Michael Smith, MD (Host): Meaningful Medicine is a Novant Health podcast bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. Today, I'm sitting down with Dr. Alex Caillat and we're going to be talking about PSA test results.

But first, I always like to ask my guest, Dr. Caillat how did you decide to become a urologist? Like what made you go down that pathway?

Dr. Alex Caillat: If I had a nickel? No, so that's a great question. Originally, I wanted to do pediatrics, actually. I like kids, loved the kids, just was not too fond of the parents, even though I know that parents are awesome and they're a vital part of that whole family dynamic. Whenever your child is sick, obviously that becomes an issue. And so a little high stress there. So going through residency, I ended up looking for something else to do and I really liked surgery and so there's a bunch of different surgical specialties out there. There's urology, there's neurosurgery, orthopedics, all that kind of stuff. And so I just methodically went through each one. What's funny is that a lot of the times the specialties will choose you.

So it's very personality based. So like orthopedics are just like, you know, big ex-sports football player kind of guys and, neurosurgeons are very methodical and type A and the urologists were just kind of really laid back and you know, had good personalities, they had good humor. What I liked is that you could do kind of like primary care stuff, so urinary problems, that kind of thing.

But then also fix people. So if they had kidney stones, they were in terrible pain. You could fix that. It was pretty gratifying. So, urology kind of chose me and I've loved it ever since. Been doing it for about 15 years now.

Host: So let's start off very basic. What is the PSA test? You know, it's been around a long time, but what is it and why is it so important to you as a urologist, as a tool for diagnosis?

Dr. Alex Caillat: It's a great question. So it basically came around mainly in the 80s, kind of started gaining some traction. But PSA stands for Prostate Specific Antigen. So it's just a protein that all of our prostates make. We as guys have prostates, females do not. They have all their own special testing that they can do. But fundamentally it's a good test. It's not a great test. It's a good test because it is specific to the prostate, so that's awesome. It's not a great test because a lot of things can make it go up and down; things such as like bicycle riding or, we have a lot of, in Davidson County, some forklift drivers or truck drivers, that kind of stuff.

So if you're bouncing around on that prostate, that number can go up sometimes. Urinary problems can sometimes make it go up. And all that. So it's good because it's specific to the prostate. It's not great because a lot of things can make it go up and down, but it's valuable because as far as from a cancer standpoint; if it does go up, it can prompt us to maybe do a biopsy.

And if we find some cancer, then usually we'll find it really early. Back before the PSA, you would find prostate cancer, but it would be kind of later on in the pathophysiology of that disease. So, it's really helpful for us. We use it as a marker. You just have to kind of take it with a grain of salt.

Host: So, you bring up some good points though, so that there are certain things that could make it go up, PSA, without it being cancer. When a man is going to get a PSA test, is there some guidelines there?

Dr. Alex Caillat: Great question. So usually what, if we see somebody referred in from a primary care physician with a PSA that's elevated, typically we'll tell them several different things. So we'll ask them about recent sexual activity, that's a huge one, long bicycle rides, bouncing around in tractors or in trucks, that kind of stuff.

If we elucidate that or urinary issues, what we'll do is we'll usually give them some Flomax or something to help them pee a little bit easier, take the pressure off the system, and then we'll recheck it just to see if it'll come down, cause it could be a false positive. But then if we're going to get that next set of testing, we'll tell them, hey, yeah, watch out for about a week before no sexual activity.

If you have any illnesses of any kind. So like when COVID was around, we had a ton of PSAs that were elevated. Any viral kind of illness can really kind of ramp up that number as well. So if they were sick for any reason, we say, Hey, don't check your PSA while you're sick. Wait two, three, four weeks until you're healthy. Then recheck the number.

Host: So before we get into what happens maybe with a high PSA and what that means, at what age should a man start getting PSA levels checked? Because from what I remember, getting a baseline is really important, right?

Dr. Alex Caillat: Correct. So. it always differs. So same with colonoscopies, with family histories of cancer. That's a big one. We usually say our African American population, because they may be at more increased risk and people with cancer in the family. We used to say, try to get a baseline around 40, 45, something like that, just so you can kind of get a number.

