Bastyr Center for Natural Health



Bastyr Center for Natural Health

Clinic Shift of Eric Yarnell, ND

Last updated 3 Jan 2011

Prostate Cancer Policies and Procedures

Screening for Prostate Cancer

1. Per guidelines, this is an individualized decision now; not everyone should be screened.

2. If high risk (African-American, high-risk family hx of PCa), screen with tPSA or PCA-3 starting at age 40 yr.

3. If normal risk, discuss benefits and flaws with tPSA. If patient insists, then discuss PCA-3.

4. In patients with known or highly suspected prostatitis: screen with PCA-3 only.

5. Discuss benefits and harms with all patients.

tPSA: several large clinical trials show it does not reduce PCa mortality in men with average risk

fPSA: no long-term outcome studies, used only to decide if elevated tPSA is due to prostatitis or BPH

6. If patient is unsure, then discuss PCA-3 as alternative.

We don’t have long-term data on PCA-3 but we know it doesn’t have false positives due to prostatitis or BPH.

7. If patient absolutely insists or is high-risk, tPSA is ok to screen.

PSA Screening Procedure

1. No DRE, ejaculation, or perineal trauma (bicycle riding, rowing, etc.) within 48 h before blood draw.

2. Draw for both tPSA and fPSA unless prior tPSA is >10 ng/ml.

3. Perform DRE after blood is drawn for PSA.

4. Interpretation:

In patients with known prostatitis: PSA hard to interpret

DRE shows nodule or clear signs of cancer: refer for biopsy

DRE negative or equivocal, then assess PSA result based on following table:

PSA Normals (Age-Adjusted)

|Test |40-49 yr |50-59 yr |60-69 yr |70-79 yr |

|tPSA |0-2.5 |0-3.5 |0-4.5 |0-6.5 |

|fPSA |0-0.5 |0-0.75 |0-2.5 |0-3.5 |

|cPSA |0-1.5 |0-2 |0-2.5 |0-3.5 |

All values are in ng/ml in this table. Regardless of age, fPSA/tPSA >20% is consistent with BPH or prostatitis.

If tPSA or cPSA is out of range, retest in 2 mon. If tPSA or cPSA is 20%, likely benign disease, retest in 12 mon (and probably with PCA-3 not just PSA).

If still elevated at retest, rule out BPH or prostatitis, consider PCA-3 then decide on biopsy or imaging.

If not elevated in 2 mon, retest in 12 mon.

PCA-3 Screening Procedure

0. Make sure the PPL lab has kits on hand to do the test.

1. Requires prostate massage.

2. Collect 30 ml urine (no more) after massage (first urine, not mid-stream).

3. Results take 2 wk to get back.

4. Interpretation: If score is >35, then patient very likely has cancer and a biopsy should be done (or, if patient refuses, cdTRUS, eMRI or esMRI).

Note: not affected by prostatitis or BPH

FOC Information to Obtain

See the “My Prostate Cancer Summary” form and fill it in with the patient. If original reports are not available, wait to complete it until they are.

1. How the cancer was diagnosed? (PSA screening, DRE, other)

2. Obtain all PSA numbers, free and total, if available (including the assay used to test them if possible)

to calculate doubling time and velocity

3. Has a prostate biopsy been preformed?

We must obtain a copy of the original biopsy report.

4. Has any imaging been done? (bone scan, pelvic CT or MRI or US)

Obtain copies of original reports.

5. What is the patient’s ethnic background? (African-Americans at higher risk)

6. Is there a family history of aggressive prostate cancer? (If a relatives was diagnosed with or died of PCa before age 60 yr = high risk)

7. What treatment, if any, has been done? (RP, EBT, BT, ADT, natural)

8. What are the patient’s goals?

Please review the basic biology and politics of prostate cancer with patients:

1. Unlike other cancers, 80% of PCa never spreads and is harmless (we can just detect it).

2. We focus on treating the causes of the cancer (lifestyle stuff) not just killing it once it shows up. Prevention not just screening.

3. There is a lot of overdiagnosis and overtreatment of PCa.

Have the patient complete the FACT-P questionnaire.

Minimum Testing to Obtain at Baseline

If patient has already had these done in the past 3 mon, then do not obtain (or discuss if it is appropriate time to repeat them).

1. 25-OH-D3

Goal is 60-90 ng/ml

Explain to the patient strong link between sunlight, low 25-OH-D3, and PCa. Explain “vitamin” D is really a hormone and highly important to immune function.

2. Prostatic acid phosphatase

Goal is 40 LU30

Used to assess immune function specific to cancer.

4. Surveillance imaging

Rather than perform repeated biopsies, we prefer to have the patient either undergo cdTRUS, eMRI, or esMRI now and then repeat this every 6 mon (Gleason 7) or 12 mon (Gleason 6). Patient can opt for repeat biopsies if they want.

Benefits: all forms can see entire prostate and local area (not just areas biopsied). cdTRUS can see angiogenesis and studied for over 20 yr. esMRI can see chemical make-up but less well studied. eMRI finer imaging than cdTRUS but not angiogenesis and much more expensive.

Discuss expenses (cdTRUS most insurance won’t pay, $800 in Seattle or else have to travel to Stanford, Phoenix, or New York; eMRI and esMRI insurance will pay).

CT is not recommended due to unnecessary ionizing radiation exposure.

Low-Grade, Localized Prostate Cancer Protocol

Definition: Gleason 3+3 or 3+4, ................
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