“So your PSA number came back high. What now?”
Let’s say, like many men, you’ve been getting your PSA checked every year as part of your routine checkup. In the past it has always hovered around 2 or maybe as high as 3.0, and suddenly it’s up to 5! Or maybe this is your first PSA test. Everyone knows that 4.0 is the magic number, anything above that means something is not right with your prostate. Right? Actually, it’s a lot more complicated than that, but for this video we’ll take that as a given. OK, so the number is high, what do you do? Well, if you’re like many men your first instinct might be something like this…
“Aaaah, I’ve got prostate cancer! Cut the *****ing thing out”!
Unfortunately there are a bunch of people in the medical community that will support and even encourage that instinct. It’s the wrong instinct.
Take a deep breath.
Now just to be clear, this video is not advocating any sort of wonder-cure and we’re not downplaying how serious prostate cancer can be. Everything we’ll talk about here is backed up by good science, the latest technology, and highly trained medical professionals.
Let’s stop and talk for a second about the prostate. No offense to our creator, or to evolution or whatever you believe about human origins, but you couldn’t find a worse place to situate an organ, especially one that can be prone to problems. It’s…”down there”. And it’s in the middle of everything “down there”. Your urethra, that tube that carries urine out from the bladder, runs right through it… as do a couple of nerve bundles that control your ability to get and maintain an erection. And its located right in there close to the rectum. So, right in the middle of three really important systems.
OK. Back to your story. You’ve got the high PSA number. What’s likely to happen now?
Your general practitioner is probably going to want to refer you to a urologist. The urologist is almost certainly going to want to perform a needle biopsy and usually right away. It’s cancer! There’s urgency! Right? Ummm. Not really. But we’ll get to that in a future video. For now, just know that for the overwhelming majority of men prostate cancer is very slow growing. You have time.
Here’s your first step in taking control. That’s what this is all about. Taking control of your own healthcare.
Unless your PSA number is crazy high (above 20 for example) or your GP has felt that something is wrong during the Digital Rectal Exam or DRE (that’s the finger up your butt exam that we all adore), you need to tell him or her that you want another PSA test. You see, that test measures a substance in the blood that the prostate gives off when it’s aggravated, and it can be aggravated by quite a few things other than cancer. Sexual activity, inflammation, certain types of heavy lifting, even riding a bike. So you’ll want to wait a few weeks, take it easy for the last few days, refrain from sex for 48 hours (you can do it), and retake the test. If your number has gone back down to near its normal level, you’re done for now. Just make sure to keep getting those yearly PSA tests and DREs.
If it remains high, then its time to move to the next step. Biopsy, right?
Nope. Not if you can help it.
The random needle biopsy, as it’s called, involves sticking a rather large needle into the area just in front of the rectum 12 times to remove samples, called cores, from different areas of the prostate.
It sounds horrible but, to be honest, it’s not terribly painful and it’s usually over in 10 or 15 minutes. A visit to the dental hygienist is probably just as uncomfortable. But it is invasive. Three percent of the men undergoing needle biopsies get infections, some of which are very serious. More importantly though, is the fact that the random needle biopsy is not very accurate. It can miss serious cancer or it can pick up low level, non-aggressive cancers that really don’t require treatment. (We’ll talk about the types of prostate cancer in a future video.)
The doctors who use the random needle biopsies don’t do it because they are mean or ignorant…maybe just a little slow to change. Until the last couple of years the needle biopsy was the best diagnostic tool that we had. Recent advances in MRI imaging have changed everything. The latest generation of MRI machines called 3 Tesla, or 3T machines, scan at a much higher resolution than the earlier machines. They enable radiologists to see all but the tiniest tumors. The tumors that they can’t see almost certainly don’t matter.
What improvements in imaging mean is that biopsies, when they are needed, can be targeted, right to the suspicious area in the prostate. No more random poking.
So, to summarize. If your PSA number comes back high:
Schedule a second PSA test.
Start doing some research. A good place to start is PCRI.org.
If the number is still high after that test, find an MRI center that does “Multi-parametric” testing using a 3T scanner (a list of 3T MRI centers is available at PCRI.org). The MRI report will provide two types of important information:
The MRI measures the size of the prostate. The scan report will enable you to determine if your PSA elevation is proportionate to your prostate size. We’ll talk about this more in a future video. As regards cancer, there are three possible outcomes:
No high grade cancer. Further monitoring without biopsy is OK.
A high-grade lesion is detected. Targeted biopsy is needed.
An ambiguous area is detected. Another MRI in 6 months may be appropriate.
Scanning the prostate in men with PSA elevation is a brand new approach that is more reliable than the old-fashioned method of using 12 random needle sticks. However, this claim is only accurate when using the very latest state-of-the-art MRI technology at approved centers. This technology is so new that finding doctors willing to abandon the old random needle biopsy approach is still a major challenge. Even so, there is a big payoff, being able to bypass those needles, those infections, and the inaccuracy is worth it.
Other MRI Resources:
Everything You Need to Know about Prostate MRI | Dan Margolis, MD
PI-RADS V2: New Recommendations for Multi-Parametric MRI | Dan Margolis, MD