I have an unusual patient at the moment. Unusual, as he highlights the dilemma associated with the diagnosis of an elevated PSA.

PSA, or ‘prostate specific antigen’ is a chemical found in prostate tissue which is our best marker, at present, of prostate disease.  It is measured with a blood test, and goes up when the prostate is ‘distressed’. Recent intercourse or heavy exercise (the two are not necessarily related) or an infection can also temporarily elevate the PSA, so it is important to rule these out as causes if you have a high blood level.The problem is that two things increase circulating PSA. One is benign and almost universal with age (benign prostatic hypertrophy, BPH or, literally, ‘harmless big prostate’) and the other is malignant, ie, cancer of the prostate (about 1 in 10 Australian males).

Carl is 55, and started having his PSA level measured and his prostate examined at 50, which is the current recommendation.  His PSA level has always been high, but when this is the case, there is another test we can do to try to discriminate cancer as the cause from BPH.  The lab measures the ratio of ‘bound’ to ‘free’ PSA, and if this is above 25% it is considered fine, and if it is below 15%, then cancer needs to be ruled out. His prostate has always been slightly larger than usual but felt normal. This year, Carl’s PSA was about the same as in previous years, but  his ratio was much lower than previously, at 15%.  I explained all this to Carl, and told him that I would talk to a Urologist (specialist in the urinary tract) and ask what he would advise.  He called me back a couple of days later and said that Carl should be seen by a Urologist and probably have a biopsy.

A biopsy involves sedation being given  so that 6-20 tiny samples of tissue can be removed from the prostate and  examined under a microscope.

The advantages of this is that if cancer is found it can be treated and hopefully eradicated early, with an operation or in situ radiotherapy, well before it has had a chance to spread to adjoining structures (bladder, pelvic nerves, bowel) or to bones.  The disadvantages are the small risk of infection (1%) and the risks associated with sedation (almost unknown) These biopsies used to be done under local anaesthetic, but it is much less uncomfortable to be put to sleep.

 Also, there is a chance that the biopsy sampling procedure misses the cancerous cells altogether and take only healthy tissue, so that Carl may be falsely reassured that he is cancer free.  There is also a theoretical chance  that one of his pelvic nerves supplying bladder control and erectile function may be damaged, as these run very close  to the prostate.  I have never heard of this happening, but any patient needs to be informed of this chance.

Carl saw a urologist and was advised of all these things.  He was told that he has about a 50/50 chance that this is a cancer.  He was also told that at autopsy, about 30% of men over 50 have prostate cancer, and that only about 10% of all prostate cancers ever become clinically significant (ie, spread).  Therefore if he does have prostate cancer, he may die without ever knowing about it.

However, prostate cancer in younger men (less than 65) while uncommon, tend to be more virulent.  Carl is highly intelligent and has read everything I have given him to help him make up his mind, and has also done some research of his own. 

The Urologist advised him to have a biopsy; Carl is inclined not to.  I understand both points of view, but having looked after many men who have died of prostate cancer, I lean more towards biopsy.  Carl feels he can live with the knowledge that he may have cancer and that it may or may not ever become a problem.  He will see another Urologist for a second opinion but I suspect this will be the same, as no surgeon would want to miss an early and curable cancer in such a young man.  His medical defense fund would also not want him to miss it.

Should Carl go ahead with the biopsy, and is found to have prostate cancer it is likely to be very early, but will be given a 'grade' of severity.  On the basis of this he will then be offered a somewhat bewildering choice of possible treatments. Twenty years ago when the practice of medicine was more paternalistic, Carl would have been told what investigations he was to be sent for and what treatment he would receive (not that the PSA test was available back then).  These days, the decision is made by the patient, in conjunction with their family/partner and their doctors.  My experience is that most patients like to be told all the information, often do their own research on the internet, but in the end ask my opinion as to what to do.  Carl is unusual in that he is prepared to follow his own head and heart.  My own experience is that if a man thinks that there is even a remote possibility that he has prostate cancer he wants the biopsy as soon as possible.  Most of us find uncertainty very difficult to live with.  Carl is unusual in that he appears comfortable with that level of uncertainty.  Alas, until we have a better set of tests to detect prostate cancer this dilemma will remain.

What you should know about the prostate

It is gland the size of a walnut situated under the bladder, wrapped around the top of the urethra (urine tube). It makes the liquid part of semen and is regulated by the male sex hormone, testosterone.

Prostate cancer is rare under 50, and most common after 65.  It affects 1 in 10 Australian men, but causes only 2-3% of male deaths.  It is typically a slow growing tumour, and most men with it die of something else.  Once it starts to spread, then it can grow rapidly.  In its early stages (‘locally confined’) it is curable.  About 9% of prostate cancers are genetic.  If your father or brother had prostate cancer, you should start having the tests at 45.

Early prostate cancer rarely causes symptoms.  More advanced cancer can cause the following symptoms, which  may  also caused by a large healthy prostate (BPH)

• a frequent need to urinate, especially at night
• difficulty stopping or starting the urine stream
• a weak or interrupted stream
• a painful or burning sensation during ejaculation or urination
• blood in the urine or semen

Accurate early detection of prostate cancer is imperfect, and is a work in progress. Most malignant prostate tumours originate in the part of the gland nearest the rectum, so many