Melanie Cole, MS (Host): Welcome to Bryan Health Podcast. I'm Melanie Cole. And we're highlighting prostate-specific antigen today, or what we refer to it as PSA. We're learning about what that is and why it's such an important number for men to know. Joining me is Dr. AJ Pomajzl. He's a board-certified urologist at Nebraska Urology.

Dr. Pomajzl, thank you so much for joining us today. So, why don't you tell the listeners what is PSA, and why is this an important number for men's health and for men to know and understand?

Dr AJ Pomajzl: Yeah. The PSA, it's a simple blood test. It stands for protein-specific antigen. And what it does is it gives us a number. Now, the number in a PSA test is different than some of your other lab work tests. It's just a protein. It's inert. it doesn't do anything to your body. So, if a man has a PSA level drawn and it's 2,000, that doesn't mean that the PSA itself is hurting the man's body.

You know, compare that to cholesterol. And cholesterol, if it's that high, it means there's actual disease process going on, plaques are being built, arteries are stiffening. It's a problem itself in the number. The PSA, it's just a flag. If the PSA is high, it means we should look into a man a little bit more closely than if the PSA is low.

Melanie Cole, MS: So, tell us a little bit about what low and high means, and is this a controversial test now? For some reason, I've heard about things in the media. Speak a little bit about what those numbers are and whether this is something that really men need to watch. Or if not, why?

Dr AJ Pomajzl: The PSA test has a actually a pretty interesting history in medicine. And the main reason is, in 2012, one of the major preventative services guidelines recommended against PSA screening. They did that for a number of different reasons, which are interesting in itself. But really, the important thing is what happened when they recommended against screening, the PSA screening actually declined by about 46%. And those numbers are from 2008 to 2022. So, the recommendation was real, and it impacted primary care physicians and how they directed their patients,. And it also kind of came with a stigma for patients themselves to avoid the test.

Now, why the history of the decision they made isn't important here is because we know what happened. And some of those things that happened were metastatic prostate cancer began to rise after 2012. In fact, metastatic prostate cancer rose 37%. That means we were missing men with localized prostate cancer, because we weren't screening them.

Some other really important studies that have finalized over the last few years done in Europe showed that there was a 13% reduction in prostate cancer mortality in men dying from prostate cancer if they were welcomed to screen. If you look at those numbers even more closely, in that study, that 13% recognizes that some men chose not to be screened. If you look at the men that were all screened, that reduced mortality by 20% to 21%. Those are pretty incredible numbers. That kind of goes to the source of why there's a stigma.

And, you know, it's interesting, the reason why prostate cancer screening is important is it's a very common cancer. It has no symptoms. You don't know you have prostate cancer until it's too late. You won't get symptoms until you develop advanced prostate cancer. Compare this to other common cancers that have successful screening protocols like breast cancer and colon cancer. Those two are dangerous cancers, but they're usually asymptomatic.

Now, I think, over the years, you look at women's health, it's had tremendous advocates. And mammography is normalized and breast cancer awareness is part of our culture. We have our NFL players wearing pink uniforms, which is awesome, and that's a good thing. And colonoscopy, I think, has the same cultural foothold. Men's health honestly hasn't had that same champion. We haven't done as good of a job making routine screening feel expected or even masculine. So, a man who skips his PSA doesn't feel like he's doing something risky, he just feels like he's being a guy.

And I think that cultural gap has real consequences, and those numbers we talked about shows that. We're not trying to compete with other screening tests. All those screening tests are important, and I recommend all of them. I think one thing that we need to do a better job of urologists and men's health champions is trying to close that gap because those real numbers have cost real lives.

Melanie Cole, MS: Well, I agree with you in all that you just said, Dr. Pomajzl. And one of the things I think that is not necessarily a stigma but also contributes to this is that men don't want to see you. They don't want to come to see a urologist. They don't want to think about getting a digital exam. They don't want to think about what's going on with the prostate because that's how men are. And so, their partners are usually the ones that shove them kicking and screaming in to see their doctors, even just for a physical. So, I think that this is this cycle of men not wanting to really even go see a doctor for really any reason. I mean, I know my husband does not ever want to go. And so, I think that that's another contributing factor.

Now, tell us about the numbers, Doctor. What are those numbers we're looking at if they get their PSA done, they get their blood work done? Tell us a little bit about what those numbers are.

Dr AJ Pomajzl: I think you're exactly right. I joke with a lot of my patients that urologists don't have very many friends. But the important thing about the PSA test, one of the cool things about it is, of all men, if you look at population studies, 90% of men that get their PSA checked are reassured. Ninety percent of men do not have an elevated PSA. So, 9 out of ten guys will get this screening blood test and walk away without any worries. In fact, they'll walk away reassured.

