We made an appointment and unknowingly entered into the contentious arena of how to respond to potentially worrisome prostate cancer tests.
Originally used to track the progress of cancer treatment, the PSA test is now widely used to detect possible signs of early-stage prostate cancer. But it is an imperfect tool — so imperfect, in fact, that recently the U.S. Preventive Services Task Force, which is charged with tracking medical practices and treatments, said the test should no longer be part of routine standard of care.The test does more harm, through unnecessary surgery, than good, the group said. The recommendation, which reversed the task force’s previous position, has been extremely controversial, with many urologists, cancer doctors and prostate cancer survivors decrying it, saying the PSA test had saved lives.
All of this, though, was well in the future. For now, all we knew was that his PSA was elevated. The question was what to do. In trying to answer that, we felt as though we’d fallen down a medical rabbit hole.
A puzzling about-face
The medical consensus has been that if the PSA number is above 4.0 and this is confirmed in a second test, a biopsy should be done. Clinicians also get concerned when the PSA number rises too quickly; a two-point rise — say, from 1.5 to 3.5 over a two- or three-year period — can be a red flag. My husband fell into the latter category. But as the urologist took great pains to tell us, the rise could mean nothing. Some men who have prostate cancer fall below 4.0, and others whose number is above 4.0 do not have cancer.
We found the doctor’s realistic assessment of the PSA reassuring, and we were sure he wouldn’t recommend a biopsy unless Jim’s third PSA, done through the urologist’s own lab, showed an increase. When the result came back, Jim’s PSA number had stabilized, but the doctor nonetheless recommended a biopsy. When Jim asked why, the doctor expressed concern about the PSA numbers and thought that a biopsy was warranted.
We were puzzled by what seemed to be an about-face: First, the PSA was not to be trusted, then it was the reason to perform a painful, invasive procedure. But the doctor seemed sure, so Jim went ahead with the biopsy the next week.
When the results came back, the doctor explained them by laying out a diagram of Jim’s prostate. He pointed to a bar, with a small area shaded in, on the lower-right segment, or core, which he said indicated the presence of a small, early-stage tumor. The doctor said the virulence of the tumor, measured by the Gleason score, was 6, which meant it was slow-growing. Two other cores had spots that looked suspicious, meaning they might develop into cancer down the road.