The PSA test, because it can be altered by so many things, usually any one number isn't super helpful. It's more of a trend over time. So if they can get a baseline early on and establish, okay, my number's a one, then we'll know that if they get checked again and their number's a three, even though that's still within normal limits; well, that's two points above what their baseline was and that could tell you something about that. So yeah, so definitely if you're at risk, African American or have prostate cancer in the family, usually the earlier you can establish that baseline, the better.

Host: So, what happens if a patient comes back with a high PSA? Does that absolutely mean prostate cancer or what do you begin to do with a high PSA?

Dr. Alex Caillat: So, usually the primary doc is who's going to pick it up first and hopefully they've kind of been seeing the patient, have them established as a patient, that kind of stuff. And so what they'll do is they'll refer them to us and then we'll kind of start talking about other stuff.

Hey, how are you urinating? How are things going there? Did you have any risk factors for that PSA going up? Let's say have any activities that could have made it gone up or any recent sicknesses that kind of thing. But yeah, definitely an elevated number in and of itself is not a definitive diagnosis of cancer.

So what it'll do is it'll, it'll eventually bring us to a decision point is do we need to biopsy this prostate and actually get some tissue is there cancer or not. Then that will definitely tell us, you know, which way to go. So if that's negative, okay, this could be a variety of other things that caused it to go up.

If it's positive, it's not the end of the world because prostate cancer is our most common cancer in guys. So there are a lot of ways to kind of fix that, but it'll definitely put us on that pathway. Okay, now we got to fix this thing.

Host: So when a patient finally has to decide, okay, I may, or maybe working with their primary care physician, it's decided that they need to see a urologist. Do you have some advice in that? What should a patient look for when selecting a specialist like you?

Dr. Alex Caillat: Being close to home is always helpful. A lot of times it's like referrals from other people, a lot of it has to do with personality. Some personalities get along pretty well. Most of the people in Novant are very, very nice. Like all the urologists that I know that are in the system are pretty stand up good characters. Everybody seems to have excellent fund of knowledge or a knowledge base. The staff that they work with all like them and, and, they appreciate their input and all that kind of stuff. So really it doesn't matter so much initially who you go see. You know, in training, everybody does biopsies.

We do a million of them. Then, if you get a diagnosis of prostate cancer, let's say, then those referrals start to happen. So you can go to like an oncology specific urologist, so somebody who's more adept at, let's say, robotic surgery if you're going to take it out, or you're going to go to a radiation oncologist if you're going to do radiation therapy.

So it kind of really depends on how you're going to fix the problem to then where that referral will go. But initially, really, most urologists deal with PSAs on a regular basis. It's kind of a standard thing, yeah.

Host: Now, of course, as from the patient perspective, right, the minute they see their PSA up above their baseline, or maybe it's the first one and it's high, whatever, they're thinking, oh my gosh, I have to have a biopsy. Is that always the case? And if it is, if a biopsy is necessary, what are the different types of biopsies?

Dr. Alex Caillat: Yeah, so not always. There are some other tests that can be done. Sometimes there's some newer tests that can maybe flesh out your risk factors a little bit more. The biopsy is definitely the most definitive of them all. So the PSA gives you a little bit of information. Some of these other tests on the market, like the 4K, some of these other PSA related scores can give you other information. But really the biopsy is going to give you the do you have cancer or not? The pathologist, he's going to look under a microscope or she, and they're going to find out, is there cancer in there or not? Once you have that diagnosis, then moving forward, there's a bunch of different ways to go from there.

But it's not the end of the world. Prostate cancer is very treatable, very curable. To put it in perspective, as far as PSAs just in general, you know, if you look at a normal PSA level, let's say, normal's kind of variable, but if you had like a number of about four or five, that's considered normal.

