BREAKING NEWS: Worried about a 10 (or above)?

Lots of wiggle room on PSA. Mantenga la calma.

(Different “10” than the one you may be thinking of?)

(Editor’s note: If I ask you, what do you think of when I say: “10.” Would it be actress Bo Derek, who personified a perfect “10” to many of us back in the day? Sadly, probably not. These days, guys of our generation, on active surveillance for low-risk prostate cancer hear “10” and immediately start worrying about our PSA (prostate-specific antigen) scores. A PSA of 10 and higher potentially means a man has prostate cancer progressing into dangerous territory and serious choices may be ahead. My friend, let’s call him “Steve,” and his doctor, a leading urologist, has some reassuring words for those of us with PSAs of 10 and a bit north. New testing standards may give you a break soon …  and more. Read on:)

By Howard Wolinsky 

“Steve” had been sitting on pins and needles for six months. His prostate-specific antigen (PSA) had been almost 10 ng/ml.

Many men on active surveillance experience “anxious surveillance” when their PSA goes above 10 into the mid-teens.

“My doctor had previously stated that when my PSA hit double-digits, it might influence his recommended treatment plan,” said Steve.

But he had a shocker on a recent test. A good one. His PSA fell from a high of 9.8 down to 6.6. A whopping 25% drop.

Steve had feared that he was suddenly going to cross the PSA cutoff of 10 and confront a choice between radical surgery and radiation.

It didn’t happen.

Instead, he felt a weight had been lifted from his shoulders, figuratively—and his prostate, actually.

Steve has remained on an active surveillance protocol.

Why did his PSA reading fall so dramatically in such a short period of time? 

He hadn’t changed his diet, nor had he started to take turmeric, pomegranate powder, or a host of other special supplements and potions that men with prostate cancer often consume to try to reduce their PSAs.

Go Blue: UMichigan changed its standards

What happened was that the lab at the University of Michigan in Ann Arbor, where Steve monitors his Gleason 6 low-risk prostate “cancer,” had converted to a new calibration for PSA testing. Michigan moved from Hybritech to WHO (World Health Organization), two standards for measuring PSAs. 

This may happen to you, too, as centers increasingly adopt WHO standards.

In Steve’s case, lab results for his most recent PSA test included the following addendum: “Values for PSA testing have been aligned with WHO calibration standards as of 11/3/21.  While new baselining is best practice, results with the new calibration are expected to be approximately 25% lower compared to prior standards (Hybritech).”  

Todd Morgan, MD, chief of urologic oncology at Michigan Medicine, is Steve’s doc.

Morgan said the lab at Michigan has joined the growing number of facilities that have switched to WHO because they feel its results are more accurate.

So don’t be surprised in the coming years if your PSA suddenly drops by 20%-25% as more as labs switch to WHO  standards.

Failure to communicate

What worries patients may not worry their docs. There often is a failure to communicate.

The 25% decline in PSAs is a somewhat artificial change in the minds of doctors. But patients find such changes reassuring.

In reality, Morgan explained readings of 10 or somewhat above are not the final word on prostate cancer, anyway.

PSA numbers get fixed in patients’ minds, causing unnecessary anxiety with the slightest increase. There really is far more flexibility and wiggle room than patients realize. Urologists need to do a better job of explaining this to patients to spare from anxiety and depression.

Don’t just depend on the PSA

Morgan said: “For somebody without prostate cancer and with a PSA of 3, 4, 5, or 8, I would almost never go straight to a biopsy in the current landscape with all the data that we have. I would generally recommend additional testing such as an MRI to help make a decision around biopsy versus further PSA surveillance.”

He said urologists like him take the often-discussed cutoffs of PSA-4-10--”with a grain of salt. I’m really thinking (it should be PSA) 2-14 or 15. It depends on prostate size. And I think it really falls on urologists to communicate with patients, and we don’t necessarily do that well. You look and the categories are classically defined as 4-10, 10 to 20, but over time PSA fluctuates a lot.”

Morgan said he and other urologists look at the PSA as just one factor in monitoring patients.

He said patients on active surveillance for low-risk prostate cancer need not panic just because their PSAs edges over 10.

