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Understanding PSA Numbers in Men · Bryan Health Podcasts

• 0:03
  Melanie Cole, MS (Host): Welcome to Bryan Health Podcast.
• 0:05
  I'm Melanie Cole.
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  And we're highlighting prostate-specific antigen today,
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  or what we refer to it as PSA.
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  We're learning about what that is and why it's such an
• 0:16
  important number for men to know.
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  Joining me is Dr.
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  AJ Pomajzl.
• 0:21
  He's a board-certified urologist at Nebraska Urology.
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  Dr.
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  Pomajzl, thank you so much for joining us today.
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  So, why don't you tell the listeners what is PSA, and why is this an
• 0:33
  important number for men's health and for men to know and understand?
• 0:39
  Dr AJ Pomajzl: Yeah.
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  The PSA, it's a simple blood test.
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  It stands for prostate antigen.
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  And what it does is it gives us a number.
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  Now, the number in a PSA test is different than some of your other lab work tests.
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  It's just a protein.
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  It's inert.
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  it doesn't do anything to your body.
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  So, if a man has a PSA level drawn and it's 2,000, that doesn't mean that the
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  PSA itself is hurting the man's body.
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  You know, compare that to cholesterol.
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  And cholesterol, if it's that high, it means there's actual disease
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  process going on, plaques are being built, arteries are stiffening.
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  It's a problem itself in the number.
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  The PSA, it's just a flag.
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  If the PSA is high, it means we should look into a man a little bit
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  more closely than if the PSA is low.
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  Melanie Cole, MS: So, tell us a little bit about what low and high means,
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  and is this a controversial test now?
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  For some reason, I've heard about things in the media.
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  Speak a little bit about what those numbers are and whether this is
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  something that really men need to watch.
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  Or if not, why?
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  Dr AJ Pomajzl: The PSA test has a actually a pretty interesting history in medicine.
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  And the main reason is, in 2012, one of the major preventative services guidelines
• 1:52
  recommended against PSA screening.
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  They did that for a number of different reasons, which are interesting in itself.
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  But really, the important thing is what happened when they recommended
• 2:03
  against screening, the PSA screening actually declined by about 46%.
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  And those numbers are from 2008 to 2022.
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  So, the recommendation was real, and it impacted primary care physicians
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  and how they directed their patients,.
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  And it also kind of came with a stigma for patients themselves to avoid the test.
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  Now, why the history of the decision they made isn't important here
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  is because we know what happened.
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  And some of those things that happened were metastatic prostate
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  cancer began to rise after 2012.
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  In fact, metastatic prostate cancer rose 37%.
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  That means we were missing men with localized prostate cancer,
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  because we weren't screening them.
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  Some other really important studies that have finalized over the last few
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  years done in Europe showed that there was a 13% reduction in prostate cancer
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  mortality in men dying from prostate cancer if they were welcomed to screen.
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  If you look at those numbers even more closely, in that study,
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  that 13% recognizes that some men chose not to be screened.
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  If you look at the men that were all screened, that reduced
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  mortality by 20% to 21%.
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  Those are pretty incredible numbers.
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  That kind of goes to the source of why there's a stigma.
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  And, you know, it's interesting, the reason why prostate cancer screening is
• 3:21
  important is it's a very common cancer.
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  It has no symptoms.
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  You don't know you have prostate cancer until it's too late.
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  You won't get symptoms until you develop advanced prostate cancer.
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  Compare this to other common cancers that have successful screening protocols
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  like breast cancer and colon cancer.
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  Those two are dangerous cancers, but they're usually asymptomatic.
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  Now, I think, over the years, you look at women's health,
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  it's had tremendous advocates.
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  And mammography is normalized and breast cancer awareness is part of our culture.
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  We have our NFL players wearing pink uniforms, which is awesome,
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  and that's a good thing.
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  And colonoscopy, I think, has the same cultural foothold.
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  Men's health honestly hasn't had that same champion.
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  We haven't done as good of a job making routine screening
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  feel expected or even masculine.
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  So, a man who skips his PSA doesn't feel like he's doing something risky,
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  he just feels like he's being a guy.
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  And I think that cultural gap has real consequences, and those
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  numbers we talked about shows that.
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  We're not trying to compete with other screening tests.
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  All those screening tests are important, and I recommend all of them.
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  I think one thing that we need to do a better job of urologists and
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  men's health champions is trying to close that gap because those
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  real numbers have cost real lives.
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  Melanie Cole, MS: Well, I agree with you in all that you just said, Dr.
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  Pomajzl.
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  Now, tell us about the numbers, What are those numbers we're looking
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  at if they get their PSA done, they get their blood work done?
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  Tell us a little bit about what those numbers are.
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  Dr AJ Pomajzl: The important thing about the PSA test, one of the cool things
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  about it is, of all men, if you look at population studies, 90% of men that
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  get their PSA checked are reassured.
