Something that is frequently said and that is true
is that most men in their life will get prostate cancer.
That's not a question.
The question is,
is it going to be a prostate cancer that is going to affect you in your life?
So, it is a natural part of aging and it happens in most men.
But the key is to find the cells that will become lethal to you,
and that's finding it earlier on in life.
Most PSA's in America are checked by primary care physicians.
So that is the place to start
if you want to get your PSA checked. If you have any other further questions,
or if there is any question about your PSA potentially being a little bit higher
than you think it should be.
Go and get a second opinion from a urologist.
We won't necessarily take you right to get a biopsy that day
and then operate on your prostate the next day.
That's not what we do anymore.
Our job is to, number one, see if you even need a biopsy.
And then if you do get a biopsy, that's positive to give you
all of the options, one of which could include
active surveillance, not doing anything right now until it gets worse.
Primarily, you should seek a getting your PSA checked
by your primary care doctor or at least ask them about it.
If you have further questions about it, then come to a urologist.
Some primary care physicians will check a PSA automatically every year,
and some won't because PSA screening is not meant for every man every year.
However, if you are at higher risk of prostate cancer,
if you have a family history, if you are black,
if you have a history of ovarian or breast cancer,
which could imply that you have a Brackin mutation,
you should seriously ask your primary care doctor about getting a PSA.
At least have that discussion.
If you want further discussion with it, then come to a urologist
and we'll talk to you more about the pros and cons of PSA screening.
We recommend that all men between 55 and 70 have a frank discussion
with their primary care physician or urologist about PSA screening,
because that is the age at highest risk of having prostate cancer.
If you yourself are at high risk of having prostate cancer.
So you have a family history African-American bracket to mutation
in your family. You should be screened and you should be given that option.
And if you're not, then you should seek a second opinion.
If you don't have any of those risk factors, it may not be necessary.
But having one PSA checked can't hurt.
If there's any question about that PSA being high,
then go see a urologist and you don't necessarily need to biopsy.
But there are plenty of men without those risk factors
that get serious prostate cancer.
So that's why I would recommend
that all men get at least one PSA checked in their life.
An elevated PSA does not necessarily mean that you have prostate cancer,
it is just a red flag that we should look into this further.
It stands for prostate specific antigen, but is not prostate cancer specific.
So if if a man has an enlarged prostate, they'll tend to have a higher PSA.
Older men tend to have higher prices.
So when the PSA reaches above a certain amount
or it looks like it's rising from what it used to be,
they'll generally get sent to us or another urologist
to look into that further.
The first thing I do is to recheck the PSA,
because it may be a false positive.
The second thing I do is look at the trend of the PSA.
Has it been going up at a steady pace?
Has been going up very sharply.
If I'm suspicious at all, we can get further test at that point.
Some of these tests are for all patients, but we can get
specialized PSA test like a four case score.
We can get urinary tests that can actually look for shedded
cancer DNA products in the urine.
And what I think is one of our strongest diagnostic tools
in prostate cancer right now is getting an MRI of the prostate.
And that's a very specialized MRI that very few centers do.
And we have Georgetown have been doing for over 10 years now.
And MRI can pick up very high risk prostate cancers,
the ones that we want to find and we want to treat aggressively.
If an MRI is negative, that doesn't mean that prostate cancer isn't there.
But it may be one of the slower
growing prostate cancers that we don't necessarily have to treat.
So, if you have an elevated PSA, I'll probably work
that up with an MRI afterwards.
If the MRI is negative,
we may still have to proceed to the next step. If it's positive.
We'll definitely proceed to the next step.
So, if we have decided that the next best step is to do a prostate
biopsy, to get that diagnosis of prostate cancer, patients can be assured
that at MedStar Georgetown University Hospital,
you are going to get the newest technology with the best results of the biopsy
and the fewest complications.
And that's because two years ago, we introduced a newer form of biopsy
that we can do in the office called a Transperineal Prostate Biopsy.
So, this has reduced the risk of infections almost to zero percent,
which was a problem with the old types of biopsies or other types of biopsies,
and also increased our diagnostic yield.
