In this episode, Gary enters the prostate cancer maze when his PSA test results increase rapidly.

This is Gary Ebersole. I’m back with another chapter of The Prostate Papers. In this episode, we get serious about all the decision points and choices that men must make in their journey through the “prostate zone.” As always, I remind the listener or reader that I’m not a doctor. I’m merely trying to provide a guide that might help you better understand what’s on the path ahead. These are my experiences and may not reflect your situation.

To illustrate The Prostate Papers journey, I’ll introduce a metaphor I use to describe my travels through the prostate zone to visualize what it feels like to be on this trip. I sometimes think of myself as a package going through a maze of conveyor belts and chutes in a UPS sorting facility. As you ride along, you’re confronted with a sequence of decisions, often with several options and various outcomes. Depending on your decision at any given point, a gate closes, and you are sent down a chute onto a different belt. As much as you would like to return to the beginning of your trip and find a more pleasant adventure than dealing with prostate cancer, the belt only moves forward, and the ride continues.

Let’s start with the first decision most men think they must make—should I have my PSA levels tested yearly? In truth, your first decision is often whether to submit to a digital rectal exam (or DRE) by your primary care physician during your annual physical exam. Unfortunately, the evidence supporting using a DRE to identify early-stage cancers isn’t great. If the DRE is part of your yearly exam, welcome to the prostate cancer maze and hop onto the “watchful waiting” conveyor belt. Another, possibly even earlier, access point to this conveyor belt is when patients report lower urinary tract symptoms to their doctor. Google “prostate cancer lower urinary tract symptoms” to get the long list of symptoms. You can expect a DRE and a baseline PSA test if you report any of these symptoms. You’re also on the “watchful waiting” conveyor belt.

Back to PSA testing, which is a stronger indicator of possible prostate cancer than either the DRE alone or patients reporting lower urinary tract symptoms. Confusing for both patients and doctors, there is no consensus on prostate cancer screening guidelines. The American Cancer Society, the American Urological Association, the United States Preventive Services Task Force, and the National Comprehensive Cancer Network all have different (sometimes contrary) recommended guidelines. For instance, the USPSTF, a government-funded nonprofit organization, recommends against PSA testing for men over 70 (I’m 75). The ACS is more nuanced and recommends continued annual screening if baseline test results reach a certain threshold. The other groups are similar. There are very good reasons for this ambiguity. The risk of overdiagnosis (and overtreatment) for prostate cancer is high. Nobody wants the prostate cancer treatment side effects if they don’t have cancer. By the same token, nobody wants an aggressive cancer to go undetected. It’s a conundrum.

As I mentioned in the first chapter of The Prostate Paper, I entered the maze voluntarily (no symptoms) and jumped onto the “active surveillance” conveyor belt four years ago at age 71. My decision was based on several factors. First, I always believe it’s better to have information on which to base rational decision-making. Ignorance is not bliss for me when it comes to my health. Second, I have always been an active participant in my healthcare decisions. I rely on the advice of medical professionals, but I’m always well-prepared...