Is PSA Density Still Relevant? #ProstateCancer | #MarkScholzMD #AlexScholz #PCRI

Summary

In this video, Dr. Mark Schles, a medical oncologist with over 30 years of experience in prostate cancer, explains the concept of PSA density, a valuable yet underappreciated term in prostate cancer diagnosis. PSA density offers deeper insights into prostate health by considering both PSA levels and prostate size, enhancing early detection and treatment effectiveness. Dr. Schles discusses the importance of PSA density in staging, monitoring treatment responses, and its role in active surveillance protocols, emphasizing the benefits of MRI for accurate prostate cancer detection and the potential of PSMA PET scans to reduce unnecessary biopsies.

Takeaways

• 📊 PSA Density is a ratio that compares prostate size to PSA levels, providing deeper insight into prostate health beyond just PSA levels alone.
• 👨‍⚕️ Dr. Mark Schles, a medical oncologist with over 30 years of experience, emphasizes the importance of PSA Density in prostate cancer staging and treatment monitoring.
• 🔍 PSA Density is particularly useful in early detection of prostate cancer through PSA screening, which can lead to effective treatment and potentially a cure.
• 🧭 Modern tools like MRI and ultrasound help in determining prostate size, which is crucial for calculating PSA Density.
• 🚫 PSA Density should not be used as a sole determinant for prostate cancer; it's an enhancement to the traditional PSA test.
• 📈 An elevated PSA Density can justify further investigation with an MRI or biopsy, especially in cases of active surveillance for low-grade prostate cancer.
• 🛑 PSA Density can help avoid unnecessary biopsies, as it provides context to PSA levels in relation to prostate size.
• 🔄 There's no direct correlation between a large prostate and aggressive prostate cancer; in fact, larger prostates may indicate fewer problems with cancer.
• 🏥 Insurance coverage for MRIs as a first step in cases of elevated PSA is widely accepted, making it a more accessible diagnostic tool.
• 🔎 PSA Density plays a role in deciding treatment options, especially in active surveillance cases where it can indicate the need for further investigation.
• 🌐 PSMA PET scans can provide whole-body scans for cancer detection but are not typically used as a screening tool due to radiation exposure and MRI's superior imaging inside the prostate.

Q & A

What is PSA density and why is it important?

PSA density is a ratio between the size of the prostate gland and the level of PSA (Prostate-Specific Antigen). It provides a more nuanced understanding of PSA levels than simply considering whether PSA is above or below a certain threshold.

How does PSA density relate to prostate cancer screening?

PSA density is used to enhance prostate cancer screening by offering a deeper insight into what elevated PSA levels might indicate, taking into account the size of the prostate gland.

What is the significance of PSA density in staging prostate cancer?

PSA density is significant in staging prostate cancer as it helps determine if an elevated PSA is due to the size of the prostate or potential cancer, which aids in deciding the next steps in diagnosis.

How does one obtain a PSA density measurement?

One can obtain a PSA density measurement by having a prostate scan to determine its size and then calculating the ratio with the PSA level.

What imaging techniques are used to determine the size of the prostate for PSA density calculations?

MRI and ultrasound are the imaging techniques used to determine the size of the prostate for PSA density calculations.

How does PSA density help in monitoring patients on active surveillance for prostate cancer?

PSA density helps in monitoring patients on active surveillance by providing context to regular PSA tests, indicating whether an elevated PSA is due to the size of the prostate or potential cancer progression.

What is the role of MRI in modern prostate cancer staging and treatment?

Accurately read MRIs are integral to modern prostate cancer staging and treatment, providing detailed information that can help avoid unnecessary biopsies and guide treatment decisions.

Is PSA density used in deciding upon a treatment for prostate cancer?

PSA density is used in daily practice to determine if further investigation with an MRI is needed when PSA levels are slightly elevated, but it's not the primary factor in deciding on treatment.

Is there a correlation between a large prostate and more aggressive prostate cancer?

Contrary to what one might think, studies indicate that men with larger prostates tend to have fewer problems with prostate cancer.