Anything above that becomes abnormal. I've met a guy, diagnosed him, he had prostate cancer, he's still alive, years later, his number is over 10,000. So that, that puts it into perspective, that range of potential PSA is very high, so when I tell people that, you know, they come in, they have a PSA of 6 or 7, they're kind of freaking out because it's maybe, you know, one and a half times the normal level.

That kind of allays some of their fears is, okay, this is a very wide range that this number could assume. So 10,000, I mean, that's, that's very high. Yeah.

Host: Yeah. Yeah. Let me give you a scenario and see what you think. Let's say I'm 78 years old. I've been checking PSAs, they've been fine all my life and at 78 all of a sudden it goes up, you know, a hundred percent or whatever it is. Is that a concern or is there a point where PSA becomes less reliable in older men?

Dr. Alex Caillat: So, PSA's can definitely go up over time. Just as our prostates enlarge, let's say, think about it like real estate, you know, you have more real estate making more PSA, so your number can be higher. So typically for a guy around 50, normal is about 4 or less, a guy in his 60s to 70s, you can get up to about 5ish, 70s to 80s, you can go up to six, six and a half, that kind of stuff. So it can go over, it's called age match controls. It can go up a little bit over time. The issue is an acceleration. So we talk about PSA velocity or how fast it goes up. Let's say the guy was stable at 2 or 3 and then all of a sudden it ramps up and it starts going, you know, 10, 15, 20, something like that, that would be obviously much more concerning. Also, prostate cancer, it's not a matter of if, it's kind of when. They usually say that 80 percent of guys by age 80 will get prostate cancer, 90 percent by 90 and 100 percent by 100.

So basically if you live long enough, you're going to get it. The issue is, is the vast majority of people are going to die with prostate cancer, not from prostate cancer. So we really want to catch it in younger guys because if you get it when you're 40 or 50, well, you're going to potentially live 20, 30, 40 years, so it's going to become an issue. But prostate cancer in and of itself, I kind of explain it, the analogy of like a freight train, it's very slow to start up, but once it's trucking down the track, sometimes if it's far advanced and you've given it 10, 15 years to grow, it's going to be hard to stop that.

Prostate cancer loves to go to the bones. That in and of itself won't kill you, let's say like pancreatic cancer or brain cancer or something like that, but it'll make your life less exciting and less fun. It'll make you feel like a million year old person. Cause it just punches out little holes in your bones and that kind of stuff.

You know, I've seen guys that get prostate cancer and let's say they choose to do nothing. Ten years later, they may still be alive. But the issue is, is now they're dealing with like these kind of chronic bone pains because of these metastases blowing out holes in their, in their bones and things of that nature. So we like to take care of it so then you don't have to deal with those quality of life issues.

Host: So that's a great lead in right there. So you want to take care of it. So if the biopsy, so PSA is up, maybe the velocity is up, you got the biopsy. It is cancer. What's our treatment options today?

Dr. Alex Caillat: Yeah, so basically, if you have a young, relatively healthy person, your main two ways of killing cancer, prostate cancer, or getting rid of it would be either surgery or radiation. Those are kind of the two main ones. There are some studies on using chemotherapy. Let's say a guy comes in and he has, let's say, metastatic prostate cancer.

It's already out of the box. Then you want to treat the whole body. Well, chemotherapy sometimes can be used. But in prostate cancer, it's not exactly the best way to go, just not as responsive. So your main ways are radiation versus surgery. What is surgery? Well, your prostate's a donut around your urine channel sitting right off your bladder.

So when you remove it, you're basically re-plumbing a guy, right? So you're taking the prostate out and then you hook the urine channel back to the bladder. If the guy's got peeing problems, two birds, one stone, right? So you get rid of the prostate, so that's not causing blockage or peeing problems anymore. So that's a bonus. But let's say if a guy doesn't really have too many peeing problems, maybe he's not the healthiest surgical candidate, that kind of thing; beams of radiation are a pretty nice, straightforward, less invasive way to go. You just shoot beams at it, and maybe it takes about a couple months to do.