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  Ninety percent of men do not have an elevated PSA.
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  So, 9 out of ten guys will get this screening blood test and
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  walk away without any worries.
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  In fact, they'll walk away reassured.
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  Now, if you look at that 10%, if you repeat a PSA on those 10% that
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  had a initial high PSA, anywhere between 25% to 40% of those guys
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  will have a PSA that normalizes.
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  And again, there you go.
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  You're slicing the pie even smaller.
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  Now, of that 25% to 40% of that 10%, you know, if we get down the
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  pathway far enough that we're worried enough about potential prostate
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  cancer and we get to that point of a prostate biopsy, of those biopsies,
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  60%-75% of them come back negative.
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  So again, the pie is sliced even lower, okay?
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  So, we're talking about a smaller percentage of men at this point.
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  And if you, unlucky enough as you may be to be diagnosed with prostate
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  cancer, a lot of those guys, up to 60% of them are managed just with
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  active surveillance or no further treatment, just close monitoring.
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  So, one of the things I want to relay is that this PSA test in a very, very high
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  portion of men, they'll be reassured.
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  They'll feel confident and better that this is something
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  they don't need to worry about.
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  And of those men that need to worry about it, most of them may never need treatment.
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  One of the most important things to know about the PSA test is that
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  it's variable depending on your age.
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  So, a PSA of 3.5
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  in a man that's 55 is drastically different than a PSA of 3.5
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  in a man that's 75.
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  Typically, as we age, our PSA rises.
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  And that's because of the natural fact that as we age,
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  our prostates continue to grow.
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  And therefore, we secrete more PSA.
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  Again, the PSA test is not a binary test.
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  It's not a test that says, "If your PSA is 4.2,
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  you're elevated, we're doing a biopsy."
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  It's not a test that says, "Your PSA is 3.9,
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  you're not elevated, we don't need to worry about you."
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  It's, just a gateway to get you into a primary care physician or urologist
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  that can better assess what that PSA value means for you specifically.
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  On top of that, there's a few other things that can affect your
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  PSA value that aren't cancer.,
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  Your PSA, it's a prostate-specific antigen, not a cancer-specific antigen.
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  Your PSA can be elevated for any number of reasons, a benign enlarged prostate.
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  It can be elevated because of biotin supplementation or a common
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  medicine that we take nowadays.
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  motorcycle riding, horseback riding, riding on your lawnmower.
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  an infection that you don't know you have, that your body's clearing on its own.
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  It's a pulse on the prostate when it's drawn.
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  It's not a binary answer, yes or no.
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  Melanie Cole, MS: So, how does a man get a PSA test, Does he do this through his
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  primary care provider when he gets that annual physical, , or Bryan On-Demand lab?
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  Tell us a little bit.
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  Does he have to come see a urologist?
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  How does he do it?
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  Dr AJ Pomajzl: They're both reasonable options.
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  At the Bryan On-Demand lab, you don't need a referral.
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  It's a walk-in lab.
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  I think the last time I checked it was $12.
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  It doesn't require insurance prior authorization.
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  That's a simple way to do it.
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  I think oftentimes the better way to do it is with your primary care physician, as
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  a part of your normal routine screening.
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  Those are the doctors that know the best about their patients.
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  They're able to contextualize these labs and make sure that if you are a man that's
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  in his early 70s and your PSA is 4.1,
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  to reassure you and appropriately work you up, maybe repeat a PSA or to get
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  you to a specialist like a urologist.
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  I think those are your two best resources, your primary care physician,
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  but also a walk-in lab, one of them being Bryan On-Demand lab.
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  Melanie Cole, MS: And if the levels are high, and you mentioned that it
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  doesn't necessarily mean that it's cancer because BPH is something that
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  also happens to men as they age.
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  Will you reassure men that it doesn't necessarily mean cancer?
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  Tell us a little bit about what a man is supposed to do if he gets a level
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  higher than you might like it to be.
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  Dr AJ Pomajzl: Right.
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  That's the exact right question.
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  So, again, the big picture is that funnel I talked about, those men that have a
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  PSA that are normalized on repeat draw, about men that have negative biopsies.
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  But really, the most important thing if you get an initial
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  elevated PSA is, again, to reach out to your primary care physician.
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  They'll know how to best direct you.
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  They'll know whether it's important to repeat a lab test.
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  They'll know whether it's important to get you right away to a specialist.
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  That's really the best resource for most men because their
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  doctors know the most about them.
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  Now, I do know that most urology practices, including Nebraska
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  Urology, we do offer self-referral.
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  Sometimes, insurance demands a proper referral, it's a formality.
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  It's not a medical gate.
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  You can always call a specialist directly and see if their
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  office would want to see you.
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  But typically, the more appropriate way is to go in through your primary
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  care physician and let them triage you to the appropriate location.
