Low PSA levels are associated with greater prostate cancer-specific mortality among men with a Gleason score of 8 to 10

Conclusions: Among patients with high-grade disease, patients with PSA levels ≤ 2.5 ng/mL or PSA levels of 2.6 to 4 ng/mL appear to have a higher risk for cancer-specific death in comparison with patients with PSA levels of 10.1 to 20 ng/mL, and this supports the notion that low PSA levels in GS 8-10 disease may be a sign of aggressive and very poorly differentiated or anaplastic low PSA-producing tumors. Patients with low-PSA, GS 8-10 disease should be considered for clinical trials studying the use of chemotherapy and other novel agents for very high-risk prostate cancers.

pubmed.ncbi.nlm.nih.gov/263...

[pjoshea13]

As you probably know, the original PSA cutoff of 4.0 for a biopsy was based on PSA not being cancer-specific & a lower cutoff finding too few cases. For a PSA between 4 & 10, 80% of biopsies are negative.

The problem is that BPH is common in aging men & BPH tends to significantly raise PSA levels.

Unfortunately, in the population of men being treated with a 5alpha reductase inhibitor, a PSA cutoff of 4.0 will tend to detect a lot more cancer than the usual 20% and at a much later stage.

For men who do not have BPH the same is true.

At the time of my first biopsy, my prostate was the size of someone in his 20's and my PSA was only 0.8. I had a 2nd biopsy only after the PSA had jumped from 1.7 to 3.0 in 3 months. The GS was 4+3. In retrospect, because I had no BPH, I should have had the 2nd when the PSA was 1.7 and the GS might have been a more treatable 3+4.

A man having a low PSA due to an absence of BPH is at a disadvantage under the usual screening guidelines. Even if the diagnosis is made at a low PSA, the GS might nonetheless be high,

The PSA era is over 40 years old. We have other tests available & they can hekp to avoid the need for a biopsy, but we rely too much on an initial solitary PSA test. PSA remains useful, but should be a part of a panel of tests. IMO

-Patrick

An alternative take on the 2016 paper is that GS=8-10 cases without BPH have greater mortality that GS=8-10 men with BPH.

(Although advanced PCa cells may produce little or no PSA, this is typically due to treatment.)

[DMohr011 in reply to pjoshea13]

Fall Oct 2019 I had my last physical exam. When it came time for the finger check, doc said they don't do this anymore, and rely totally on the PSA numbers. My PSA was 1.2 .

One year later, after biopsy, PSA 1.2 Gleason 9-10. But Google said it was BPH!

Would he have felt something with the exam? Who knows.

Dave

[pjoshea13 in reply to DMohr011]

Hi Dave,

One reason that the PSA test became popular is that the digital rectal exam [DRE] usually detected cancer when it was too advanced to be cured.

When the PSA test was created, the idea was that it would be used to detect/monitor progression. It was not viewed as being a good tool for screening. Even so, PSA+DRE was better than DRE alone. Some docs now think that DRE adds nothing. From a statistical standpoint they are doubtless correct, and there are many men who would prefer to skip the DRE, But I might not be here without that DRE.

The notorious rulings from the U.S. Preventive Services Task Force [USPSTF] should have led to the adoption of an enhanced PSA test - leading to fewer biopsies & less treatment, but until Medicare steps in, that will not happen soon.

Perhaps one day, a blood/urine test will eliminate the invasive DREs & biopsies of today?

-Patrick

[bigbassman in reply to pjoshea13]

I ended up in late 2016 with a Dx of Stage 4 Pca, Gleason 8 just after several DREs and ultrasounds indicated no "remarkable" results. PSA went from 4 to 18 over 4-5 months. I had historically low testosterone before and since. I had 37 sessions of EBRT, brachytherapy, and a further 10 sessions of radiotherapy to pelvic lymph nodes. 18 months of triple blockade ADT. My PSA has been undetectable in the intervening 5+ years. Currently awaiting bone scan results after several months of sciatic and leg pain. I had to initially pay for my own MRI in 2016 to convince my hospital prostate cancer clinic to get on board. Not a great hand to play.

[Hidden in reply to DMohr011]

You need to find a different doctor. "they don't do this anymore". [expletive deleted!] HE doesn't do it anymore, not THEY. I did have to get after my doctor to get the DRE I had been getting routinely from my previous doctor since my mid 40's. When he finally got around to it he detected abnormal firmness on one side. BTW, being associated with a medical school he was in thrall to the USPSTF and refused to order a PSA test. That DRE got me sent to a urologist for a biopsy. Gleason 8. PSA, which the urologist had to order? Only 2.7.

[JRPnSD]

I am convinced that there is no good news for any of us with GL 8 or greater (GL9 here). I still can't help but feel good about my undetectable PSA while on ADT.

[LearnAll]

There are men whose prostate churns out PSA like coca cola from a vending machine...I am one of those men. Was diagnosed only when PSA reached 830. There is member on this site who started with PSA of 10,000. He is still alive after many years.High PSA producing cells are like civilians who are still doing their regular job..of producing PSA. At times indulge in unlawful activities. They are not very distorted and mutated. In contrast, very low PSA producing cells have got so distorted that they are unable to do their regular job of producing PSA and are extremely different looking. . These cells have become full time criminals. Hence, these low PSA producing .. type of cells multiply like crazy and cause much more damage. Also, Neuroendocrine cancer cells produce almost No PSA.

[DMohr011]

BPH - Yup, that's what I thought. 1.2 PSA reading said it. But the biopsy said otherwise. Gleason 9-10. The Urologist knew with the finger check, and said right then, chances are high that I have a rare cancer that does not express PSA.

He was right. Pathology said Ductal Form, very high risk. Radiation Doc from Mayo showed me the charts of low PSA/high Gleason in relation to overall survival. Not good stats at all.

I focus on the other chart. The one that doesn't exist yet. The one that I am making the line extend.

After a rough start to things last year, today I show undetectable.

Let the good times roll!

Dave

[SUPERHEAT12]

Gleason 9 (5+4) with Psa of about 2.5 when diagnosed....Glad I found Dr. Myers.

[monte1111]

I'm with you on the PSA. But let's not get rid of the DRE. So many doctors and interns gave me a DRE that I was starting to enjoy it. Some wiggled their finger so much, I could tell they were enjoying it. Let's not take the fun out of prostate cancer.

[j-o-h-n in reply to monte1111]

My My, you're so gullible......some Doctors wiggled their finger? I bet you didn't even ask them why they weren't wearing rubber gloves.....My My no DRE. just PRE....

Good Luck, Good Health and Good Humor.

j-o-h-n Wednesday 04/20/2022 11:39 PM DST

[monte1111 in reply to j-o-h-n]

What? Me gullible? I totally understood the shortage of rubber gloves.

[j-o-h-n in reply to monte1111]

Now that was a quick quip....... I salute you sir, with my wiggly finger...

Good Luck, Good Health and Good Humor.

j-o-h-n Thursday 04/21/2022 7:06 PM DST

[monte1111 in reply to j-o-h-n]

I pray it has a glove on it.

[j-o-h-n in reply to monte1111]

LOL

Yep all eleven digits..

Good Luck, Good Health and Good Humor.

j-o-h-n Thursday 04/21/2022 7:13 PM DST