PSA Testing for Prostate Cancer: What It Can and Cannot Tell You

What you're describing is the androgen depletion syndrome — you have abolished testosterone, so the patient develops post-menopausal-type symptoms. In our practice, for patients who have undergone androgen deprivation, we educate them not to panic, start gabapentin and sometimes an anti-anxiety medication, and for central obesity and related issues advise calcium and vitamin D supplements, a high-protein, low-fat diet, regular exercise, and sunlight exposure, since bones become fragile and there is increased risk of coronary artery disease and hypertension. We sometimes also use denosumab if the patient is very incapacitated by hot flashes and sweating. You did the right thing for your patient — surgical castration is the most practical option where injectable androgen analogues or antagonists aren't reliably available.

False positivity of PSA is very common, so I would follow this patient regularly, first checking for infection. I would repeat the PSA after 6 weeks — if the high PSA was due to infection, a course of antibiotics should show a downward trend by then; if it doesn't trend down, you should have a high suspicion of prostate cancer. You can also check the free-to-total PSA ratio — if it's less than 25%, that supports the diagnosis. If the DRE is normal and there's no biopsy facility, you can follow the patient for a year and check PSA velocity — if it goes beyond 0.75 per year, refer to a centre with TRUS-guided biopsy or MRI facilities. With a PSA of 10-20, there is roughly a 10-30% chance of harbouring prostate cancer, so this should be investigated further rather than dismissed.

This is a sign of chronic prostatitis — patients with chronic infection in the prostate get calcium deposited in the glandular secretions over time, which is the mechanism behind the calcification. If the patient is asymptomatic and PSA is normal, I would not worry. If symptomatic, try medical management first, and only if that fails should you consider a surgical procedure. Prostatic calcification itself does not cause any harm — it is simply a telltale sign of chronic infection in the prostate.

In our country this facility is not widespread and is not yet widely accepted by the urology community here, though it is practised in the West by urologists, medical oncologists, and interventional radiologists. I would add that prostate cancer is usually slow-growing, but the prostate also has BPH growing alongside it, and patients with even locally advanced or oligometastatic disease often die from the obstructive mass effect of the prostate on the bladder neck and ureters rather than from the cancer itself — which is why, as a surgeon, I usually still consult even locally advanced or oligometastatic candidates for robotic radical prostatectomy, aiming for clear margins, early continence, and preserved erectile function.

There is no real comparison — they serve different purposes. Orchidectomy is chosen for metastatic (stage 4) disease, such as a patient with multiple spinal metastases who cannot walk. Radical prostatectomy is chosen for patients whose expected lifespan is more than 10 years, who are fit for surgery, and who have organ-confined, locally advanced, or oligometastatic disease (one or two spots on PSMA PET). Orchidectomy is simply a form of androgen deprivation — nowadays we hardly do it routinely because injectable or oral androgen deprivation therapy is available; it's now used mainly for stage 4 disease.

An experienced clinician can feel for a hard, irregular nodule suggestive of prostate cancer through digital rectal examination, with roughly 50 percent accuracy in raising suspicion.

No. PSA is a widely available surrogate marker used alongside clinical examination, but a normal PSA does not exclude the possibility of early prostate cancer.

PSA can be falsely elevated by a recent prostate massage, digital rectal examination, catheterisation, prostate biopsy, or an underlying infection or benign prostatic hyperplasia, all of which increase PSA secretion without indicating cancer.

In India, suspicion typically begins once PSA rises beyond 4 nanograms per decilitre, but African patients may harbour prostate cancer at a PSA level as low as 2.5 nanograms per decilitre.