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  Melanie Cole, MS (Host): Tell us about what's exciting in your field, Dr.
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  Pomajzl.
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  If someone is diagnosed with prostate cancer, what are some of the exciting
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  things that you've got going on?
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  Because there are so many more tools in your toolbox now for dealing with this.
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  There's watching and waiting and hormonal therapies.
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  There's so much going on.
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  Just tell us some of the exciting bullet points here.
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  Dr AJ Pomajzl: Prostate cancer, because it's so common, there's
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  a lot of actionable information being created every day.
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  Prostate cancer being treated in the '80s is entirely different from prostate
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  cancer being treated in the early 2000s, which is entirely different than
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  prostate cancer being treated in 2026.
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  So again, one thing I want to reassure men is that prostate cancer is common.
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  But up to 60% of men that are diagnosed with prostate
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  cancer, won't need treatment.
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  They'll just be either watched closely with what's called active surveillance,
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  where we watch that cancer very closely and do some genetic tests on it and
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  do some advanced MRI diagnostics.
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  And a lot of times, of the men that are diagnosed with prostate cancer, up to
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  60% of them have it, it's never treated.
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  When we don't treat prostate cancer, we do one of two things.
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  Most commonly, we're doing something called active surveillance, where we're
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  using advanced genetic tests to properly assess the cancer and how aggressive it is
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  and see if it's one that's safe to watch.
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  We use repeat PSAs and advanced imaging like MRI to make sure the
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  cancer never affects a man's life.
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  But if that cancer does show that it's aggressive or on biopsy, it proves
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  to be a more aggressive prostate cancer, we have become very good at
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  robotic minimally invasive surgery.
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  The robot has changed how we treat prostate cancer.
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  And nowadays, almost all urologists are doing robotic radical prostatectomies,
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  and outcomes are excellent.
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  And some of the men I diagnose, if they have cancer that's in a favorable
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  position, I can do a more advanced anatomical technique where I spare a
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  lot of the pelvis when I remove the prostate gland, that leads to quicker
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  functional returns after surgery.
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  Our radiation oncologist colleagues who again treat prostate cancer
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  just as effectively as we do, they've changed the game.
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  A lot of times, they're transitioning from what could have been 40 traditional
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  radiation treatments to being able to treat a prostate cancer appropriately
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  in as little as five sessions.
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  So, there's a lot of activity in prostate cancer research, because it's such a
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  common cancer and it affects so many men.
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  The field changes almost every day.
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  Melanie Cole, MS: Yes, it's a very exciting time in your field.
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  And so Dr.
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  Pomajzl, wrap it up for us.
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  Give men and the partners that love them your best advice about PSA, about prostate
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  cancer, about whether they need a referral and how someone can get an appointment
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  to get this very important test done.
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  Dr AJ Pomajzl: So, prostate cancer, it's so common.
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  And if we spoke more about it, I think most men would be surprised how many
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  of their coworkers or their friends or their relatives have had to go
• 12:48
  through a prostate cancer diagnosis.
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  There is an amazingly simple, cheap, low-risk test.
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  It's a blood draw.
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  It can be as cheap as $12 out of pocket.
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  And just getting that test will make 90% of men feel good and
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  know that they don't need to worry about prostate cancer at this time.
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  If we diagnose prostate cancer, the whole point of the PSA test is to find
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  those men that we're worried about.
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  Well, we know with data that if we follow the PSA test and use
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  it to screen men, we can reduce prostate cancer mortality by 13%.
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  And that's a conservative number.
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  That means for every 450 men approximately that are screened, one
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  more man will be there to watch his granddaughter play softball or to
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  celebrate his son's wedding, or to hold his granddaughter for the first time.
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  These are real numbers.
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  And I myself have had the blessing to sit across from a man who was
• 13:47
  diagnosed appropriately and treated appropriately and came out on
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  the other side a cancer champion.
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  But I've also had the hard role of sitting across from a man who came to my practice
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  with a PSA of 450 and severe back pain because he had metastatic prostate cancer.
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  Again, that's nobody's fault.
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  But the more men we can screen and the more men we can appropriately counsel,
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  the less men that will happen to.
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  Melanie Cole, MS: Great information.
• 14:15
  So well said.
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  Doctor, thank you so much for joining us and really sharing your incredible
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  expertise for the listeners today.
• 14:23
  And I'd like to thank our Bryan Foundation partner, Cirrus Systems.
• 14:28
  And to listen to more podcasts from our experts, you can always
• 14:31
  visit bryanhealth.org/podcasts.
• 14:33
  That concludes this episode of Bryan Health Podcast.
• 14:36
  Remember to always subscribe, rate, and review Bryan Health Podcast on Apple
• 14:41
  Podcasts, Spotify, iHeart, and Pandora.
• 14:43
  Until next time, I'm Melanie Cole.