Now, if you look at that 10%, if you repeat a PSA on those 10% that had a initial high PSA, anywhere between 25% to 40% of those guys will have a PSA that normalizes. And again, there you go. You're slicing the pie even smaller. Now, of that 25% to 40% of that 10%, you know, if we get down the pathway far enough that we're worried enough about potential prostate cancer and we get to that point of a prostate biopsy, of those biopsies, 60%-75% of them come back negative. So again, the pie is sliced even lower, okay? So, we're talking about a smaller percentage of men at this point. And if you, unlucky enough as you may be to be diagnosed with prostate cancer, a lot of those guys, up to 60% of them are managed just with active surveillance or no further treatment, just close monitoring.

So, one of the things I want to relay is that this PSA test in a very, very high portion of men, they'll be reassured. They'll feel confident and better that this is something they don't need to worry about. And of those men that need to worry about it, most of them may never need treatment.

Another thing you mentioned, and you're exactly right, there's a stigma that comes with a prostate test, and we've all heard all the standup jokes about digital rectal exams and urologists. A lot of times, in my practice and I think most urologists' practice, the digital rectal exam is becoming less of a screening tool and more of a staging tool. And what I mean by that is the PSA test is what's going to screen most men for prostate cancer. The digital rectal exam is a test that's usually reserved at this point for staging a man that is being worked up actively for prostate cancer. So, a lot of physicians, urologists, or primary care doctors may not even do a rectal exam. Some do, and that's fine. But it is becoming less of a thing nowadays.

So there's some great guidelines out there that we refer to the AUA, the NCCN. They kind of give us direction on how to follow a man's PSA. And one of the most important things to know about the PSA test is that it's variable depending on your age. So, a PSA of 3.5 in a man that's 55 is drastically different than a PSA of 3.5 in a man that's 75.

Typically, as we age, our PSA rises. And that's because of the natural fact that as we age, our prostates continue to grow. And therefore, we secrete more PSA. Again, the PSA test is not a binary test. It's not a test that says, "If your PSA is 4.2, you're elevated, we're doing a biopsy." It's not a test that says, "Your PSA is 3.9, you're not elevated, we don't need to worry about you." It's a gestalt thing. It's a sliding scale. And really, it's just a gateway to get you into a primary care physician or urologist that can better assess what that PSA value means for you specifically.

On top of that, there's a few other things that can affect your PSA value that aren't cancer., Your PSA, it's a prostate-specific antigen, not a cancer-specific antigen. Your PSA can be elevated for any number of reasons, a benign enlarged prostate. It can be elevated because of biotin supplementation or a common medicine that we take nowadays. It can be elevated from motorcycle riding, horseback riding, riding on your lawnmower. It can be elevated for an infection that you don't know you have, that your body's clearing on its own. It's a pulse on the prostate when it's drawn. It's not a binary answer, yes or no.

Melanie Cole, MS: So, how does a man get a PSA test, Doctor? Does he do this through his primary care provider when he gets that annual physical, if he's good enough to get his annual physical, or Bryan On-Demand lab? Tell us a little bit. Does he have to come see a urologist? How does he do it?

Dr AJ Pomajzl: They're both reasonable options. At the Bryan On-Demand lab, you don't need a referral. It's a walk-in lab. I think the last time I checked it was $12. It doesn't require insurance prior authorization. That's a simple way to do it. I think oftentimes the better way to do it is with your primary care physician, as a part of your normal routine screening.

Those are the doctors that know the best about their patients. They're able to contextualize these labs and make sure that if you are a man that's in his early 70s and your PSA is 4.1, to reassure you and appropriately work you up, maybe repeat a PSA or to get you to a specialist like a urologist. I think those are your two best resources, your primary care physician, but also a walk-in lab, one of them being Bryan On-Demand lab.

Melanie Cole, MS: And if the levels are high, and you mentioned that it doesn't necessarily mean that it's cancer because BPH is something that also happens to men as they age. Will you reassure men that it doesn't necessarily mean cancer? Tell us a little bit about what a man is supposed to do if he gets a level higher than you might like it to be.

Dr AJ Pomajzl: Right. That's the exact right question. So, again, the big picture is that funnel I talked about, those men that have a PSA that are normalized on repeat draw, about men that have negative biopsies. But really, the most important thing if you get an initial elevated PSA is, again, to reach out to your primary care physician. They'll know how to best direct you. They'll know whether it's important to repeat a lab test. They'll know whether it's important to get you right away to a specialist. That's really the best resource for most men because their doctors know the most about them.

