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Old 11-16-2009, 04:28 PM   #1
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ejaculation or DRE before psa blood draw

I have read conflicting reports concerning the extent of the impact, if any, of DRE or ejaculation prior to the blood draw for a psa test. I know the easy answer is "don't ejaculate within 48 hours before blood draw" and "don't do DRE before blood draw." But for those of us whose psa test history includes some that violated these good suggestions, I am interesting in reading credible studies evaluating the expected impact of a pre-blood-draw DRE or ejaculation. I recall reading one study suggesting the extent of the impact may be age-related. Any direction? Thanks.

Last edited by medved; 11-16-2009 at 04:29 PM. Reason: correct typos

 
Old 11-17-2009, 12:20 AM   #2
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Re: ejaculation or DRE before psa blood draw

Quote:
Originally Posted by medved View Post
...I am interesting in reading credible studies evaluating the expected impact of a pre-blood-draw DRE or ejaculation.

Hi medved,

The commonly accepted approach is, as you have written, "don't ejaculate within 48 hours before blood draw" and "don't do DRE before blood draw." However, I took a peek in www.pubmed.gov to see what report abstracts might be available on this.

I didn't count, but I found about a dozen reports on studies in exactly this area, and to somewhat surprise I found that they were roughly split in half—about half concluded that there was a statistical significance in PSA results (after ejaculation or DRE), and about half concluded the differences weren't statistically significant. Most of those abstracts that provided the mean shifted number of ng's per mL tended to be typically only in the tenths.

The range of concluding comments swung (surprisingly) wide, from this: "A significant postejaculation serum PSA elevation does occur, it is thus recommended that men abstain from ejaculation for 24 h prior to PSA sampling."

To this: "There were no statistically significant differences in PSA levels before and after ejaculation or between the groups. These results suggested that there was no physiological relationship between ejaculation and PSA level. Conclusions: Based on our data we conclude that sexual activity does not preclude the use of PSA to screen men for prostatic cancer."

Pretty widely varying comments, huh?

Most of the studies addressed ejactulation; fewer talked about DRE. I would imagine DRE might have more variation in results because of varying "agressiveness" of the DRE itself.

The AUA's PSA Best Practices (2009 Update) says the following: "Ejaculation and DRE have been reported to increase PSA levels but studies have shown the effects to be variable or insignificant. For this reason, PSA testing can be performed with reasonable accuracy after rectal examination."

So, my conclusion-of-the-conclusions is that ejaculation or DRE shortly before PSA blood draw appears to have some effect on results, but not very much (sometimes statistically significant, sometimes not), but if you are concerned about tenths of ng/mL differences, then definitely avoid tests after these situations.

To look at the abstracts that I saw, go to www.pubmed.gov and search "psa AND ejaculation" (57 total results, as of tonight).

Does this help? I scanned through some of your old posts...you wrote in August about having a 1.7ng/mL result after a DRE. You also wrote then that your urologist had prescribed finasteride, and I recall your other inquiries about chemoprevention. Your PSA results seem relatively low to me, albeit on the unfavorable side of the average for 45 yrs. What, if any, actions have you been taking? Just curious.

best wishes...

 
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Old 11-17-2009, 10:17 AM   #3
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Re: ejaculation or DRE before psa blood draw