How does PSA density play a role in active surveillance for men with prostate cancer?

PSA density is used in active surveillance to monitor men with prostate cancer, helping to determine if there are other issues if the PSA is higher than expected based on prostate size.

What is the significance of PSA density in deciding whether a man needs a biopsy?

PSA density can indicate if a man might need a biopsy. If the PSA density is elevated, it justifies moving forward with an MRI or, in some cases, a biopsy.

Why is MRI preferred over PSA density for initial screening of prostate cancer?

MRI is preferred over PSA density for initial screening because it provides more detailed images inside the prostate without the need for radiation exposure.

Outlines

00:00

🔍 Understanding PSA Density

Dr. Mark Schles, a medical oncologist with over 30 years of experience in prostate cancer, explains PSA density as a critical term for staging and understanding prostate cancer. PSA density is a ratio comparing prostate size to PSA levels, offering deeper insights beyond the standard PSA threshold of 4. An elevated PSA with a large prostate may still indicate a normal PSA density, while a small prostate with high PSA suggests abnormal density. This concept is pivotal for early detection and treatment, potentially preventing prostate cancer-related deaths with effective treatments.

05:02

🧬 PSA Density in Prostate Cancer Screening

PSA density plays a significant role in prostate cancer screening, especially when deciding on further diagnostic steps like MRI or biopsies. Dr. Schles emphasizes the importance of MRIs in modern prostate cancer staging, which are more accurate and less invasive than random biopsies. PSA density can also be used to monitor patients on active surveillance, helping to determine if an elevated PSA is due to a large prostate or potential cancer. The discussion highlights the shift from traditional biopsies to MRI-first approaches in managing prostate cancer.

10:03

🩺 The Role of PSA Density in Treatment Decisions

In clinical practice, PSA density aids in treatment decisions, particularly for patients on active surveillance. It helps differentiate between a high PSA due to benign prostatic hyperplasia (BPH) and that which may indicate cancer. Dr. Schles discusses the correlation between larger prostates and a lower likelihood of aggressive cancer, contrary to common misconceptions. PSA density also guides further diagnostic steps, such as determining the need for a targeted biopsy or additional scans like PSMA PET scans, which can provide a more comprehensive view of potential cancer spread.

15:04

🌟 Empowerment in Prostate Cancer Management

The video concludes with a call to action for patients to be proactive in their health management. It encourages patients to understand their PSA levels, prostate size, and the implications of PSA density before medical consultations. This empowerment leads to more informed discussions with healthcare providers, potentially resulting in better treatment outcomes. The video also suggests reaching out to support lines for personalized guidance and emphasizes the importance of shared decision-making in healthcare.

Keywords

💡PSA

PSA stands for Prostate-Specific Antigen, a protein produced by the prostate gland. High levels of PSA can indicate prostate cancer, though it can also be elevated due to non-cancerous conditions like prostatitis or an enlarged prostate. In the video, PSA is discussed as a key marker for prostate cancer screening and monitoring, with the introduction of PSA density providing a more nuanced understanding of its implications.

💡PSA Density

PSA Density refers to the ratio of a man's PSA level to the volume of his prostate gland. It is used to more accurately assess prostate health, as it accounts for the size of the prostate. The video explains that PSA density can help differentiate between an elevated PSA due to a larger prostate versus a potential cancer, thus guiding further diagnostic steps.

💡Prostate Cancer

Prostate cancer is a type of cancer that occurs in the prostate, a gland in the male reproductive system. The video discusses the importance of early detection and staging of prostate cancer, emphasizing the role of PSA density in managing and treating the disease.

💡MRI

MRI stands for Magnetic Resonance Imaging, a medical imaging technique used to visualize internal structures of the body. The video highlights MRI as a crucial tool in prostate cancer detection, staging, and treatment planning, especially in conjunction with PSA density.

💡Staging

Staging in the context of cancer refers to the process of determining the extent of cancer in the body. The video mentions that PSA density can be a helpful tool in staging prostate cancer, providing more information than just a PSA level alone.

