Dear Dr. Roach: I am a 74-year-old man. I was diagnosed with prostate cancer in 2019 and had my prostate removed in 2021. My PSA level was 0.39 on my three-month follow-up visit, but it has increased to 1.460. In my mind, if the procedure was successful, the PSA should be zero. I had a PET scan in May 2022, showing that the gland was completely gone. I have complete confidence in my urologist, but I’m just wondering if there is something he may not be telling me. — E.B.
Answer: Prostate cancer is often treated with surgery, with the intent to cure the cancer. About 30% of the time, and usually within five years of treatment, the PSA level will rise. The fact that your PSA level was not zero after surgery suggests some prostate tissue was left. However, I can’t answer whether this is cancerous or not.
A positron emission tomography (PET) scan looks for metabolically active tumors. About 80% of prostate cancers will take up the dye used in PET scans, fluorodeoxyglucose, and sometimes normal prostate tissue will as well. The negative PET scan is good news, but does not definitively answer whether you have recurrence of prostate cancer or not, or even if there is any residual amount of prostate tissue left.
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However, the rising level (yours has doubled twice in two years) suggests there is prostate tissue somewhere in your body. When a PSA level doubles in less than three months, that’s a sign that aggressive cancer has returned. Your doubling time is roughly one year. Men with a doubling time greater than three months had an excellent prognosis — a less than 1% prostate cancer mortality rate after eight years.
Your urologist has other information than can help determine how worried you need to be about the PSA level rising after surgery, and it’s important to have a frank discussion.
Dear Dr. Roach: I received an email from the office of my primary care physician, who is part of a hospital-based system, that said: “Your doctor is part of an accountable care organization. We’ve teamed up with other doctors, hospitals and health care providers to make sure you get the best care.”
What are the patient implications of being part of an ACO? Is it an attempt to stop me from seeing a specialist outside of their system? Is there anything I should be concerned about? — M.C.
Answer: The goals of accountable care organizations are to both reduce costs and increase quality of care. There have been many studies that have looked at how well ACOs have achieved these goals, and how both patients and providers rate the experience of care.
A recent review of all published studies suggests that ACOs do reduce costs without reducing quality of care (as measured by some well-studied but not always perfect metrics). Most studies show that quality metrics (such as proportion of patients getting their appropriate breast and colon cancer screening tests) are better in ACOs than in traditional fee-for-service models.
Studies that looked directly at patient implications found that patients rated ACOs better in timely access to care and in provider communication.
In short, the available evidence suggests that ACOs do not impact quality of care or patient experience, but only time and your experience will show what happens in your case.
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