Kcon - many thanks for your helpful post. I actually read one study that suggested, in younger guys, ejaculation could possibly reduce psa results -- so, as you suggest, results seem to be all over the place. In the future, I will avoid either sex or DRE before psa test. My risk factors are (1) my father died of metstatic p ca, and (2) significantly higher than typical psa for my age (psa history starting at age 39 has been: 1.4, 1.3, 1.42, 1.74, 1.7, and most recently 1.5). As I noted, one of these was a day after having sex and another was post DRE, hence my question. They have also been using 2 different labs and assays. I also have some relatively minor urinary symptoms (frequency, etc.). They are no big deal, but probably more common of a guy who is 60 than one who is 45. I have consulted with two urologists, at JHU. The first suggested (only after I raised the question, which led to a discussion of the REDUCE study results and related matters) that it might be a good idea to take finasteride for prevention purposes, and gave me a prescription, though he noted there is no evidence on the effect of finasteride on someone who takes it for, say, 20+ years. I subsequenly heard another (more prominent) urologist at that same institution speak at a public program, and recommended against finasteride or dutasteride for chemoprevention. So -- being a careful sort of guy -- I made an appointment with him. He recommended against taking the finasteride or dutasteride for prevention purposes (and added that he personally does not take the drug even though he also has a family history of lethal prostate cancer). He suggested a good diet and exercise, and a psa test once a year, and nothing more than that. I also asked him about taking a statin, and he said he does not think the evidence is sufficient to recommend statins for p ca prevention, though he acknowledged that if one takes a statin for other reasons, there could be an ancillary benefit in p ca prevention. (On the issue of DRE before psa, ejaculation before psa, and different labs, he said these are all good things to avoid, but no big deal in my case). I think his general view is that I am way too knowledgeable about prostate cancer for someone who does not have the disease, and that I should not spend time worrying about it. Maybe he has a fair point, though I learned a lot during my father's illness and would like to avoid going through what he went through. Besides, knowledge is good, right? As to your "what have I been doing" question? The answer is I have not taken the finasteride. The advice of the (second) doc I saw at JHU, and Dr. Walsh's similar view, and Dr. Catalona's view, and the uncertainties concerning long term use of finasteride, and the "masking" potential (which I know is a disputed issue) have influenced me not to start finasteride YET. But I am continuing to review the literature, and I may start at some point. If I do start, I might be inclined to use dutasteride instead of finasteride. Regards,

 
Old 11-17-2009, 11:14 AM   #4
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Re: ejaculation or DRE before psa blood draw

Thanks for the update on your situation. I agree, "knowledge is good."

You've probably seen some of Jim's postings on lifestyle tactics. Your doctor recommended diet & exercise. My understanding is that if one makes and sticks with a commitment to change lifestyle, that the PC-devil may likely stay away for a long time. Treatment is no fun; I hope you can avoid it for a very long time or forever.

best wishes...

 
Old 11-17-2009, 11:17 AM   #5
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Re: ejaculation or DRE before psa blood draw

Sounds like you've thoroughly covered the issues concerning you. I can only add anecdotal evidence from my own personal experience. Over 12 years ago I experienced a PSA spike from mid 3's to low 4's following a vigorous DRE. I retested a few weeks later and PSA had returned to "normal level". Based on that experience and an arrogant defensive reaction from my urologist when I questioned his performing DRE prior to blood draw, I changed urologists. Everything stayed stable for 4 more years and then PSA began gradual rise over 6 month period from 3.6 to 4.2 to 4.5 resulting in a positive biopsy of early stage low risk PCa which was promptly cured by radical open bi-lateral nerve-sparing prostatectomy in 2001. Undetectable PSA's since with almost zero side effects. Dx and surgery occurred at age 69.

 
Old 11-17-2009, 12:02 PM   #6
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Re: ejaculation or DRE before psa blood draw

If I ever get prostate cancer, I hope I get the kind that you appear to have had! (Of course, not getting it at all would be fine too!)

 
Old 11-17-2009, 05:11 PM   #7
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Re: ejaculation or DRE before psa blood draw

Hi medved,

Kcon's post is outstanding, and shs50's post added a real-life example, but I want to comment on the recommendations you got from Johns Hopkins. Ill put it in green in an excerpt from your third post.


Quote:
Originally Posted by medved View Post
... I have consulted with two urologists, at JHU. The first suggested (only after I raised the question, which led to a discussion of the REDUCE study results and related matters) that it might be a good idea to take finasteride for prevention purposes, and gave me a prescription, though he noted there is no evidence on the effect of finasteride on someone who takes it for, say, 20+ years.

First you need to know something about where I'm coming from. My third serious consultation was at Johns Hopkins with a doctor to whom they referred patients they rejected for surgery as too risky. I subsequently had another series of consultations with a radiation doctor there, and, following my decision to rely solely on hormonal therapy with a strong interest in triple hormonal blockade, later in the year, with the recommendation of my local medical oncologist, I had a consultation with Dr. Mario Eisenberger, MD, at Johns Hopkins. Dr. Eisenberger is a highly respected medical oncologist and world-class prostate cancer researcher. At the time I saw him on 11/3/2000, my PSA trend had been flattening out at around 0.6 after falling from 113.6 (after initial plunges in first five months, dropping by a third monthly since starting double blockade Lupron + Casodex). Here's the PSA pattern he was looking at: mid July 1.3 to mid August .9 to 9/16/00 .7 (just before Proscar) to .6 on 10/10/00,I had been on Proscar since 9/17/2000.

