PSA is a subject that is often brought up to me during my seminars and with private consultations. To most men it is only initials for a test that states whether they have cancer, potentially have cancer, benign prostate hyperplasia (BPH=enlarged prostate) or they can be relieved to go home feeling free of prostate disease. The answers to these initials (PSA) are not complicated, but should be understood, so a discussion of the prostate can be discussed intelligently with the physician and most often relieve the client of unnecessary anxiety.
PSA (prostate specific antigen) is a protein that is produced almost exclusively by the cells of the prostate. Its function is to keep the prostate fluid (semen) watery so the sperm can swim. Another purpose of this protein is to dissolve the cervical mucous cap to allow the sperm to enter. Although present in large amounts in prostate tissue and semen, it has been detected in other body fluids and tissues. Interestingly PSA is found in concentrations of female ejaculate roughly equal to that found in male semen. It is also found in breast milk and amniotic fluid. Low concentrations of PSA have been identified in the urethral glands, endometrium (uterus lining), normal breast tissue and salivary gland tissue. In addition PSA is found in the serum of women with breast, lung, or uterine cancer and in some patients with renal cancer.
In the male PSA is normally found in the blood but at low levels (about 0-4ng/ml = nanograms/millimeter= one ng=one billionth of a gram). PSA levels can be increased by prostate infection- irritation, digital rectal examination (DRE), benign prostate hyperplasia (BPH), and recent ejaculation. All the latter can produce a false positive result. Ejaculations should therefore not be present for 24 hours before a PSA test and a DRE should not be done before blood is drawn for this test. Exercise within 24 hours of the PSA exam can also give e a false positive (high). There is also a urological debate whether the PSA normally goes up gradually with age and therefore different normals should be considered. The prostate gland generally increases in size and produces more PSA with increasing age; it is normal to have lower levels in young men and higher levels in older men. Age-specific PSA levels are as follows (age group, upper normal): (40 – 49years, 2.5), (50 – 59years, 3.5), (60 – 69years, 4.5), (70 – 79years, 6.5). But keep in mind that age related normals are still controversial and in practice the 0-4ng/ml is the gold standard.
So in the former paragraph one can see that besides from the cause of cancer and BPH the PSA can rise from other causes. I have already mentioned the PSA can rise just from having intercourse or any ejaculation before the blood serum is drawn or from exercising before the blood is drawn. It can also be elevated due to testosterone converting to the stronger testosterone, dihydrotestosterone (DHT). This latter can happen if the man is on an anti-aging regimen of taking testosterone and he is one of the rarer males that will convert the testosterone to DHT. It happens but the conversion can be stopped either with pharmaceutical intervention,with natural supplementation or with tweaking the testosterone regimen.
Increased levels of PSA may suggest the presence of prostate cancer. But if mildly elevated 7 out of 10 men will not have the prostate cancer. However, prostate cancer can also be present in the complete absence of an elevated PSA level, in which case the test result would be a false negative. Statistically 2.5 percent of men with prostate cancer will have a negative PSA. Obesity has been reported to reduce serum PSA levels; therefore, this can also give a false negative and delay early detection. This may explain the worse outcomes in obese men that have the pathology of prostate cancer but no symptoms, signs or elevated PSA.
Using the PSA test to screen men for prostate cancer is controversial because it is not yet known for certain whether this test actually saves lives. Moreover, it is not clear that the benefits of PSA screening outweigh the risks of follow up diagnostic tests and cancer treatments when the test is positive.. For example, the PSA test may detect small cancers that would never become life threatening. This situation, called over-diagnosis, puts men at risk of complications from unnecessary treatment. The procedure used to diagnose prostate cancer (prostate biopsy) may cause harmful side effects including bleeding and infection. Prostate cancer treatments, such as surgery and radiation therapy, may cause incontinence (inability to control urine flow),and erectile dysfunction (erections inadequate for intercourse), So the best way to use the serum PSA is to have a base line as an index to refer to for future PSA tests. If this baseline test is normal but the next test goes up about 2 points then suspicion should be heeded by the physician and the test repeated in 2-4 months along with watchful waiting. For example: If my PSA is 1.4 for the first test then one year latter it is 3.6 this is looking a little suspicious. Watchful waiting and a good history plus symptoms and signs that can raise the PSA should be questioned.
Then there still exists the debate at what age is the PSA elevated naturally. But I believe that the above paragraph with the PSA rising more then 2ng/ml in one year is a good indication that further testing and observation should be taken seriously. Also if the man is on testosterone this should be stopped for a few weeks and certain tests should be retaken and reviewed. There are some blood test markers for prostate cancer and a retesting of hormones if the man is on testosterone therapy. Then if so desired by the client and with the consultation of the physician testosterone can be restarted but possibly with a different regimen. There, are different ways of using the anti-aging testosterone that can be tailored to this situation and followed and as mentioned altered to stop testosterone converting to DHT. But in a different blog I will show the evidence based information of why testosterone is not the cause of prostate cancer but rather estrogen is the cause. Note that I only believe in bio-identical testosterone produced by a compounding pharmacist. By doing so I can have the testosterone made specifically for the individual and tweaked if necessary. Also, the body does not know what to do with synthetic hormones since the cells were evolved only for human bio-identical hormones.