Now, I do know that most urology practices, including Nebraska Urology, we do offer self-referral. Sometimes, insurance demands a proper referral, it's a formality. It's not a medical gate. You can always call a specialist directly and see if their office would want to see you. But typically, the more appropriate way is to go in through your primary care physician and let them triage you to the appropriate location.

Melanie Cole, MS (Host): Tell us about what's exciting in your field, Dr. Pomajzl. If someone is diagnosed with BPH or with prostate cancer, what are some of the exciting things that you've got going on? Because there are so many more tools in your toolbox now for dealing with this. There's watching and waiting and hormonal therapies. There's so much going on. Just tell us some of the exciting bullet points here.

Dr AJ Pomajzl: Prostate cancer, because it's so common, there's a lot of actionable information being created every day. Prostate cancer being treated in the '80s is entirely different from prostate cancer being treated in the early 2000s, which is entirely different than prostate cancer being treated in 2026.

So again, one thing I want to reassure men is that prostate cancer is common. But up to 60% of men that are diagnosed with prostate cancer, won't need treatment. They'll just be either watched closely with what's called active surveillance, where we watch that cancer very closely and do some genetic tests on it and do some advanced MRI diagnostics. And a lot of times, of the men that are diagnosed with prostate cancer, up to 60% of them have it, it's never treated. When we don't treat prostate cancer, we do one of two things. Most commonly, we're doing something called active surveillance, where we're using advanced genetic tests to properly assess the cancer and how aggressive it is and see if it's one that's safe to watch. We use repeat PSAs and advanced imaging like MRI to make sure the cancer never affects a man's life. But if that cancer does show that it's aggressive or on biopsy, it proves to be a more aggressive prostate cancer, we have become very good at robotic minimally invasive surgery.

The robot has changed how we treat prostate cancer. And nowadays, almost all urologists are doing robotic radical prostatectomies, and outcomes are excellent. And some of the men I diagnose, if they have cancer that's in a favorable position, I can do a more advanced anatomical technique where I spare a lot of the pelvis when I remove the prostate gland, that leads to quicker functional returns after surgery.

Our radiation oncologist colleagues who again treat prostate cancer just as effectively as we do, they've changed the game. A lot of times, they're transitioning from what could have been 40 traditional radiation treatments to being able to treat a prostate cancer appropriately in as little as five sessions. So, there's a lot of activity in prostate cancer research, because it's such a common cancer and it affects so many men. The field changes almost every day.

Melanie Cole, MS: Yes, it's a very exciting time in your field. And so Dr. Pomajzl, wrap it up for us. Give men and the partners that love them your best advice about PSA, about prostate cancer, about whether they need a referral and how someone can get an appointment to get this very important test done.

Dr AJ Pomajzl: So, prostate cancer, it's so common. And if we spoke more about it, I think most men would be surprised how many of their coworkers or their friends or their relatives have had to go through a prostate cancer diagnosis. There is an amazingly simple, cheap, low-risk test. It's a blood draw. It can be as cheap as $12 out of pocket. And just getting that test will make 90% of men feel good and know that they don't need to worry about prostate cancer at this time. If we diagnose prostate cancer, the whole point of the PSA test is to find those men that we're worried about. Well, we know with data that if we follow the PSA test and use it to screen men, we can reduce prostate cancer mortality by 13%. And that's a conservative number. That means for every 450 men approximately that are screened, one more man will be there to watch his granddaughter play softball or to celebrate his son's wedding, or to hold his granddaughter for the first time. These are real numbers. And I myself have had the blessing to sit across from a man who was diagnosed appropriately and treated appropriately and came out on the other side a cancer champion.

But I've also had the hard role of sitting across from a man who came to my practice with a PSA of 450 and severe back pain because he had metastatic prostate cancer. Again, that's nobody's fault. But the more men we can screen and the more men we can appropriately counsel, the less men that will happen to.

Melanie Cole, MS: Great information. So well said. Doctor, thank you so much for joining us and really sharing your incredible expertise for the listeners today. And I'd like to thank our Bryan Foundation partner, Cirrus Systems. And to listen to more podcasts from our experts, you can always visit bryanhealth.org/podcasts. That concludes this episode of Bryan Health Podcast. Remember to always subscribe, rate, and review Bryan Health Podcast on Apple Podcasts, Spotify, iHeart, and Pandora. Until next time, I'm Melanie Cole.