PSA 4.3 on a physical exam sent me to a urolgist.  The first thing he
did was a Free PSA test.   That result of 19 justified the biopsy, which
detected Gleason 6.  Seems to me they are using the FRee PSA test.

For the individual patient, the free PSA reading would be moot if he had
a biopsy.  So I suppose doctors don't bother with fPSA unless the
patient declines a biopsy.

jimhoney

Dick Smith wrote...snip...

Hi Dick...Small world (or something like that), I was reading similar
information at the Brady website this morning.  At

http://urology.jhu.edu/prostate/advice1.php

they say, "Investigators at the Brady Urological Institute and the
Baltimore Longitudinal Study of Aging discovered that free PSA is
predictive of the aggressiveness of prostate cancers. Using frozen
serum samples to measure PSA and free PSA long before the diagnosis of
cancer was made, it was found that the percentage of free PSA (PSA in
the blood not bound to proteins) distinguished between aggressive (high
grade) cancer and non-aggressive cancer 10 years before the cancers
were diagnosed. The percentage of free PSA in the blood fell as the
tumors progressed toward the date of diagnosis. A percent free PSA of
15 or lower was predictive of the diagnosis of aggressive prostate
cancer 10 years later."

I forget how much more a "free  plus total" PSA test costs compared to
"total" only, but there can't be that much of a difference.  So I asked
myself a question similar to the one you're asking, if free PSA can tip
you off 10 years before the biopsy finds something, why don't docs
routinely call for the combined test when your in for yor yearly
physical..duh?  BTW, I suspect we all know the answer...Best wishes and
good health, Ron

I wonder if they have ever been able to qualify it with a recurring ratio to
Gleason.

My primary care doc did the free PSA when the regular PSA came back 5.0.
The free PSA came back 6%.  Not good according to what you listed below, but
they caught mine early, so I was lucky.

As to the study, etc., when was the book published?  There is probably a lot
of water under the bridge since then.  Maybe the relationship was not
verified or is not that direct.

I have some questions about all this, and some thoughts.

The first question is:

   By "aggressive" tumors, do the researchers mean tumors with
   high Gleason grading?  Or do they mean tumors that spread
   and kill people?  In other words, is it possible to have a
   high Gleason score and high free PSA or a low Gleason score
   and low free PSA?  Are we looking at independent variables
   or not?

The second question is:

   Is it possible to have a low free PSA and not have cancer,
   or have a high free PSA and have cancer?

As for why doctors aren't doing free PSA tests, one reason is
that they haven't followed this research.  I asked my current
radiation oncologist if he would give me a free PSA test.  He
said he would if I wanted, but he didn't know what it's
significance was and couldn't interpret it for me.

Based on your report of Dr. Walsh's report, it seems to me that
free PSA might be useful for the following purposes:

   1. Help with early diagnosis.

      Presumably a higher complexed PSA with a very high free
      PSA is less suspicious than a high complexed PSA on its
      own and a biopsy might be postponed for a while.

      Conversely, low free PSA might merit a biopsy even if
      the complexed PSA is not that high.

   2. Provide confirmation of biopsy analysis.

      If the free PSA measurement and the biopsy Gleason
      grading agree - there is good reason to believe them.
      If they disagree, e.g., high Gleason + high free PSA, or
      low Gleason + low PSA, then there might be special
      reason to go get a second opinion on the biopsy and
      maybe have more or repeated testing.

   3. Diagnose post treatment PSA rise.

      This is a wild speculation, but maybe if a man has a PSA
      rise after treatment, perhaps the free PSA would help
      him to determine whether to try less aggressive
      treatment (e.g. intermittent ADT) or more aggressive
      treatment (e.g., triple ADT).

      I've read that free PSA can also help distinguish
      between a PSA failure and a PSA "bounce" after
      radiation.

Everyone should note that the above speculations about the
usefulness of free PSA have about the same authority as my
speculations on quantum mechanics, brain surgery, and rocket
fuel formulations.

In other words, I don't really know what I'm talking about here
- just speculating.

   Alan

My first uro went straight to fPSA, but said he didn't place that much
faith in it. %ages were around 16, IIRC. My positive biopsy suggests it
was a good marker.

--
Peter Headland

I had PSA of 5.0 at age 45, found during routine blood screening for my
annual physical.  The urologist to whom I was referred requested repeat PSA
and fPSA, came back at 4.9 and 7%.  So, underwent three separate biopsy
sessions (yeah, that was been fun - not), last one with Dr. Fred Lee.  
Fortunately they all were negative, showing only limited inflammation.

It certainly seems possible to have low free PSA and still not have pCA,
though the statistics I've seen say it's also more likely to be pCA with
low fPSA.  Less than 10% has been said as very indicative, but it seems to
vary with every study.  Maybe they just missed hitting it with all the
biopsies, but the risk of that seems pretty small.

Guys with multiple negative biopsies, yet elevated PSA and low fPSA seem to
be a very gray area to urologists.  No one seems to have a cut-and-dried
strategy for dealing with it.  What to do?  They seem to fall back to the
method of watching for a rising PSA before they do anything else.

Time will tell.  I'm still nervous about it, to be honest.  All this
"predicts x years early" stuff makes me concerned that with my numbers I
have a significantly increased likelihood in the not-too-distant future.

Also, Walsh's 2001 book in the section on "Bound and Free PSA" says even
after "multiple biopsies", a persistently low fPSA merits "further
biopsies", but doesn't say anything about how many or how often.  My uro
says unless I get a significant rise (like >0.75/year for 2 years) in PSA
over time we won't do anything further about it.  My PSA runs around 3.3 to
4.0, and the fPSA hangs between 7% and 10%.  

I don't know what to do from here.  Mostly I try not to think about it,
except for my annual PSA test and the wait for results (which most of you
are certainly familiar with!).