PSA test for prostate cancer

' I trained as a general surgeon and for a while in addition to general surgery I was looking after urological patients so I know a little bit about urology. And if a man, say over the age of 50 presents with symptoms, which suggest an enlarged prostate, then part of the work-up of that patient would be PSA testing to exclude the possibility of cancer of the prostate.

Do you think that at that stage the man should be given information if the tests were to come back positive about possible treatment options in the future or not?

This man has symptoms and if his PSA is very high and he has an enlarged prostate then it is very likely he's got cancer of the prostate and we're more concerned at that stage about the current status of his health and the treatment there and then rather than consider what might happen in the future.

So you wouldn't necessarily discuss the future about the possible options if it turned out to be cancer, you wouldn't discuss that before he had his PSA test?

No at this point, it's part of the work-up in the differential diagnosis of benign prostatic hypertrophy and malignant prostatic hypertrophy, this man has urinary tract outlet obstruction, we need to diagnose it and then treat it appropriately.

Are there any other circumstances in which a PSA test might be appropriate do you think?

With the current state of knowledge no.

Do you mind explaining why?

Perhaps I should qualify that. I've emphasised a gentleman above the age of 50 who has prostatic symptoms, there I suppose might be a rare occasion when a man like that presents with skeletal pain and bone scan or x-ray shows skeletal metastases then I suppose you could do a PSA to look for the source of the primary. It is quite uncommon but you can get metastatic prostatic cancer without the symptoms of prostatic enlargement. Beyond that I cannot think of an indication for PSA testing because we're then in the area of PSA screening and in my opinion PSA screening is as yet of unproven value.

Well I suppose it all started when I'm fortunate enough to have a, a fulltime job. I, I'm a teacher and my age is sixty-seven now and I, I started having to get up more and more in night time to go to the toilet. And it got to the stage where it was a, six or seven times a night. And my job was beginning to suffer because my sleep. I was getting sleep deprivation. And I thought to myself I ought to do something about it and went to the doctor who gave me some pills to try and cut down the number of times that my sleep was interrupted. Unfortunately it didn't work all that much although it temporarily it, it maybe cut it down to two or three times a night. It then it started to build up and build up and build up and I've had to take some more and more pills until eventually I got really frightened of it because I, I sat, I tried to urinate one night and I couldn't actually do it. I had to sit down and actually press my stomach in order to actually pass, pass urine. So then I really, [laugh] I did get frightened. Ok. And went to the doctor again whose a, who is now given me, asked me to do another, another test and go to a specialist.

Did the doctor at that stage discuss what the test might be or did they mention the PSA test?

Yes they did. At that stage they suggested I had it. There was very little explanation from the doctor although a wonderful doctor. I mean really I would go to nobody else but there was no explanation on the, on the test itself. They just said would you like one? And I presumed like all patients that that was the natural thing to do. And therefore it was like all tests if, if it was over certain percentage it would tell you whether you had cancer or it, if you were under a certain percentage it would tell you it wouldn't. So I felt it was, it was a thing you probably had to do.

Did the doctor at that stage say that the PSA test was a test to see whether or not you had prostate cancer or what? Can you remember in your own words the, how the conversation went?

No. She merely said, 'I advise you to have the, the test in so far as it's possible that if, you know, if it's above a certain limit then we would take one action. If it's below a certain limit we'd take another.' We avoided the actual word 'cancer' funnily enough at that particular stage.

Right.

But there was no, no analysis of how successful the test was, had proved. I mean how many people had, was above the limit but didn't have cancer and those below the limit but still had cancer. We didn't go into that kind of detail at all.
 

I have a friend he had, had problems passing water and we used to talk about it and then that, in talking about it, it sort of jogged my brain and I said, to myself, 'Well, wait, this is something, I never had a problem passing water, but when you're younger and you're passing water it, it sort of spout out, to a distance like to this window there. But as time go by it started, the distance started to drop. Now, I put that down, when you're going in age and, you know, you're not as young as you used to be. But how wrong was I? 

So, I got a bit concerned and I rang my doctor for an appointment. And I saw him, the following day, which was a Friday. And he asked me, the doctor, my GP asked me, 'Well, how long this is been going on?' I had to admit now that I told him a lie. Because I noticed it about, 'Oh, dear, I'm going to get me into trouble this.' I told him about six months when in actual fact it was more than that. And he gave me a good telling off..

Hmm.

So he said to me, 'I want you to go and have blood tests and come back see me within two weeks time.' Which I did. And I went to the, when I had the blood tests I went back to see him in two weeks' time and he, he told me about this prostate, up until then I didn't know what he was talking about, It sound foreign to me. 
 

Yes well ten years ago I started having problems passing urine and therefore I went to the doctors and arrangements were made and I had a TURPS regarding the prostate gland. And I was under the impression that I'd had a full prostatectomy, it was my fault I hadn't taken much notice, so ten years afterwards when I started having problems, waterworks problems again I didn't take a lot, I thought, Oh, this is just old age, it can't be my prostate because I've had it removed.' But then I started to pass blood so I took a sample of the urine to the doctor and he immediately, to my GP and he immediately had me admitted to the local hospital. And that's when on admission they did a blood test. Now they didn't tell me that they were doing a PSA, I didn't even know what that was. They did a PSA test on the blood and found that my PSA was very much higher than it should have been, they didn't tell me how much higher and if they did I've forgotten but they said it was very high and then they warned me that it did look very likely that this was prostate cancer. 'How can I have prostate cancer, I haven't got a prostate?' 'Oh yes, you have.' And then I realised that I hadn't had it removed. So I'd left it too late really and the tumour was quite well established. So then having had a biopsy then to confirm the fact that it was a tumour then I was offered the opportunity of having treatment which I took which was hormone treatment to start with and that's what I'm still on the hormone treatment.
 

' and then last Autumn when they were doing the annual check-up and so on and took a bit of blood I noticed that they hadn't put PSA on it. She said, 'Oh no we don't, we don't like to frighten people because it gives false positives sometimes.' Well nowadays most of my pals have had prostate problems of one kind or another and the Big C, cancer, is not as petrifying as it used to be by any means, people talk about it so I asked her to put it on and she put it on in biro on the thing and it came back 7.3. So I thought well the doctor is going to ask for another PSA test and to my surprise he didn't, he put me in for the full biopsy which is not a very pleasant experience having a camera crew stuffed up your backside and so on. And full biopsy and it's also, you know you have to be on heavy antibiotics afterwards in case they've given you an infection and so on. And I would've thought a second PSA would've done but in fact he was absolutely right to panic, or not panic, to press the red button because I think it was partly because I'd lost 4' kilograms without intending to, my weight just dropped by that amount and also I was having erectile problems, I'd actually got some Viagra from him which was slightly unexpected I thought and so may be that triggered some worry in his mind and he sent me off. And he was absolutely right it was a Gleason score of I think 7 and they reckoned something like 40% of the, may be it's more than that, of the prostate was cancerous. And so that's what started the PSA thing. It's since gone down to 0.1 while I was on hormones and it's now 0.2, it's doubled, so it's still zero, still nothing. and I would certainly encourage people to have a PSA test but have it checked if it comes out positive, just have a second one, much cheaper than having this awful biopsy.