After doing a full exam, his advice to me was to continue the Lupron and Casodex but to "throw away" the Proscar. Admittedly the Proscar had not resulted in a dramatic (if any) decrease in the three plus weeks I'd been on it, but my oncologist and I thought I should at least finish the three month supply. Well, my PSA on 11/25/00 plummeted to .3, and the downward drop continued from there all the way til it hit <0.01. I later learned that Dr. Eisenberger was particularly well known for his work with chemotherapy, but that Johns Hopkins as an institution was not known for its work with hormonal therapy. In fact, it was in that school of thought that considered it best to reserve hormonal therapy until a patient developed symptoms of well-advanced, late-stage cancer. To many of us, that's backwater type thinking.

As to the 20 year usage issue, that's true: no definitive studies. But if that's the criterion, you would not be doing prostatectomies, radiation, cryosurgery - any of the major therapies. Also, and this is really key: it's extremely likely that something better than finasteride or Avodart will become available within the next ten years. That's based on the track record of prostate cancer for improvement. Just consider this: for a long time Proscar was the only 5-alpha reductase drug (5-ARI) approved, so long ago that it became available generically a couple of years back. Then Avodart came on the scene, and it should be considerably better for most men.



I subsequenly heard another (more prominent) urologist at that same institution speak at a public program, and recommended against finasteride or dutasteride for chemoprevention. So -- being a careful sort of guy -- I made an appointment with him. He recommended against taking the finasteride or dutasteride for prevention purposes (and added that he personally does not take the drug even though he also has a family history of lethal prostate cancer).

It still strikes me as odd that doctors so often do not keep up with developments outside their specialties, and for surgeons, drug developments and hormonal therapy are not in their specialty other than as secondary tool-type technology. I'd bet that surgeon had not kept close track of the finasteride prevention trial results, and he was probably unaware that the dutasteride (Avodart) prevention trial had been favorably reported this year.

He suggested a good diet and exercise, and a psa test once a year, and nothing more than that.

That's too mild and general, and unfortunate in discouraging the drugs. Did he recommend cutting out red meat, dairy and egg yolks? Did he recommend increasing fish and fish oil? Did he recommend vitamin D, lycopene and suggest pomegranate? Without these and other specific recommendations, the man trying to prevent prostate cancer is adrift.

Did he give you a rationale for opposing use of finasteride and dutasteride? I suspect he has not kept up with research reports, perhaps because he has been busy with his main urological work. I've personally become convinced that urologists, with a few exceptions, are not well versed in hormonal therapy for prostate cancer. I hope for his sake that he changes his view.

I also asked him about taking a statin, and he said he does not think the evidence is sufficient to recommend statins for p ca prevention, though he acknowledged that if one takes a statin for other reasons, there could be an ancillary benefit in p ca prevention.

Again, his comment suggests that he has not kept up. The research I've looked at has indicated strongly that statins reduce lethal prostate cancer, but also that they probably do not reduce the incidence of prostate cancer. Try this search on www.pubmed.gov: " prostate AND statin ", with these limits activated: only items with abstracts, Humans, Clinical Trial. I just got two results, and the second one is relevant to incidence. If you knock off the clinical trials limit, you get 87 hits as of tonight.

... As to your "what have I been doing" question? The answer is I have not taken the finasteride. The advice of the (second) doc I saw at JHU, and Dr. Walsh's similar view, and Dr. Catalona's view,

All surgeons who concentrate on surgery and very likely not so much on drugs. Have you considered adding a medical oncologist who specializes in prostate cancer to the mix? He's likely to be up-to-speed.

and the uncertainties concerning long term use of finasteride, and the "masking" potential (which I know is a disputed issue)

It should no longer be disputed among people who have reviewed the research. It enhances detection rather than masking it when properly viewed.

have influenced me not to start finasteride YET.

I've been there, done that. I had a number of reasons for believing the doctors who said back in 1999 that PSA testing was very controversial. I wish I had pushed harder, earlier, which you are clearly doing.

But I am continuing to review the literature, and I may start at some point. If I do start, I might be inclined to use dutasteride instead of finasteride.

Dutasteride would be my choice if I had not had such good results with finasteride. A few men have genes that prevent benefit with the drug, but tests can reveal that (it should reduce DHT sharply), and those men can switch to finasteride.