💡Active Surveillance

Active surveillance is a management strategy for patients with low-risk prostate cancer, where the disease is monitored closely without immediate treatment. The video discusses how PSA density can be used to monitor patients on active surveillance to determine if the cancer is progressing.

💡Biopsy

A biopsy is a medical procedure to obtain tissue samples for analysis, often used to confirm a cancer diagnosis. The video discusses the role of PSA density in determining when a biopsy might be necessary, especially in the context of an elevated PSA.

💡Benign Prostatic Hyperplasia (BPH)

BPH is a non-cancerous enlargement of the prostate gland. The video clarifies that while BPH can cause an elevated PSA, it is not typically associated with aggressive prostate cancer, contrasting it with cancer-related concerns.

💡PSMA PET Scan

PSMA PET Scan is a type of imaging that uses a radioactive tracer to detect prostate cancer cells. The video compares PSMA PET Scans with MRIs, discussing their respective advantages and when each might be used in the context of prostate cancer screening and diagnosis.

💡Digital Rectal Exam

A digital rectal exam is a physical examination performed by a healthcare provider to feel the rectum and prostate gland. The video mentions that skillful doctors could estimate the size of the prostate through this method, which can be relevant to calculating PSA density.

💡Shared Decision-Making

Shared decision-making is a model of clinical practice where healthcare providers and patients work together to make decisions about medical care. The video encourages patients to be informed about their health, including PSA levels and prostate size, to engage in shared decision-making with their medical team.

Highlights

PSA density is a useful term for prostate cancer staging and understanding PSA behavior.

PSA density provides deeper insights into prostate health beyond just PSA levels.

PSA density is a ratio between prostate size and PSA levels, offering a more nuanced view.

An elevated PSA with a large prostate may not indicate a problem, unlike with a small prostate.

PSA screening with modern tools can significantly reduce prostate cancer mortality.

PSA density is particularly useful for early detection of prostate cancer.

MRI and ultrasound are imaging methods used to determine prostate size for PSA density calculation.

PSA density is crucial for patients on active surveillance for low-grade prostate cancer.

Elevated PSA typically leads to immediate biopsy, but knowing PSA density can change that approach.

Accurate MRIs are integral to modern prostate cancer staging and treatment.

PSA density can help avoid unnecessary biopsies by providing context for elevated PSA levels.

Insurance coverage for MRIs is widely accepted, especially with elevated PSA.

PSA density plays a role in treatment decisions, especially in active surveillance.

Larger prostates have fewer problems with prostate cancer, contrary to common belief.

PSA density can indicate other issues like prostatitis or more aggressive cancer variants.

PSMA PET scans can provide whole-body scans to ensure no cancer is missed.

Saturated biopsies are less necessary with accurate MRIs, which have replaced the need for such invasive procedures.

PSA density is a key piece of information for shared decision-making with medical teams.

Empowerment with medical information leads to better patient outcomes.

PSA density is more informative than PSA levels alone for prostate cancer management.