They do about 10 minutes a day. It's like going to the coffee shop every day for 10 minutes. Shoot beams of it, and then that'll kill the cancer as well. So usually the younger, healthy guys will kind of go towards surgery just to be done with it. The older, maybe less healthy people, we could easily shoot beams at it and kill it that way.

Host: So when you speak to a patient about these options, and that was very clear, thank you for that. What are some of the questions they have for you? I know most guys are going to be concerned about side effects, libido, what do you mostly hear?

Dr. Alex Caillat: The number one question usually is, what would you do? Or what would you do for your father or whatever? That's a tough one because everybody's a little bit different. Everybody has different, backgrounds. Maybe they had a family member who had a bad run in with some surgery or had a bad run in with radiation.

So you're kind of coming in with that baggage. So I try to feel the person out. I'm not trying to make any decisions for them unless there's something that would really kind of highlight that, okay, surgery is probably going to be better for you. So the first thing I'll usually ask is, well, how are you urinating?

Are you peeing okay? If a guy has a lot of urinary problems, typically it's from the prostate. And so if you radiate that, so radiation is kind of like, let's say a very focused sunburn, right? So it's UV radiation going at something. So it's going to make it angry. It's going to kind of get worse. So it would amplify or worsen their urinary complaints.

Whereas if a guy has urinary problems, if you take the prostate out, that could help his urinary problems. So the first thing I'll do is like fork in the road is like, well, how are you urinating? You peeing okay or not? If they pee pretty well and urinating pretty well and we don't think that they're going to need anything later on in the future, then radiation is a great option.

If they're really young, let's say less than 60, or they have urinary issues, well then the, the literature kind of goes more towards the surgical realm. And so if they're a good surgical candidate, you would remove it. And then you would talk about potential side effects, right? So what are potential issues with surgery?

Well, A, surgery is stressful. So if they have any heart related issues or potential risk factors for stroke or heart attack or whatever, that plays in. Surgery also, you're replumbing the guy, right? So you're taking a piece of the urine channel out and hooking them back together. So leakage, especially at the beginning, it's going to be an issue.

But, your body's an amazing thing, if you give your body some grace and some time, typically it will heal itself and your sphincter muscle will start to work, in your favor. The other issue would be sexual side effects, right? So that's going to happen. Anything you do to the prostate, it's our main sex gland.

That's going to have some issues. Typically those are on the front end. Anytime you're going to operate on something, let's say down low, things are going to shut down temporarily because your body's like, Ooh, just something just that happened down there. Let's, calm down. So usually we kind of let the guy heal for a little while.

 If sex is an issue, like it's an important issue for him, we'll rehab him back up, right? So we can do that with pumps and oral medicines like Viagra and Cialis. We use injectable meds, which are awesome. One's called Trimex, which is a bunch of medicines in one. It's a liquid version. And so we'll try to rehab him back to normal.

A lot of guys don't really realize that actually if you use radiation, the way radiation works, it shrinks up blood vessels to the tumor. That's how it chokes it out and kills it. Well if you shrink blood vessels down in that region, that's going to hurt erections too. It's just not going to hit you on the front end.

It's going to hit you later on. So, either way, with the prostate, it's not going to make erections any better, that's for sure. But hopefully with surgery, we try to rehab them back up to kind of where they were pre-op.

Host: I've been reading more and more about some newer let's call them potential screening tests for prostate cancer other than PSA. What do you, what do you think about that,

Dr. Alex Caillat: Even though I'm relatively young, I guess I have a lot more platinum coming in than before, but so I'm kind of wary of a lot of kind of new testing options, like there's Cologuard for colonoscopies and all that kind of stuff. I'm kind of a traditionalist, you know, so, I just recently got my colonoscopy last week and it turned out well, thank God, but, there's nothing that beats the biopsy. The PSA, it's cheap, you know, it's a great screening tool. There are always a lot of new kind of technology coming out as far as like either blood tests or urine tests or whatever, trying to pick up cancer in a different way.

 But in my hands, I just feel like the old traditional way actually works really, really well. So if it ain't broke, don't fix it. I'm not a huge proponent of all the newfangled technology, like, for example, a big thing now for treating prostate cancer is focal therapy, so that it's kind of big in Europe.