We actually noticed that we can sample a lot more of the prostate
this way than we could with the way we used to do the biopsies.
In addition, with the MRI's that we get at Georgetown,
we can use those to pinpoint where we want to focus our biopsies
to make sure that the patient gets an accurate diagnosis.
One of the most common
questions I get is what is a normal PSA?
If I'm taking a test or I need to give you an answer or
what's on that, the lab form will say that a normal PSA
should be less than four, but it is not that easy.
Patients at different ages have different PSA levels.
So, all of that comes into play when someone comes in with a PSA level to me.
All that matters to me is how old you are
and what were your past PSA's, and not necessarily a total PSA level,
because a PSA of two may be considered
normal in an older man who's in his 60s.
A PSA of two and a man in his 40s is not normal.
But if we use that cutoff of a four, then
we would be missing a potential prostate cancer in that young patient.
So, the normal PSA is individualized for each patient based on
how old they are, also how big their prostate is.
And also, if they have any other symptoms, if they're having burning
with urination, it could be a false elevation because of an infection.
So for me, it's more the trend in your PSA.
And if that trend changes, so each person in general
will have their own baseline PSA that I will follow over time.
Now, there are some pieces that are very worried.
Any PSA over 10 is certainly worrisome.
But when you get to saying that a normal PSA above
is below four and above four, it's much more nuanced than that.
Annual PSA screening is not for everybody.
However, I do advocate that
every man gets at least one PSA checked in their lifetime.
Now, PSA screening for every single man every year is probably too much
because there are a lot of men that will not be at high risk for cancer,
and they may get a diagnosis of a very low risk cancer, and that may
lead to a very aggressive treatment that's not needed.
So, that's why I say it's not for everybody.
However, for high-risk men,
black men, men with a family history of prostate cancer.
Men that have the bracketed gene, they need to be screened every year.
So the general recommendations of the American Urological Association
are that all men at least have a discussion
with their primary care physician or urologist about PSA screening.
The pros and cons, whether they should get it
between ages 50 and 70, that's for the general population.
Again, for men at risk, black men, men with a family history, men
with Brackett's gene, they should be screened every year
in that age group from 55 to 70, probably even earlier.
We would advocate that those men get checked starting in their 40s,
either age 40 to forty five, depending on which guidelines you follow.
I also advocate what's called the baseline PSA,
and that's what I recommend every man should get in his 40s.
Some men may get aggressive prostate cancers without any of these risk factors.
And we see that, unfortunately, all too often.
And just checking one PSA in their 40s may have prevented that.
So what's called the baseline PSA is just checking a single PSA
level in all men in their 40s.
If that PSA is over one to one point two, they're considered a higher risk.
And those are patients that I check every year.
I put them in the same group as all the other men
with high risk prostate cancer,
and I check every year.
If that PSA is less than one and they don't have any other risk factors.
They don't have to worry about PSA screening every year until they're 55.
And then when they reach that age
from 55 to 70 when prostate cancer is most common,
they can get it checked every year to two to three years, but
it does not have to be done every year.
So the key to prostate cancer screening is not
let's not screen anybody, it's not let's screen everybody.
It's let's screen
the people that are at high risk and do it selectively and do it intelligently.
If I get a patient that has
a family history of BRCA2 gene, we will send them to our excellent
genetic counselors at Lombardi Cancer Center who will then do a full profile --
genetic risk profile.
And if they come back with the BRCA2 mutation, that's
when we'll start screening them very thoroughly.
PSA is the main intro screening test, which leads to a red flag
to maybe get what I call second level PSA testing.
And that can include blood tests that add on to the PSA
that is more specific for prostate cancer, less specific for,
say, enlarged prostate or prostate inflammation.
And that can include for a case or a higher prostate health index.
That can include a urinary test that detects DNA...tumor
DNA in the urine called an exosomedx.
So, in some patients where I'm on the fence
whether we should proceed with getting a biopsy or not,
those are the type of tests that I would get.
And I would also consider getting an MRI on those patients.