Transcripts

today we're going to talk about PSA

density now this isn't a super common

term in prostate cancer but it's a very

useful term and Today medical oncologist

Dr Mark schules who's focused solely in

prostate cancer for over 30 years is

going to break down what PSA density is

and how you can apply it to your

case in today's video Dr sches we

talking about a term called PSA density

now this is not a common term in

prostate cancer for a lot of people even

when I research prostate cancer I have

to research it specifically I don't

think a lot of people pay attention to

it but it's very important when it comes

to staging and when it comes to how PSA

acts it gives us a lot of information

about the prostate so can you explain

what PSA density is think of PSA density

as a Step Beyond the normal or abnormal

PSA of four people are uh using PSA in

many different roles staging uh

monitoring response to treatment but

when you talk about PSA density for the

most part not always but for the most

part we're looking at PSA screening and

that is the policy of checking PSA in

healthy people who are trying to make

sure if they have prostate cancer that

they catch it early at a curable stage

and with all the modern tools at our

disposal I personally believe that if

people do PSA screening it's almost

impossible to ever die of prostate

cancer because you're going to catch the

disease so early and our treatments are

so effective that people can either have

their disease cured or controlled for

the rest of their lives PSA density is

an enhancement of just saying hey the

PSA is above four check it out the PSA

is below four I'm perfectly fine you

can't really obtain a PSA density unless

you have scanned the prostate and

developed a sense of how big the gland

is and this whole PSA density thing

really is nothing more than a ratio

between how big the prostate is and how

high the PSA is if the PSA is elevated

but your prostate big then your PSA

density is still normal if your PSA is

elevated and your prostate is

small then your PSA density is abnormal

and so this is a a useful way to try and

get a deeper understanding of what the

PSA is telling you rather than just a a

broads spread population Norm of it's

above four or it's below four before I

get to my next question please click

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pc.org donate now back to my

