason for rejecting a biopsy for men with PSA below 4.0 is the need to minimize unnecessary biopsies. This is not as bad as it may sound, because 90% of all CaP occurs in older men whose "normal" PSAs are near 4.0 or higher.
The physician's expertise and each man's wishes are factors in deciding to order, or skip, a biopsy. An extremely important factor in reaching a biopsy/no biopsy decision is the presence, or absence, of CaP in the man's family. In specific cases involving men who are black or younger than age 50, exceptions may be made and a biopsy desirable. Doctors and men alike should bear in mind that the younger the man, the more he has to gain by detecting CaP before it becomes incurable.
You ask why tables of "normal" levels of PSA don't include levels above 10.0. Answer: PSAs above 10.0 have such a high rate of CaP it is almost standard practice to order a biopsy. No PSA above 10.0 is "normal" in terms of CaP probabilities.
Q-5: I am 63 and in good health except my prostate is fairly large. How often should I have a PSA exam?
A: Your question is a good one, and applies to all men at risk of CaP. Our guidelines:
1. Caucasian/Asian men: This assumes you began PSA exams at age 50, or about age 45 if CaP was found in your father, brother(s), 2 or more uncles, or both grandfathers.
As long as your PSA remains normal, or better than normal for your age (see tables in the discussion of CaP diagnoses), get examined every two years. This recommendation probably differs from once-a-year exams usually recommended previously. However, large-scale research has found that when PSA's are normal for the man's age and race, repeat exams every other year are sufficient. Why aggravate yourself with annual exams if every-other year is sufficient?
Caucasian/Asian men older than age 75: When your PSA level is normal or below for age 71, consider skipping exams unless you expect to live ten or more years. African-American men: Assumes you began PSA exams five years younger than recommended for Caucasian/Asian men. Follow the guidelines listed immediately above.
3. Men with a "spike" in their PSAs, regardless of race: Although the PSA may be normal, or below, for age and race, the cause of a "spike" needs detection. It may be from different causes, including ejaculation within 48 hours of the test. If there is no indication of a prostate infection, follow up the "spike" with a PSA in three months, and no later than six months from the date of the "spike."
The Society discourages PSAs more frequently than 90 days apart, unless special problems justify a briefer interval.IMPORTANT! These guidelines do NOT apply to PSA tests following surgery or radiation. Post-therapy PSAs are discussed in a future section on therapy "Outcomes."
Q-6: Why do some doctors refuse to give PSA tests? What good do PSA tests do?
A: One possible reason a doctor won't give a PSA test is the way he is paid. For a doctor paid by the number of men he treats ("capitation"), drawing blood and reporting the results can mean fewer men treated and loss of income. Worse yet, the test may turn up prostate cancer. That would really eat up time. Result: don't do PSA exams.
Another reason stated by the anti-PSA group is that PSA testing, followed by the diagnosis and treatment of prostate cancer, has never been proven to increase the length of men's lives. This is true; there is no proof. To explain fully why there is no proof of PSA's life-saving benefits would require at least 20 pages of research results pro and con on PSA testing. Our answer to the question comes down squarely in favor of PSA testing as the best way we have to find CaP while it is curable. Men who have been cured of CaP include Army generals, corporate presidents, sports stars, famous singers, a number of U.S. senators, and big-city mayors. The worst PSA-skeptic will not argue that these men, and thousands more like them, are very much alive these days.
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