ASK MAYA APA

Dear Maya Apa, 

I am a 60-year-old male. I have had hypertension for the past two years. During my routine check–up, I got to know that my prostate is now enlarged; that was six months ago and at that time my PSA was 3.5ng/ml. 

Recently I was facing some difficulties originating? for which I consulted a physician. Up on investigation my PSA was found to be 9.4ng/ml. I have not seen my doctor yet and there is no one to look after me. My grandfather died of prostate cancer. Do I also have prostate cancer? Why is my PSA increasing? Can you please explain and advise me on this matter.

- Troubled

Dear Troubled, 

Thank you for sharing your problem with us. 

PSA is prostate specific antigen, a protein produced by both cancerous (malignant) and noncancerous (benign) prostate tissue. PSA helps to liquefy semen. A small amount of PSA normally enters the blood circulation and a test is done to measure the level of PSA in the blood, as you have also mentioned. 

PSA helps to detect small tumours that do not reveal symptoms and detecting prostate cancer early by screening PSA level and other physical examinations reduces the chance of leading to severity. 

It will be helpful for all readers to know that based on published reports, men who have a prostate gland that feels normal on examination and a PSA less than 4, have a 15 percent chance of having prostate cancer. Those with a PSA between four and 10 have a 25 percent chance of having prostate cancer, and if the PSA is higher than 10, the risk increases and can be as high as 67 percent.

It is a myth to think that a high blood-PSA level is harmful to you - it is not. High blood PSA levels are however an indication that something may be wrong in the prostate.

Most men have PSA levels under 4 (ng/mL) and this is the cut-off value for concern about the risk of prostate cancer. If a man's levels of PSA are high, it might be an indication of either prostate cancer or some kind of noncancerous prostate condition such as infection of prostate (prostatitis); enlarged prostate and these could be simply due to aging. 

There is no evidence that infection (prostatitis) or enlarged prostate (benign prostatic hyperplasia) leads to cancer, but it is possible for a man to have one or both of these conditions and to develop prostate cancer as well.

Prostate gland increases in size and produces more PSA with advancing age, so it is normal to have lower levels in young men and higher levels in older men. 

As now you know, there could be many reasons of increased PSA so other physical examination called digital rectal examination (DRE) will be conducted by your doctor to exclude those causes. 

Along with clinical history and PSA, DRE - digital rectal examination is an important way to evaluate the condition of prostate as well as rectum. 

Knowing risk factors for prostate cancer can help understand if one is at risk and to go for PSA screening and further physical examination – 

Age – after 50 years, chances of having cancer increases substantially but majority of prostate cancer is found in men aged 60 years and above. 

Race - black men have a higher risk of developing and dying of prostate cancer than other racial groups.

Family history- if grandfather, father, brother have had prostate cancer at an early age, your risk is considered very high. 

Diet - high fat diet and obesity may increase your risk of prostate cancer. 

Endocrine factor – testosterone (male hormone) is responsible, it's more likely no testosterone, no cancer.

Drug - finasteride (treats male hormone testosterone), ditasteride (to treat enlarge prostate gland).  

As you do have risk factors, you should visit your doctor with your reports to have a DRE done and further evaluation because PSA level combined with DRE can help you reassure that it is unlikely to have prostate cancer. So do not be scared just with one positive investigation report. 

As we have stated, there are many reasons for which PSA level can rise; to exclude other causes of DRE (digital rectal examination) is done by your physician if PSA level is continuously rising. 

If any suspicious lump is found during DRE then the doctor will recommend additional tests to determine the nature of the problem. 

Tests include: 

Urine R/M/E and culture – to check if any urine infection present

Blood test- alkaline phosphatase in blood will be higher than normal

Imaging test – 

  a. Transrectal ultrasound 

  b. X-ray or cystoscopy 

Finally, if all of these are positive or hint towards a malignant growth, your physician will recommend a prostate biopsy. Tissues collected from your biopsy are sent to pathologist in laboratory to observe under the microscope. If it is cancerous (malignant) pathologist grades it from 2-20 according to the Gleason System of grading. The higher the number, the more abnormal the tissues are compared to normal prostate tissue.

Dear Troubled, even though your PSA is elevated with enlarged prostate, along with a positive family history, until further investigations are done nothing can and should not be concluded. 

So do not be anxious, for there may not be any reasons to be! Just consult your physician. Early prostate cancer is asymptomatic. Only advanced stage give rise to symptoms; if someone is faced with any of the following signs or symptoms you should consult your physicians as these may indicate towards an enlarged prostate -

Frequent need to urinate especially at night

Difficulty starting and stopping a stream of urine

A weak or interrupted urine flow

Leaking of urine when laughing and coughing

Inability to urinate standing up.

Painful and burning sensation during urination and sex

In advanced stages-

Blood in urine

Dull, deep pain or stiffness in lower back, upper thighs, lower abdomen.

Loss of appetite, weight loss, fatigue, nausea, and vomiting

Swelling of legs

Weakness of legs, bone pain and may have constipation

Prostate cancer is mostly a very slow progressive disease. In fact, many men die of old age, without even knowing they had prostate cancer. Therefore, I would advise you to consult a specialist physician soon for further assessment. Now, there are many treatment options are available no need to be scared of it.

Your case has given us the opportunity to discuss the matter at length, which we hope, will not only benefit you but all people facing prostate related issues. We hope for your long health.

Always by your side, 

Maya Apa 

The question was referred to Dr Yeafi Umme Awal, Medical Specialist