Regards,
Take care,

Jim

 
Old 11-18-2009, 09:20 AM   #8
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Re: ejaculation or DRE before psa blood draw

The (second) doctor I consulted at JHU - the one who recommended against taking finasteride for chemoprevention - was Ballentine Carter. He may or may not be "right" with his recommendation, but I am convinced that his view is not the result of lack of knowledge or a failure to focus carefully on the issue. He was, among other things, a member of the panel that authored the American Society of Clinical Oncology/American Urological Association 2008 Clinical Practice Guideline entitled "Use of 5a-Reductase Inhibitors for Prostate Cancer Chemoprevention" and is certainly very familiar with the REDUCE study results, and the predecessor study. So I do believe that he has given substantial thought to the issue, and is knowledgeable. That does not mean, of course, that he is right -- he may not be, and I ultimately may start taking this drug -- but his view cannot be easily dismissed.

Yes, I have considered seeking further advice on this question from a medical oncologist. I may ask Dr. Charles Meyers for his advice.

Regarding diet, I have made these changes: I eat nearly no red meat, not much dairy (I love cheese and it has been hard to give up), relatively high fiber diet, salad for lunch 5 days a week, 1000 i.u. per day of Vitamin D3, 8 oz per day of pomegranate juice, a good amount of fruits and vegeitables, broccoli sprouts a few days a week, at least two servings a week of cooked tomatos, and a glass of red wine every day. Oh, on occassion I eat something that is not so great for me -- I am not perfect and will never get to 100%. But the changes I have made are pretty significant and I am doing 95% a good job with it. I do not get enough exercise. I have a very demanding job, which makes that one tough.

My father refused to make these sorts of lifestyle changes, even when his p ca became advanced. His view was "I have lived a really good life, and enjoyed it, and I am going to keep doing and eating whatever I want, and the consequences will be what they will be." Even when he was on oxygen 24 hours a day, and painkillers, with liver and lung mets, he was going out for dinner and ordering liver and onions. I respect his (and anyone's) right to take this approach -- or any approach they want -- but the outcome was not pretty.

 
Old 11-18-2009, 03:02 PM   #9
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Re: ejaculation or DRE before psa blood draw

Quote:
Originally Posted by medved View Post
I do not get enough exercise. I have a very demanding job, which makes that one tough.
If the job is not physically demanding (to the point where you get exercise doing your job), you may want to try to overlay exercise on your commuting by walking, running, or bicycling to work (or to public transportation to work).

 
Old 11-18-2009, 09:57 PM   #10
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Re: ejaculation or DRE before psa blood draw

IADT3SINCE2000 is right on the money as usual. The NY Times reported last week that leading experts in breast and prostate cancer cannot understand why people are indifferent or resistant to taking drugs proven to prevent breast and PCa whereas many persist in using older nutritional supplements such as Saw Palmetto, Lycopene, etc which are ineffective as preventatives. Finasteride and Dutasteride were mentioned as proven effective prostate cancer preventatives and Tamoxifen and Reloxafin for breast cancer.
Some experts hypothesized that the reluctance may be because people who do not have cancer don't want to take medications which were given to people with cancer but would rather cling to dietary and nutritional supplements even though they haven't been proven to prevent cancer because natural products are associated with health rather than disease. Also many Dr's are reluctant to prescribe proven medications because of patient resistance and anxiety that maybe the Dr knows something he isn't revealing.
Its not uncommon, I suppose,for anything thats counterintuitive or emotionally uncomfortable to be slow to catch on despite what the research points to.

 
Old 11-19-2009, 07:31 AM   #11
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Re: ejaculation or DRE before psa blood draw

What would be most interesting, to me, would be to ask whether the leading urologists and medical oncologists in the prostate cancer field are taking dutasteride/finasteride themselves, for prevention purposes. I think that would show what they really believe. I was prepared to start taking finasteride until I consulted with a doctor who I regard as very knowledgable, who recommended against it. So now I am on the fence. I plan to seek other views, including if possible from Dr. Meyers.

 
Old 11-19-2009, 02:22 PM   #12
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Re: ejaculation or DRE before psa blood draw

That would be interesting and enlightening. Most experts never say what they're taking themselves and are usually focused on treatment rather than prevention. Better for business.

 
Old 11-23-2009, 09:33 PM   #13
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Prostate cancer prevention drugs

Quote:
Originally Posted by shs50 View Post
The NY Times reported last week that leading experts in breast and prostate cancer cannot understand why people are indifferent or resistant to taking drugs proven to prevent breast and PCa
Do you mean for people who are not known to be at increased risk due to family history or something like that?