“Do any of us (urologists) who see many patients with prostate cancer really feel that a patient with low volume Gleason 6 cancer and a PSA of 11 isn’t eligible for surveillance? Absolutely not. That’s not the case. We see fluctuation all the time and part of my job as a urologist is really helping patients understand that there is going to be fluctuation.”

PSA surprises—the other way

We patients should know by now that activities before undergoing a PSA blood test--such as having sex, riding a bike, or having a digital rectal exam before testing--can artificially raise our PSAs.

“What patients did yesterday, or the day before, maybe what they ate, is really going to impact their PSA. So, urologists already are baking in 20-25% fluctuation easily just in our normal routine counseling, and there is almost no scenario that I would make a change in recommendation for somebody with a PSA of 11 versus a PSA of 8.”

Morgan stressed the importance of PSA density, which is calculated as total PSA (ng/ml) divided by prostate volume (ml) to determine how clinically significant prostate cancer is and whether MRIs, biopsies, or molecular tests may be in order.

I mentioned to Morgan my friend who had ignored his prostate care for about a decade and whose PSA had reached 13 when he finally addressed his health. A transperineal biopsy showed no sign of cancer.

His doctor at Mayo Clinic told him to go out and celebrate. It was a huge relief because the 13 PSA had caused him sleepless nights.

Morgan said, “Imagine somebody with a PSA of 13 but with a prostate that is 150 grams. That PSA of 13 doesn’t sound so high to me,” Morgan said. “Now, somebody with a PSA of 13 and a prostate of 30 grams, that’s a different story. Their risk of prostate cancer is totally different than in the patient with a150-gram prostate.”

He said the use of this data is different in men who have undetected prostate cancer who are undergoing PSA screening vs. those with diagnosed prostate cancer on active surveillance whose Gleason grade, tumor volume, and stage represent much more important data than their PSAs. Take that PSAs.

Until last year, guidelines from the National Comprehensive Cancer Network suggest that PSAs of 3, rather than the traditional 4, should be the cutoff in healthy men between the ages of 45 to 75, Morgan said.

“This shift to the WHO calibration would certainly push me towards 3 or maybe a little bit lower for younger men to consider additional testing, such as MRI or additional biomarkers on the way to considering biopsy,” he said.

So, guys, worry a bit less about a PSA of 10. Relax. Be happy. Maybe think of that perfect 10 from so, so long ago.

(Dr. Todd Morgan/UMich)

Dr. Morgan, manning the ramparts for patients on AS

By Howard Wolinsky

You might remember Dr. Todd Morgan, chief of urologic oncology at the University of Michigan.

Last September, the National Cancer Community Network (NCCN)  knocked down active surveillance as the preferred treatment for low-risk prostate cancer and put it on par with radical prostatectomy and radiation therapy,.

Morgan, as an NCCN panel member representing UM on the Prostate Cancer Early Detection Panel, stood up alone for patients. He defended the 2018 guideline many urologists had fought for over 30 years to recognize AS as the No 1 choice for men with low-risk prostate cancer.

After a twitterstorm among urologists, and backlash from patient groups, including Active Surveillance Patients International, AnCan and ZERO, NCCN reversed itself and restored AS as the preferred management for low-risk prostate cancer in its guidelines for low-risk disease. 

(I broke the stories on this in MedPageToday.com

“One-Word Change in Prostate Cancer Guideline Has Some Urologists in Arms 

https://www.medpagetoday.com/special-reports/apatientsjourney/94840

“NCCN Reverses on Guideline Change for Surveillance in Prostate Cancer”

https://www.medpagetoday.com/urology/prostatecancer/95949)

In my mind, Morgan is right up there on the Mount Rushmore of righteous urologic experts, including Klotz, Carroll, Carter, Albertsen, and Chodak, who developed and deployed AS to spare men like us from unnecessary interventional treatment.

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Please take TheActiveSurveillor.com survey on transperineal v. transrectal biopsies. Go to https://bit.ly/35mD6OY

Some interesting trends are emerging, such as the growing number of men who have opted for transperineal biopsies. Hope to see if the stats hold up with more data.