In our journey around the sun, we have reached the shortest day of the year, which, although my brother-in-law informs me is not to be feared…”the sun shall return”… is still not a bad time for reflection. This was a year when I said goodbye to one of my oldest patients, a retired physician with whom I had coffee or breakfast every Wednesday for over 20 years. He came to my lab or office, and in the last years, I went to his home. We measured our lives to some extent by those intervals, sharing stories of our families, our medical training, and of course solving the world’s problems. One thing we did not do was obsess about his PSA. Indeed, for the most part we ignored it.
I cannot count the number of times I have thought to myself (and occasionally commented aloud) “If it were not for the PSA, you would no doubt be out there playing golf, skiing, biking, taking a grandchild to the park, or just enjoying life.” Far too many of my patients let their PSA control their lives. Living from one PSA to the next is a bad way to mark the passing of time.
In a lovely essay in this week’s New Yorker, Alan Burdick discusses “how time became psychological.” He quotes Plato: “The instant, this strange nature, is something inserted between motion and rest, and it is in no time at all.” And he proposes that Augustine, writing in the year 397, “plucked time from the realm of physics and placed it squarely in what we now call psychology. ‘In you, my mind, I measure time’…To consider this present is to glimpse the soul, Augustine argued.”
The PSA clock, for many physicians and patients, is dehumanizing. It is a technical artifact of modern medicine, one so sensitive that it provides a second hand when we should be looking at the hour hand, the calendar, or the seasons. Imagine if your cardiologist could measure the thickening of your coronary artery year by year in microns as plaque builds up. Would you want that test? Would it change how you lived if you knew for certain that you will die from a stroke in 8 years?
This is not to say that we can’t use the PSA to guide treatment or make decisions. A younger person with aggressive prostate cancer who must fight with every tool available may well benefit from close observation of the PSA. On the other hand, in Dr. Walsh’s series of men (reported by Pound) who had rising PSA after surgery, it was 8 years on average before anything was revealed on a bone scan or CT scan, and another 5 years before they died. Did these men benefit from the PSA’s? To be sure, treatment options have changed in the 17 years since that series was reported, but we need perspective. Another of my physician patients (a thoracic surgeon) had his prostate removed and never checked his PSA again. About 9 years later, he presented with bone metastases, and is now doing well on androgen ablation. He doesn’t come in for PSA’s. He is in his early 80’s and enjoying his life. I suspect I will see him when he develops new symptoms, and then we can discuss his alternatives. I hope that won’t be for many years, and indeed, that is entirely possible.
So on this winter solstice you might pause to consider all of your blessings and turn off the PSA clock in your mind. 47 years ago today (on the longest night of the year), I got married. Two careers, three kids, four grandchildren later, I don’t look at my PSA. Rather, I try to enjoy my Time in a Bottle. If you are in a contemplative mood as this year ends, click on that link and enjoy the holidays! Good wishes and glad tidings to you and yours in the coming year.
prost8blog 
Beautiful – thank you!
Dr Mike–HAPPY Anniversary, Great article!! Enjoy the Grand kids!!
Keep your Mach up, Tim
Thank you for this, Dr. Glode.
Bill Putnam
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Dear Dr Mike
I really enjoyed your commentary on the PSA . I have no change in spread of the metasases from the Lumbar/Cervical area in 3 years. BUT the PSA is now doubling every 3 months, now at 12.0. MY doctor wants me to move on to abaretirone acetate (ZYTEGA). I have resisted and am still on Lupron. Enjoying a happy retirement and travel, i do not want to be hospital bound by a new treatment and its side effects. I resist the phobia of PSAdom. At the age of 79, quality of life rules. Glad to hear you are enjoying family and retirement. Happy Holidays to you and your family John
Hi John. Consider the abiraterone (or enzalutamide) whenever you wish. In my experience, the side effects for most men are not a lot different than whatever you are already experiencing on Lupron. As you know, “there is no magic number” when it comes to using psa to decide on a new treatment alternative. I miss seeing you. Hi to Robert.
thank you for your response john
This was really nice.
Thanks for reminding us to live for the moment, enjoying the life and the love ones that we have. Jim Croce is an enduring favorite of mine and says it well.
Ray
Dr. Glode: excellent blog on The PSA Clock. Rings so true for me. Are you still seeing patients? I seems as though from your blog posting.
Touching . . . and so true.
Dr Mike, Excellent article, and a great reminder, To lives one life despite cancer
Dan
Words to live by….
Thank you Mike
Happy Anniversary to! We also reached 47😉
Dear Dr. Glodé: I just saw this blog post when I got this week’s ASCO Conn ection, and have taken the liberty of “passing it on” to the reader’s of The “New” Prostate Cancer InfoLink — please see here.
Mike Scott
Your advice seems appreciated by your patients, and I’m glad for that.
But if I received it, I’d look for a physician who understood me better.
I always want the best possible information about the future. I labor under no superstition that knowledge of a risk increases the risk. If I could peek into a celestial book and learn with certainty the date and cause of my death, I’d be very grateful for the information and would use it in every aspect of my long-term planning, from 401(k) contributions to travel plans to relationships, finances, and the hundreds of unpleasant activities I willingly undertake because I think they will postpone my death and/or make my old age more comfortable.
Dear Dr Mike,
I just read your blogs about PSA’s. Good insight. What’s your take on PRAD scores?
Carl
PiRad scores for MRI seem to be improving our use of the technology. A ways to go, but I’m optimistic.
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