If so, it may be the valid concern that drugs that affect hormones like testosterone and estrogen may have undesirable side effects related to the drugs' actions on testosterone and estrogen. For example, limiting the effect of testosterone may increase the risk of osteoporosis and diabetes type 2.

 
Old 11-24-2009, 07:40 AM   #14
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Re: Prostate cancer prevention drugs

Hi tjlhb,

There is an answer to your question in the previous post, #13. I'll quote what you said as it is short:


Quote:
Originally Posted by tjlhb View Post
Do you mean for people who are not known to be at increased risk due to family history or something like that?

There are really two main groups that are potential consumers of these preventive drugs: those with no known risk, as you mention, and those known to be at elevated risk due to less-than-ideal PSA or DRE results, family background, race, age, and probably coming soon - genetic testing results.

Personally, if I were in the first group (not even close in reality) but knew what I've learned about all tactics for helping to prevent prostate cancer, I would use lifestyle tactics and also take a low-dose statin drug, but I would not add either finasteride or Avodart. On the other hand, if I had some indication I was at higher risk, I would try one of them. I would probably choose finasteride as it is inexpensive and appears to pack the same preventive punch as Avodart. If I were not in the 10% to 20% group of patients who experienced decreased erectile function or libido, I would stay on the drug. I would probably stay on it too if the decreases in function or libido were minor. In summary, I'm convinced the best course at present is to focus the preventive potential of finasteride and Avodart (dutasteride) on men at higher risk of prostate cancer.


If so, it may be the valid concern that drugs that affect hormones like testosterone and estrogen may have undesirable side effects related to the drugs' actions on testosterone and estrogen. For example, limiting the effect of testosterone may increase the risk of osteoporosis and diabetes type 2.
At least for the vast majority of men taking finasteride or Avodart, testosterone is not decreased. In fact, for most of us it will increase somewhat. That's because, when we are taking either drug, less of our testosterone is being converted into dihydrotestosterone (DHT), which is a much more potent fuel for prostate cancer. Therefore, most of us taking one of these drugs in order to lower the risk of prostate cancer will experience the benefits of added testosterone. In fact, these drugs are banned in the Olympics because for most of us they will tend to enhance performance. Therefore, risk of osteoporosis and diabetes is not a consideration. Moreover, because these drugs decrease DHT, and because DHT is a big factor for some of us in male pattern baldness, some of us will grow more hair in the male pattern baldness areas. (Happened to me! ) We will also benefit from somewhat smaller prostates as BPH (benign prostatic hyperplasia) is counteracted.

I'm not up to speed on the estrogenic effects, but I know there is a very small incidence of growth of more breast tissue for some men on these drugs. My impression is that estrogenic effects are minor.

To me, the greatest concern in taking these drugs would be the impact on reproductive capability for those men still interested in pregnancy. The drugs cut down somewhat on the volume of semen, and the label cautions women who may become pregnant to have no direct contact with the medication. Dr. Charles "Snuffy" Myers, one of the experts in hormonal therapy for prostate cancer, advises me to consider banking sperm if they are interested in child bearing and want to take one of the drugs.

Take care,

Jim

 
Old 11-24-2009, 08:51 AM   #15
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Re: Prostate cancer prevention drugs

Quote:
Originally Posted by IADT3since2000 View Post
At least for the vast majority of men taking finasteride or Avodart, testosterone is not decreased. In fact, for most of us it will increase somewhat. That's because, when we are taking either drug, less of our testosterone is being converted into dihydrotestosterone (DHT), which is a much more potent fuel for prostate cancer. Therefore, most of us taking one of these drugs in order to lower the risk of prostate cancer will experience the benefits of added testosterone. In fact, these drugs are banned in the Olympics because for most of us they will tend to enhance performance. Therefore, risk of osteoporosis and diabetes is not a consideration. Moreover, because these drugs decrease DHT, and because DHT is a big factor for some of us in male pattern baldness, some of us will grow more hair in the male pattern baldness areas. (Happened to me! ) We will also benefit from somewhat smaller prostates as BPH (benign prostatic hyperplasia) is counteracted.
However, while DHT is more potent fuel than testosterone for prostate cancer, BPH, and male pattern baldness, couldn't it also be more potent fuel when it comes to avoiding osteoporosis, diabetes type 2, and some other conditions that risk may increase when one has low androgens? While testosterone may be more effective on skeletal muscles, DHT may be more effective on other bodily functions; reducing the conversion of testosterone to DHT may have unintended or undesirable side effects.

 
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