conversation with Dr schles so when

we're talking about scanning the

prostate are we just talking about MRIs

or what other forms of Imaging would you

use MRI ultrasound in the old days

skillful doctors could do a digital

rectal exam and estimate the size of the

process Prostate PSA density U although

it was developed for accurate uh

prostate cancer screening so if your PSA

density is elevated that's a

justification to move forward with an

MRI or in the old days a biopsy but it's

also helpful in our patients that are

monitoring uh low-grade prostate cancer

on an active surveillance protocol

because they're getting PSAs on a

regular basis so if the PSA is running

on the high side uh then it needs to be

interpreted in light of how big their

prostate gland is so a somewhat elevated

PSA in someone that has a big prostate

does not raise the alarm bells that

would occur if someone had an elevated

PSA with a small prostate so in a

typical situation when it comes to

screening for prostate cancer a man has

an elevated PSA typically he's going to

a doctor and then oftentimes he's really

sent to a random needle biopsy right

away and then even surgery or radiation

pretty quickly so where would the MRI

fit in does a man need to advocate for

himself because that PSA density seems

like it's a good piece of of information

that fits into this whole scene well

performed and accurately read MRIs are

an integral part of of modern prostate

cancer um staging and treatment the uh

information that men get from an MRI is

just so useful in so many ways and I

contend in many ways can help men avoid

having to get a biopsy at all modern M

are getting to be so accurate they are

literally more accurate than a random

biopsy and certainly they're a lot less

invasive a lot less

uncomfortable and you get this

additional information of course about

how big the prostate is which helps you

contextualize uh the PSA if it is

elevated is it because of a cancer or is

it because of a big prostate or

sometimes even both screening and

staging uh is for me the first step in

someone that has a suspicious PSA uh to

try and determine if there's uh

consequential prostate cancer present so

is MRI covered you know in that

situation typically where men have a

rising PSA to get an MRI first I haven't

run into difficulties getting MRI

insurance coverage for um some years now

the it's quite rare for any push back

from insurance companies if men have an

elevated PSA it seems to be widely

accepted now that getting an MRI is a

very reasonable First Step so would PSA

density ever play AP part in deciding

upon a treatment one way we use I use

PSA density in my day-to-day practice is

not so much for screening

because I have a very low threshold for

getting an MRI there's no radiation it's

covered by insurance and I don't like to

be guessing about whether or not

prostate cancer is present anytime a

question comes up of well maybe the PSA

is a little out of whack I typically get

an MRI make sure that there's not a

cancer present men can can have

significant cancers with normal PSA so

there have been even studies done

looking at doing MRIs and people with

normal PSA to see how often you can find

uh clinically significant prostate

cancer and they do find it's not common

but uh the reason we haven't just moved

to doing MRIs and skipping PSA

altogether is because thankfully

prostate cancers tend to grow slowly and

uh spread slowly so if even if you miss

it at its very early Inception stage as

it gets uh a little bit bigger and

produces a little more PSA in most cases

you're going to diagnose the prostate

cancer while it's still curable so

having a a PSA as a first step is think

is a logical and economical way to

screen but uh using a low threshold to

get an MRI uh and find out what's really

going on uh just makes a lot of sense to

me the question I've gotten oftentimes

is patients are wondering if there's a

correlation between a large prostate and

prostate cancer being more aggressive or

there being more prostate cancer over

time because the gland is larger and

your PSA density is higher is there any

correlation there's a correlation but

it's actually in the opposite direction

uh it turns out that studies indicate

that men with bigger prostates actually

have fewer problems with prostate cancer

we're not quite sure why that is having

an enlarged prostate is an issue that's

on a totally different track it's called

benign prosthetic hypertrophy than the

whole issue of prostate canc answerer

and all the complications and questions

that are associated with that so big

prostates are good unless from a cancer

point of view um they can be problematic

in the creation of urinary discomfort

side effects frequency and whatnot but

that has nothing to do with the

misbehavior of prostate cancer so in

situations where men do have these

larger prostates and maybe their PSA is

around 10 and they have 100 cc prostate

does that mean that they you know if the

MRI comes back clear that it's most

likely a BPH situation or because it's a

their PSA density is so high there's

other things we need to look at and

screen for using PSA density uh on an

ongoing basis in my day-to-day practice

is more in our men who are undergoing

active surveillance and we're doing MRIs

once a year to make sure that the little

spot of lowgrade cancer isn't growing

and everything seems fine but the PSA

density is elevated so these men could

have other issues because their PSA is

running higher than it should based on

how big their prostate is so what are

these issues well one is non-specific

prostatitis inflammation of the prostate

that's common we've pretty much ruled

out that it's just a big prostate

because we've looked at the size of the

gland and we see that the ratio the

ratio is supposed to be less than 0.15

if you divide the PSA into the prostate

volume the third thing is is this a

situation where somehow the Cancer's

gotten outside the prostate the MRI

isn't SE seeing it should we be

concerned that this person on active

surveillance has a more aggressive

variant that we're missing and uh that

uncertainty was always a big problem

until uh the Advent of psma pet scans

which allows us to scan the whole body

and make sure that these men who are

running PSA levels higher than what we

would expect uh probably from

prostatitis but possibly from a cancer

that you're missing uh now we can uh get

these very accurate uh scans pet scans

of the whole body and have greater

confidence that we're not missing

something that's escaped so an issue

that I've seen pop up a couple times and

I don't know that this is super um

prevalent but it is an issue I wanted to

address is that I've seen men with large

prostates come in to these centers and

they do get an MRI scan and then they

tell them because their prostate is so

large you know we can't do a targeted

biopsy we're going to be a saturated

biopsy and we're going to make sure we

check the entire prostate and for the

audience a saturated biopsy is anywhere