It's starting to come over here. There's only a couple centers around, I think, UNC or somewhere in Raleigh, I think they do a little bit there. But so I'll have patients come in like, hey, you know, I have some cancer, but it's just in one spot by the biopsy. I want to do this focal therapy and I'm not against it.

I just don't do it. I'll get guys where they need to go. And I don't know if it's just anecdotal, if it's just my own personal kind of history with it, but it seems like a lot of those guys come back and the cancer comes back. So, when we do biopsies, if you think about it, you have a prostate that's about the size of a golf ball or so.

We're taking 12 biopsies of that, which are just small little cores of maybe three hairs thick. you know, you'll pick up some cancers. Are you going to get them all? Maybe not. If you do CAT scans and MRIs, will it see everything? Maybe not. And so, you know, you may say, oh, we just have cancer in one spot here, let's just fix that.

But, that cancer could be anywhere in the prostate, we just haven't found it yet. And so, yeah, I'm not huge on focal therapies or kind of new experimental stuff.

Host: There could always be a few cancer cells floating out in there that are just ready to explode that you don't find, you don't know, right? Yeah, I know. I think that's great. Gold standard tests and treatments are considered gold standard because they have a good, not just clinical history behind them, historical history.

So, I'm on board with you and all that. So let's kind of summarize a lot of this and I, I want to end this mostly by guys, get your PSA checked. Get a baseline start, right, let's just get that going, but what are some of the things that a man can do to lower the risk of prostate cancer?

Dr. Alex Caillat: That's a great question. So, prostate cancer is one of the few, actually, that can be altered by your diet. So, my wife gets on me a lot about eating cookout or a lot of the not so healthy options that are out there. Basically things that are high in trans fats, saturated fats, like basically unhealthy food, will increase your insulin like growth factor one, which is like an inflammatory cytokine, which basically means that if you eat crappy food, it'll inflame your system. And prostate cancer is very reactive to that.

So if you eat poorly, the chances of you getting prostate cancer or if you had prostate cancer, activating it, making it worse is high. So I have a great example. There's a local pastor in town, great guy, he was about 20, 30 pounds overweight, but he was average build. Like you would look at him, you wouldn't say he was fat or anything.

 Very nice gentleman. And so he came in, he had cancer, he had urinary issues. We went through the whole pathway, figured out he had some cancer. And then when I went over the options, he's like, well, you know, I kind of don't want to do radiation or surgery right now. Are there any other options?

I said, well, you could try to lose some weight, you know, drop 20, 30 pounds, get all that fluff off of you, eat better, you know? And we just recheck the PSAs and just kind of see what happens. And his PSAs were in the 8 to 10 range at the time. And so I saw him back three or four months later, we checked the PSA.

He had dropped 20, 30 pounds, was playing softball on a regular basis, was eating healthy food, and his PSA dropped down to the normal range. So we actually watched him for almost a year or two and his numbers stayed stone cold normal. He looked super healthy. He was in excellent shape. And really the only reason we eventually took his cancer out and took his prostate out is because of the urinary problem.

So he actually had a lot of blockage from his prostate. He had a really big prostate. And so we then eventually removed his prostate. His biopsy pathology and his final pathology two years later were actually the same. So his cancer did not progress at all over that two year period. The PSA remained the same. So that shows you the power of kind of a healthy diet and lifestyle. So I think that could benefit us all just in all aspects of life.

Host: Well you said it at the beginning of this podcast that the body is so resilient. And it's like good food, get active, get good sleep. I mean, it's kind of basic stuff, right?

Dr. Alex Caillat: Now you can science, yeah.

Host: Look what the body could do, right? That's fantastic. This was a great conversation. I know the audience learned a lot about PSA and what to expect. So thank you so much for coming on the show with me today. Listen, if you want to find a physician, you can visit NovantHealth.org. For more health and wellness information from our experts, you can visit HealthyHeadlines.org. I'm Dr. Mike. Thanks for listening.