So, do you have any stories of prostate cancer patients who have had prostatitis in your
practice?
Yeah, thanks Alex. This is a really somewhat difficult area of being a prostate oncologist,
having to deal with men that are running high PSA levels. Most of our patients have prostate
cancer and as I'm sure our audience is aware, there are many types of prostate cancer that
can be monitored without treatment and we use PSA monitoring to keep track of them.
Prostatitis causes the PSA to act in a wonky fashion and one of our standby standard methods
for monitoring is sort of out of the window.
Let me just share a quick story about a patient of mine from Hawaii. Diagnosed back in 2007;
75-year-old attorney now; PSA was only 5; he had an ultrasound showing a normal sized
prostate. We talked about big prostates causing high PSA, but this man had a normal-sized
prostate and in 2007 his PSA was normal. For a 42cc gland, his PSA was about 5, which is
fine. He did have a biopsy showing favorable intermediate-risk prostate cancer—3+4=7
with 10% grade 4 in one core from the right side apical part of his gland. He has a history
of what we call acute prostatitis. Acute prostatitis means that someone can feel something. They're
sore, they have a fever, or difficulty urinating, and he was treated with antibiotics and he
got better as oftentimes acute prostatitis responds nicely to that. So, he had several
biopsies over the years and it always came back showing Gleason 3+3 and he was on Proscar
during this time. Proscar is a medicine that blocks dihydrotestosterone and it lowers PSA.
So, we talked about how his PSA was normal at 5 for a 40cc prostate, but for someone
on Proscar, that's actually abnormal because we're supposed to double the PSA. And, indeed,
when he stopped the Proscar, I think it was around 2017, his PSA went up to 10 and then
it went up to 16 and with his history of prostate cancer, this made everyone nervous. And he
wasn't having any urinary symptoms that would suggest acute prostatitis. Had another MRI,
he had another targeted biopsy, 3+3, nothing serious, and at one point his PSA got all
the way up to 20, and so, fortunately, there's a new type of technology out that we've been
talking about called PSMA PET scans and these PET scans can detect cancer anywhere in the
body and we wanted to make sure that his cancer hadn't spread and that we were missing something
with this high PSA, and, thankfully, the PSMA PET scan showed only uptake in the right area
of the prostate where his biopsies have been positive and nowhere else in his body to our
great relief. So, this is a sort of thing we struggle with men who have low-grade cancer
and high PSAs. If they're not symptomatic, we call it chronic prostatitis and it's pretty
much the only thing we can use to explain why his PSA runs so high. He doesn't have
a big prostate; he doesn't have a bad prostate cancer; therefore, he has an inflammatory
process (and some of his biopsies have shown some inflammation). Tough situation, but not
at all uncommon. A lot of patients that are on active surveillance deal with these erratic
PSAs due to background noise from the prostatitis.
So, you mentioned that your patient was on Proscar, so what was that about? What was
that being used for?
When PSA levels are running high, we know that Proscar can lower PSA in men that have
enlarged prostates and it doesn't lower PSA very well in men that have cancer. So, it's
tempting to administer some Proscar, otherwise known as finasteride, Avodart or dutasteride
(these are all the same category) to see if the PSA level will come down to validate that
it is a prostatitis problem and not a cancer problem. The problem with these medicines,
of course, is that they are known to inhibit or suppress libido and so men's sex drives
can really taper off when they're on these medicines. Not in everybody, probably 25-30%
of men. So, whenever I prescribe them, I. warn them about that and tell them to stop
it if that problem appears, but it can be handy and we did see that in this patient
whose PSA was maintained in the 4-5 range for a long time until when he stopped it,
then it ballooned up to 15 even 20, indicating that, once again, less likely to be a cancer
problem. More likely to be an inflammation problem.
So, Dr. Scholz, in the case that you read you talked about the PSMA PET scan and that
is new technology, this incredible imaging that has come out lately and we're waiting
for FDA approval here in the US, but can you talk about how impactful that imaging is on
now being able to tell whether it's an enlarged prostate, whether it's prostatitis, or just
really being able to clarify that it is a cancer where it is.
Yeah, well, of course, being a cancer doctor, most of my patients—we have hundreds and
hundreds of men—that have low-grade prostate cancers that are on monitoring and if their
PSA starts misbehaving, then we get quite concerned and we've always had to deal with
the possibility that we're missing something. You know, is it not showing up on an MRI?
is it not showing up on an ultrasound? Are we missing it on a biopsy; Is there high-grade
cancer lurking in a corner or even in some other part of the body—maybe it has even
spread, and this is what goes through everybody's minds, patients and doctors alike when the
PSA runs high, so this new scan is so accurate and it's very sensitive, so we have found
it quite comforting in these patients that are running high PSAs, presumably from chronic
prostatitis that when the scan shows that there's only a small spot of cancer in the
prostate, where we expect it to be and it's nowhere else in the body, that we're still
on the right track. We are calling it prostatitis and we're not being fooled and lulled into
thinking there's not a problem with the cancer when actually there could be. The scans are
so much more accurate than the ones we had in the past. It's very comforting to know
there's nothing outside of the prostate.
So these PSMA PET scans, we're still waiting for them to kind of be widespread in the US.
Can you see those same nodes in a 3T MRI and can that be the same confirmation as a PSMA
scan would be?
The problem with MRIs for detecting abnormal lymph nodes with cancer is they have to be
so chock full of cancer that they need to enlarge over half an inch in diameter. So,
by then, you know, you're really dealing with something that's become somewhat advanced.
It's too late; you don't want to wait around for an MRI to show an enlarged lymph node.
You want to find the cancer a lot earlier than that, and this is the advantage of the
PSMA PET scan is that you can pick up spots that are 3 or 4mm across.
Thanks for watching! If you would like more information about anything we spoke about
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