The significance of the Free PSA and then “the wait.”

Free Psa low…damn it!!!

Your PSA, rectal exam and biopsy report – Understanding the specifics of your disease is key to making the right decision.

I had been checking my PSA for years and had watched it slowly creep up to just above normal. I decided to obtain a Free and Total PSA to see if it would offer any guidance regarding pursuing a biopsy. (In your blood, a portion of PSA is free (unbound), and a portion is bound by blood components. A low Free PSA indicates a higher possibility of a positive biopsy.) The day after my blood was drawn, my nurse Tina approached me with the lab report indicating a very low Free PSA.

She had drawn a frowny face next to the lab value. I was crestfallen. “Tina, did you really have to put the little unsmiley face on it?” I decided at that moment that the time had come for me to have a prostate biopsy. I asked my partner to do it at lunch that very day, and the pathologist had the tissue samples in his hands by 1:30 p.m.

That evening my wife and I met at a little cabin we have on Lake Sidney Lanier, which is not uncommon on my half-day off on Thursdays. I had not told her that there was an issue with my PSA or that I had had a biopsy that day at lunch. I debated mentioning anything to her before I knew the biopsy results, but I chose to have her involved in the drama of waiting for the results and all the possibilities that entailed. “Karen, I had Bill do a biopsy on my prostate today. My PSA is slightly elevated, and I want to be sure that it doesn’t mean I have a problem.” (Remember, you don’t start with the C word. You tell a patient and his wife, “There may be a problem with,” ” They found something,” or “They have some concerns about…”) We were sitting on the cabin’s porch at the lake, and I had a panoramic view of the little piece of property where I spend a good portion of my weekends cutting grass, fishing, and working on the little vegetable garden we have there. My weekend ritual has become for our dog Chloe and me to pack up the trash in the back of my 1985 Toyota truck (my first car with air conditioning), take it to the county compactor, and then go to the lake. For years I have spent my weekends out there, always making a point to be home, as my mother would say, “by the time the street lights come on.” As we were sitting there, out of nowhere, I said, “I don’t really love this place Karen. I enjoy coming out here, but I don’t really love it. I mean I wouldn’t really miss it.” She looked at me with disbelief. “What are you talking about John? You know you and Chloe love this place; are you thinking you are going to die or something? That’s crazy.” My wife (like most patients who have their prostates biopsied) didn’t understand the possibility of having the “bad” kind of prostate cancer, the Frank Zappa kind. Frank Zappa died shortly after being diagnosed with inoperable prostate cancer, at the height of his musical career, in his 50s. That was my fear, and I will tell you it was real. As I pondered the possibilities of my pathology results, I gravitated to an acceptance that having the “slow-growing kind” of prostate cancer would be okay, but I prayed, “Please don’t let me have the bad kind.” If you have favorable parameters, you may die of prostate cancer, but it will take many years. If the biopsy has unfavorable parameters, the prognosis is unpredictable, with a higher likelihood of the cancer progressing quickly. I had seen this played out in patients of mine; I knew this, but my wife and family did not. I elected not to elucidate my concerns about the dual nature of prostate cancer to my wife; I had awakened her enough.  This time period of “waiting on the results” really gets you thinking, and I was becoming very philosophical about my mortality, with a mentality of “what will be, will be” starting to set in.

5 Replies to “The significance of the Free PSA and then “the wait.””

  1. I’d like to know the significance of a low free PSA result (17%) eight months after radical prosectomy and 33 sessions of daily radiation? I can’t seem to find any information that specific relates to free PSA results after treatment when total PSA is <0.1. Any help appreciated.


    1. The free Psa is used before the first biopsy and before the diagnosis of prostate cancer has been made. It helps make a decision whether to pursue a biopsy or not. After treatment the ultra sensitive Psa is used to monitor the cancer treatment. JM


      1. Thank you John, by the term ultra sensitive psa do you mean you just focus on the total PSA result and ignore the % of free PSA?


  2. John, I now know what this term means. We saw my husband’s oncologist today and when asked should he have this done she said that it’s of no use as the total PSA result every three months is enough. Perhaps in Australia this test is not so commonly recommended. Now fourteen months since diagnosis, 16 weeks in hospital following robotic surgery with infection to pelvic bone and abductor muscles, 6 and half weeks of daily radiation, 3 emergency admissions with retention, removal of staple that went astray and now bleeding every three days….. a very steep learning curve to say the least. Your ‘diary’ and additional comments have been very helpful and informative.


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