PSA ANXIETY

By Dr. Paul Schellhammer

PSA, the acronym for prostate specific antigen, is a test familiar to many
men whose acquaintance with it has been an emotionally charged experience.
That's because PSA is a marker of prostate cancer: In fact it is the best
cancer marker available in today's practice of medicine. Since half of all
American men over 60 and more than three-quarters of those over 80 harbor
some cancer cells in their prostate gland, it's easy to understand the
impact PSA may have. But, as important as it is as a tumor marker in the
detection and treatment assess?ment of prostate cancer, PSA reading can
create problems if not kept in perspective. First, the PSA level does not
reflect all the factors which affect the course of prostate cancer.

Furthermore the PSA number is a constant reminder of disease status that can
work on the minds of prostate cancer patients. Men who have low PSA's after
treatment and high hopes for a cure can crash psychologi?cally when the
number begins to increase because a PSA rise points to recurrence of
disease. Those with high PSA levels, although they feel physically well,
must endure the dark clouds and distress generated by the threat of
progressing cancer.

Simply stated, prostate cancer patients tend to evaluate their quality of
life, even life expectancy, on the PSA number. It tends to become a Holy ?
or Satanic ? Grail rather than just one component of the diagnosis and
evaluation of treatment of prostate cancer.  Over the years, I have learned
that most patients tend to place great importance on their PSA levels. When
I visit such a patient, introducing myself with "How are you?" the
inevitable rejoinder was "How's my PSA?" If I was able to provide a good
number ? zero or low and stable ? there was an obvious sigh of relief. If
the number was not what would be considered a safe range, extensive
reassurance and explanation became necessary. It was clear that the
patient's attitude and assess?ment of his treatment was overwhelmingly
influenced by his PSA number. I did not truly realize how much this was the
case until PSA numbers became part of my life.

Some background information about PSA is in order. PSA is used to identify
men at risk for prostate cancer; after diagnosis and treatment it is used to
identify the success or failure of the treatment applied. I believe strongly
that the routine assessment of PSA during periodic health checks called PSA
screening, will identify cases of prostate can?cer earlier so that treatment
can decrease prostate cancer mortality. This opinion is not yet supported by
the necessary clinical stud?ies, however. (Such investigations are
cur?rently underway in both Europe and America.) Despite this opinion that I
hold that PSA screening is beneficial, I also recognize that many patients
will receive the diagnosis of prostate cancer and be treated in order to
rescue only some from death from disease. Indeed, treatment is not necessary
for certain patients, specifically those who harbor a slow?ly growing tumor
that will not cause problems for the remainder of their lifespan. This may
seem counterintuitive, but prostate cancer is a disease of many stripes akin
to a barnyard analogy of turtles (slow moving) and birds (fast flying) and
other animals in between.

There's a saying that many men don't die of prostate cancer, they die with
it. In other words, it's quite possible for cases of prostate cancer to be
so slow in developing that patients live to advanced years before
suc?cumbing to other diseases. When urologists are sure that a patient has
this type of problem they can adopt the `if it ain't broke, don't fix it'
approach. The problem, of course, is to determine if a case of prostate
cancer really is of the slow-growing type. Is it really a "tur?tle", or is
it more "birdlike"?

Research efforts are currently directed towards identifying with greater
certainty those patients whose cancer may behave like a bird and for whom
treatment and cure is nec?essary because of the aggressive nature of their
disease. In our laboratory, we are ana?lyzing serum and tissue from men with
and without prostate cancer to measure the protein constitution of each. The
science and method?ology is termed Proteomics and has been dis?cussed in
prior newsletters. It is hoped that these characteristic protein signatures
or pro-files will be able to separate turtles and birds, and other animals,
and also provide added value to PSA in the diagnostic process.

In the meantime, we work with the tools at hand, prominent among them that
PSA reading. The most common treatment for PSA diagnosed cancers, is surgery
or radiation therapy. Physicians directing treatment will tell the patient
and his family that the measure of success of his treatment will be
determined by examination, but especially the quarterly, semiannual, or
annual PSA level. The desired objectives would be an undetectable PSA in the
case of surgery and very low, stable PSA if radiation therapy is employed.

After surgery, which removes the entire prostate, it is anticipated that the
PSA level will become undetectable. If this occurs the patient is, of
course, overjoyed, and the physi?cian will reinforce the patient's sense of
pleas?ure and satisfaction especially against the background of disruptive
changes in urinary and sexual function that the patient is likely to
experience immediately after surgery. The bottom line is that his zero PSA
is a significant reward for his pain, discomfort and dysfunc?tion.
Buttressed by a zero PSA, the postoper?ative patient's physical and mental
forces become concentrated in recovering, healing, and recuperating. These
are energy-consum?ing processes and the patient can still be con?sidered
under treatment. Being under treat?ment is actually quite comforting; a
patient draws strength from andfinds security in the support provided by his
physician and medical staff. When recovery nears completion and the
discomfort and dysfunction begin to resolve, the `under treatment' umbrella
is removed which, in many patients, triggers a sense of insecurity. The
patient is no longer moored closely to the pier of active therapy but finds
himself adrift in a sea of some uncer?tainty. His only anchors are his visit
to his sur?geon and, more critically, a periodic PSA read?ing ? and he
awaits that PSA number with a great deal of apprehension.

Patients who undergo radiation therapy rather than surgery face a different
problem with respect to their PSA readings. Successful therapy will
ultimately lower the PSA to unde?tectable or only slightly detectable
levels. Unfortunately, the fall to low numbers may take several years and,
to make matters worse, the decline will not be in a straight line. It will
have a sawtooth pattern, up one time, down another. Understandably, this
will produce anxiety in the patient. He will worry that the decline in his
PSA is too slow, or if it seems to be rising, that he needs more treatment,
and so on. A physician has to exercise great patience and provide adequate
counseling to allay those fears.

Studies have shown that most prostate cancer patients indicate they do not
mind being otherwise sick as long as their PSA readings are good. In other
words, their PSA number has become more important to them than their quality
of life. This should not be the case. Physicians recognize that a rise in
the PSA level, though it likely indicates disease activity, does not
necessarily mean that imme?diate treatment is necessary. It may take months,
even years, for the disease to cause symptoms, and indeed symptoms or
problems may never appear! This is a difficult situation with which most
prostate cancer patients feel uncomfortable, and understandably so. While we
all face a ticking clock and know in the back of our minds that someday
death will arrive, a rising PSA is a forceful reminder that the clock is
ticking ? and why it's ticking. This is disturbing and unsettling. Almost
everyone has had the experience of being sick and then recovering. But this
is not the same as facing a rising PSA. The increasing num?ber places a
known impediment to the quality and perceived duration of life. The clock is
no longer remote. The enemy has entered the gates and there is an
overwhelming desire to do something to block the PSA rise, and thrust the
enemy aside. n