Friday, August 3, 2012

The System Sometimes Works - Why a baseline PSA is important.

Here's a success story and for once i'm impressed, not only did the system work, it worked when by all rights this patient would normally have slipped through the cracks and the results probably would have ultimately proven to be fatal.

This is the main reason men should have a baseline PSA performed in their 40's.

A 53 year old patient presented with a PSA of 1.1 but has a palpable nodule in his prostate, that has been biopsied and is confirmed to be cancer.

The patient has a family history of prostate cancer, his father died from metastatic prostate cancer. His primary care physician had been performing routine (annual) PSA screenings. I'm not sure what prompted the primary care physician to follow up but this man had three good reasons for follow-up:

1. Family history, his father died from prostate cancer.
2. Rising PSA.
3. An abnormal DRE.

Normally if a 53 year old male has a PSA of 1.1, it could/would be considered normal. Most physicians still use the magic number of a PSA of 4.0 as an action level to follow-up. Even the more recent recommendations is 2.5 for men under 70 (and that's for those that even still agree to do screening PSA's).  In this man's case his PSA actually went from:

Date                PSA
Sep-08             0.6
May-09            0.6
Nov-09            0.7
Nov-10            1.4

The primary care physician repeated the PSA in May 2012 and it had dropped to 1.1 (I left it out of the graph because it confuses it) but the primary care physician performed a DRE. It indicated this was not a bad reading I personally think one should have been performed within 3 months of the first abnormal reading but... low and behold they felt a firm nodule on the prostate. The patient was referred to the Urologist who decided to perform a biopsy. Of the six cores removed, one of them was positive for Adenocarcinoma with a Gleason score of 6 (3 + 3) in 10% of the sample.

This could have gone bad at so many junctures. What if;

1. If the physician looked at the PSA only and said, 1.4 is normal, not an unreasonable decision even for  53 year old..
2. If the nodule was on part of the prostate that was not within reach of the finger.
3. If the primary care physician was not experienced enough to recognize the nodule was not normal.
4. If the biopsy had missed the tumor (it's still possible some of the other cores did miss other tumors).

Bottom line, you need to look at the whole picture. Even if the nodule(s) weren't palpable, the PSA velocity indicates there is something bad going on here. The doubling time was 1 year. Having 3 years of constant readings followed by 2 indicating an increase is a big red flag. This patient needs treatment, he is 53, the chances are good that if left untreated, the cancer will cause his demise.

GOOD WORK to all those involved.

Get a baseline PSA performed! Then annual screening (every two years might be acceptable if your young and have no family history or other contributing factors).