So further testing would include a free PSA. Most PSA in the blood is bound to serum proteins. A small amount is not protein bound and is called free PSA. In other words the PSA protein can exist in the blood by itself unattached, or it can join with other substances (protein) in the blood. When it is by itself, it is known as free PSA. With benign prostate conditions (such as BPH), there is more free PSA, while cancer produces more of the attached form and therefore, the free PSA is less then 25%. If a man’s attached PSA level is high but his free PSA level is less then 25% the presence of cancer is more likely. It is easiest to just remember that the free PSA should be above 25%.
Since this can be a confusing concept let me write it in another way. PSA, a protein produced by prostate gland cells, circulates through the body in two ways: either bound to other proteins or on its own. PSA traveling alone is called free PSA. The free-PSA test measures the percentage of unbound PSA; the PSA test measures the total of both free and bound PSA. About 75% of men with an elevated PSA do not have prostate cancer. a free PSA greater than 25% is more likely to have a benign condition than to have cancer, making a biopsy unnecessary. Men with a total PSA in the same range and a free PSA below 10% need to have a biopsy. More likely than not, they have prostate cancer ( Harvard Medical SchoolOriginally published April 2009; last reviewed March 21, 2011. )
So the tests that I do in the case of a rising PSA are:
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free PSA
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ultrasound
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repeat the PSA in 3-4 months making sure that events that could give a false positive have not happened.
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DRE-digital rectal exam or have the urologist do this since. I so often refer to them if there is a chance of serious pathology.
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IF the man is on testosterone the laboratory chemistry I order are:
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testosterone free and total
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estradiol
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sex hormone binding globulin (SHBG)
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another PSA and free PSA if the last one was more then 3-4 months
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dihydrotestosterone (DHT)
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if there is a suspicion because of signs or/& symptoms it warrants caution. I believe the best way to handle any doubt is to get another opinion from a urologist.
Many men were diagnosed with, and treated for cancers that would not have been detected in their lifetime if they had not had screening and, as a consequence, were exposed to the potential harms of unnecessary treatments, such as surgery and radiation therapy . Here I am just stating results and not giving advice as to what each individual should do if there is a possibility of prostate cancer. This is up to the individual with guidance from their own physician. Just investigate all options before making a decision.
Scientists are also researching ways to improve the PSA test, hopefully to allow distinction between cancerous and benign conditions, as well as slow-growing cancers and fast-growing, the latter being potentially lethal cancers. These new tests that they are researching and developing are too numerous for this blog and they are still in investigative states. But the reader can investigate all these potential diagnostics via the Internet and should do so if they believe they have a problem since research and progress come about so fast. Too often physicians do not know all the research being done outside their expertise and area and it is up to the concerned client just to Google further information and bring it up to their physician.
I hope this short excursion into PSA helps those men that have anxiety about not understanding the PSA test.
Author: Alan J. Sault MD. ABHM-Diplomat Emotional Vampires and Your Hormones: an holistic physician’s view of how stress affects your-well being and what you can do about it
holisticsecondopinion.com .
This caveat is true not only for BPH but should and could be applied to all aspects of alternative, complementary, and my field Holistic medicine. To know the difference of the three latter types of medicine please go to my blog on this: (Complementary, Alternative, Holistic: What’s the difference). There is a difference! One must understand that many diseases and disorders have similar and often the exact same symptoms and signs. Therefore, to get the right diagnosis a healer must know this. This list of similar symptoms and signs is called the Differential Diagnosis (DD). All students in medical school, osteopathy school and a four-year Natural medical college learn about the DD. What a good healer also learns over time is that each person is an individual and that the designated treatment might not work for that individual and alternative treatments or combinations must be considered, or even sending the client to a different expert. Case presentation for an example: A man starts to get the symptoms and signs of BPH (Benign Prostate Hyperplasia): urgency to urinate, split stream, nocturnal urination, frequency and difficult starting and maybe some dribbling on completion. Being that he is holistic he starts and continues to use a quality controlled prostate supplement rather than the allopathic pharmaceutical with known side effects. Some promoted alternatives to the pharmaceuticals are: saw palmetto, stinging nettle, beta sitosterol, lycopene, zinc, selenium to name just some. All of these work especially in combinations but that does not mean that they are curing and not just halting the problem. Worse is if the holistic treatment is hiding another evolving problem. Eventually he develops right lower flank pain anteriorly and posteriorly about 8 AM. He stays in bed until 3 PM with the pain being rated about 8-9/10; when his wife decrees that they journey off to the emergency department (ED). After several hours in the waiting room the nurse asks for a urine sample. After a few minutes he needs to urinate again and asks for a urinary filter believing it could be a kidney stone that he could catch for diagnosis (since there exists different types of stones). They say they do not have any (even though they are one door down from the entrance to the ED). He urinates and the pain drops from an 8 to about a 3. He goes along with a stone theory diagnosis but he still undergoes a CT scan. The diagnosis comes back as hydronephrosis (kidneys bilaterally enlarged) and therefore potentially dangerous to losing both kidneys. This hydronephrosis has been quietly developing over many months because the prostrate was enlarging to the point of being enormous and thereby blocking the full emptying of the urinary bladder. Because the bladder was retaining residual urine and continuing being stretched to accommodate the residual urine it was not only losing its muscle tone but also enlarging enough to partially block (at this point) the complete emptying of the kidneys which were accommodating by enlarging and potentially could be destroyed. This latter would mean dialysis for life. He finally had to undergo a 3 hour robotic surgery of the prostate and saved the kidneys.
Holistic Second Opinion 