between 30 to my knowledge 30 to 40

needles so not only are they coming to

get a biopsy period random needle biopsy

now we're going to the next level of

saturated biopsy have you seen this

happen and what would you tell men who

are being told that they absolutely need

this I think the saturation bipsy where

not the typical 10 to 12 to 14 needles

which I also believe is not necessary

but again 20 30 40 uh needle biopsies

done often times under general

anesthesia uh was something that made

sense in an era where the MRIs were

unreliable we knew that with the old

random biopsies that 20% of the time the

random biopsy would miss something

consequential in a quarter corner of the

gland and that just because the biopsy

came back favorable there's still a

possibility that cancer was undiagnosed

the saturation biopsy was designed to

overcome that the reason I never

recommend saturation biopsies uh is

because the MRIs address that issue

there are uh naysayers about MRIs who

say well the MRIs are only 90% accurate

so what about the 10% we don't want to

have anything sneak under the rug and uh

someone be harmed because they the MRI

missed a consequential cancer well if

you look at what is missed by a modern

MRI read at a state-of-the-art center

it's a always a tiny high grade leion

that could say picked up if someone had

a radical prostectomy it was missed on

the MRI but it's never been demonstrated

that these tiny lesions are dangerous I

contend that uh men who have a clear MRI

should get a another MRI 12 months later

and if a consequential small lesion was

missed it will grow and become

detectable over time and it'll still be

caught at a curable stage much much

better to have an MRI 12 months later

than argue for putting someone in the

hospital giving them general anesthesia

and then harpooning them 20 to 40 times

with large boore needles the

relationship between these two

Alternatives is just glaringly favorable

in the idea of just do another MRI in a

year to protect against that 10% of men

that are missed we don't even know that

those 10% are ever going to turn into a

consequential cancer the we know when

men die and they do autopsies that many

men have small consequential higher

grade tumors that haven't harmed them

and uh the I think the right approach is

to watch these people get an MRI once a

year and treat the ones that start to

manifest that you can see can grow on

sequential MRIs and uh and don't don't

mess with the other ones because you and

I have talked about psma and this you

know PET Imaging that finds prostate

cancer specifically and we talk about it

so much on the Channel A lot of people

are wondering in the screening process

why we're not using psma instead of MRIs

and can you even know your PSA density

from a psma if we didn't have MRIs maybe

we would be thinking about using psma

pet scans uh as a substitute for random

biopsies and saturation biopsies but if

you compare the advantages and

disadvantages of psma versus MRI MRI

actually gets uh more refined images

inside the prostate psma gives you

better images of the rest of the body

MRIs don't have any radiation associated

with them psma pet scans you get a a

exposure to radiation which is uh

manageable if you have to do it but for

a screening tests on an annual basis

when you have an MRI that has no

radiation at all and shows more refined

pictures inside the prostate where you

really care I don't think there's any

rationale for doing psma pet scans as a

screening tool what about as a

substitute for a biopsy men do get these

MRIs and they may see a shadow which

they they call it a pyad score ring from

one to five and the fours and fives

typically need to get a targeted not a

random bipsy but just kneels at The Spot

psma pet scan is a potential alternative

to biopsy because it's also about 90%

likely to pick up cancer if it's present

so if a man has a pyes 4 5 lesion on an

MRI but a psmi pet scan doesn't light up

there he's can estimate there's about a

90% chance that that's not a

consequential cancer even though the MRI

shows a shadow there and that individual

might be able to avoid a biopsy so there

is a place for PSM pet scans in the

earlier elucidation of who needs

biopsies and staging and all these sorts

of things but as a routine screening uh

tool the MRI is a much better

tool when screening prostate cancer the

typical system is that men have a rising

PSA and then they're usually sent for a

random needle biopsy but if you can get

an Imaging study ahead of time before

the random needle biopsy ask your doctor

about it and say I would like to know

the size of my prostate whether that's

based off an Imaging study or the

digital rectal exam and that way you can

know how large your prostate is and what

your PSA should typically be based off

of that and as we talked about PSA

density this is a really great piece of

information to know ahead of time we are

a big believer that you should have a

shared decision-making experience with

your medical team which means you

educate yourself you know what your PSA

is you know what it typically does you

know the size of your prostate you know

ahead of time when it comes when you

come into those doctor's appointments

and that way you are working with a set

of information about you as a particular

case and when you're talking to your

doctor you're just having a more

educated experience with him you're

having a better conversation and often

times time and time again we have seen

that patients who Empower themselves

with their own history their own medical

information have greater outcomes better

outcomes over time because you're

becoming the CEO you're becoming in

charge of your own health and that's

very important because when you're in a

system there's a lot of things that you

know insurance companies or academic

systems there's a lot of things that

patients you know are in when it comes

to prostate cancer but if you know your

own health your own information it can

help guide you through that process so

that you get better care customized care

and have better outcomes when it comes

to prostate cancer treatments down the

line so if you need help with your

particular case you can contact us at

pc.org helpline these are prostate

cancer patients who have been through

this you know situation they've

navigated all this before they've been

trained bar a medical oncology team and

they can give you information not advice

but it's a great way to empower yourself

before you step into those doctor's

appointments so that you can ask him

would this be right for me is this not

and that way you get the answers that

you need so I would really encourage you

to contact them also if you have topics

or questions you would like us to cover

in future videos you can leave it in the

comment section below this video and

give us give us a thumbs up if you found

this video helpful please remember most

of all you're not alone and we really

appreciate that you watch this channel

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