Is PSA Density Still Relevant? #ProstateCancer | #MarkScholzMD #AlexScholz #PCRI
Summary
TLDRIn 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
🔍 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.
🧬 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.
🩺 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.
🌟 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.
Mindmap
Keywords
💡PSA
💡PSA Density
💡Prostate Cancer
💡MRI
💡Staging
💡Active Surveillance
💡Biopsy
💡Benign Prostatic Hyperplasia (BPH)
💡PSMA PET Scan
💡Digital Rectal Exam
💡Shared Decision-Making
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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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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