WA News News & Reports Exercise effects when measuring PSA?
Exercise effects when measuring PSA?
Written by Dr Sandra Mejak
Wednesday, 28 June 2017

 

Research has concluded that cycling for exercise can increase prostate specific antigen (PSA) in the short term. The mechanism is unknown but has been postulated to involve both mechanical stimulation of the perineum and increased blood flow. Should abstinence from cycling, or even other forms of exercise, be therefore advised when doing this test?

The PSA in context

The controversies surrounding the PSA test are beyond the scope of this article. PSA is produced by both malignant and benign prostate cells, and PSA levels are known to increase in benign prostatic hyperplasia, prostatitis and prostate cancer.

The probability of cancer occurring given an elevated PSA is 1 in 3, although prostate cancer can still be present with a normal PSA.

Procedures that increase PSA include radical prostatectomy, ultrasound-guided needle biopsy, and transurethral resection of the prostate – the increase in PSA is far greater than 100%, and the PSA can remain elevated for days to weeks.

Non-invasive manipulations, such as ejaculation, digital rectal examination (DRE), and cystoscopy also increase PSA but to a lesser degree, and for shorter periods of time than surgical manipulations. It is also recognised that free PSA (fPSA) has been shown to be eliminated within 2-33h, whereas total PSA takes 2-3 days, and that if PSA is elevated, the lower the fPSA:tPSA ratio, the higher the likelihood of cancer.27062017-Bicycle-pedal-PSA

Cycling and PSA

The evidence of cycling causing an increase in PSA has been mixed, though many of the studies that did not show an increase had methodological deficiencies in either the age of men tested (too young), or distance cycled (too short).
More recent studies have confirmed that cycling increases PSA. My own paper (Mejak, Bailis, and Hanks, 2013) showed an average increase of 9.5% in total PSA in healthy male cyclists, when measured straight after cycling. Other studies also confirm an increase with cycling (Safford 1996, Oremek 1996, Kindermann 2011, Frymann 2006, Rana 1994).
So if prolonged cycling increases PSA in men of screening age, what about other exercise? The evidence suggests other exercise can increase PSA but the relationship is not as clear-cut. When other exercise has caused an increase, it has been less than with cycling, and is more likely in older men, in those who already have cancer, and with more intense and/or longer exercise.

What should a practitioner advise?

  • One possible approach is to repeat an elevated single random PSA test after 48 hrs abstinence from cycling (and probably ejaculation and DRE). If it remains elevated, treat the elevated result with the usual further investigation or monitoring. [The alternative is to advise every patient undertaking a PSA test to avoid cycling (and probably ejaculation and DRE) for 48 hrs beforehand, but this method is harder to control and document accurately.]
  • Avoidance of all exercise for 48 hrs before PSA testing may have merit, when compliance and accurate documentation are not problematic.

By Dr Sandra Mejak

While communication is one thing, investigation of notifications is another. We believe good doctors want the bad ones weeded out but they don’t want to be part of a witch hunt or get buried in lawyers, politics or paperwork.

The national Medical Board can respond to a complaint or act on the advice of the WA Medical Board to establish an assessment panel to either examine the health or performance and professional standards of a doctor. Health consumers are represented on panels along with medical practitioners.

The Medical Board and AHPRA have undisclosed lists of doctors who are approved by them as panellists and probably as expert witnesses. Many of these people, we believe, were ‘grandfathered’ across when National Law first came in (2010). Their impartiality is as unknown as they are. Then we have expected biases of the legal assessors, chosen by AHPRA, possibly thrown into the mix.

Is there a problem, Houston?

It is important this is sorted to everyone’s satisfaction as 42% of doctors in our survey thought panellists could lack impartiality to a serious extent.

In fact, only one quarter of doctors we surveyed (n=195) were happy with the impartiality shown by AHPRA or the Medical Board in processing a complaint (with 36% unhappy and 39% undecided). Nearly all of those who were unhappy said they were concerned that unfairness will be seriously damaging to someone. Investigation is a very confronting experience.

If someone is being investigated by a panel, either the panel or the person being investigated can opt for a more out-in-the-open State Administrative Tribunal (SAT) judicial hearing – the panel usually refers because it feels the evidence before it constitutes more serious professional misconduct.

What Fair Doctors Want

Talking to doctors, they appear to want an apolitical system of investigation that is fair and timely. They want to be treated reasonably. Unlike the legal profession, their work is mostly built around trust and honesty. They do not want a return to the ‘good old days’ where those with a political bent in the medical profession could influence what the Medical Board did.

While this is a very difficult area for us to investigate, with arguments and counter-arguments at every step, we cannot understand why the Medical Board would turn to arguably the most political organisation, the AMA, for its counsel (the national Board Chair met earlier this year with “senior leaders from AHPRA and representatives of the AMA” to workshop doctor complaints).

Why? Our e-Poll responses raise a question mark over the AMA’s involvement (and we don’t think AMA members have been polled on this issue.)

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