With his retirement date approaching, St. Louis-area high school teacher Ken Chadwick decided to take advantage of his school’s health insurance while he still had it and obtain a number of routine medical exams and tests.
In November 2021, he saw his primary care physician, who did a PSA blood test, which screens for possible prostate cancer. Over the previous four years, Chadwick’s PSA level — which stands for prostate-specific antigen, and higher levels may be an indication of cancer — had risen incrementally, from zero nanograms per milliliter of blood to 1 to 2. Now it was above 3.
“But my primary care doctor said as long as my PSA level was below the benchmark of 4 [nanograms], I had nothing to worry about,” Chadwick said.
Six months passed.
Chadwick began having trouble urinating, so he went to see a urologist, who performed a procedure that involves looking inside the bladder with a small camera. The exam revealed a nodule, which was concerning, so the urologist did another PSA test.
In the time since Chadwick’s visit to his general practitioner, his score had zoomed from 3 to 10. A subsequent biopsy found cancer in every one of the 13 sites biopsied on the gland, nine of them with an aggressive form of the disease.
Two months later, surgery would reveal that Chadwick’s cancer, which had colonized 60% of his prostate gland, had also metastasized to nearby tissues, lymph nodes and bones. He had Stage 4 cancer, the most advanced.
Since then, he has undergone a grueling regimen of treatment.
“It knocked my socks off a little,” said Chadwick, 63, recalling how he felt when he learned of the seriousness of his condition. “I’ve always been in pretty decent shape, and I eat pretty well. And, yeah, I probably was angry.”
Angry, because Chadwick learned from two different urologists — one in St. Louis and another in Colorado, where he and his wife moved after his diagnosis — that primary care physicians may have misperceptions about how to interpret the PSA test, potentially putting patients’ lives at risk.
“It’s more common than you’d think,” said Dr. Clay Pendleton, a urologist in Steamboat Springs, Colorado, and the prostate, bladder and kidney cancer specialist who has been treating Chadwick’s advanced prostate cancer and who performed his surgery.
A native of Tyler, Texas, who trained for five years at the M.D. Anderson Cancer Center, Pendleton said confusion and controversy has surrounded prostate cancer diagnosis and treatment through the years, especially since the treatment can sometimes render a man sexually impotent or incontinent for the rest of his life.
Most men with prostate cancer have a type that will never threaten their lives, with the only treatment needed being active lifetime monitoring of their PSA levels and other exams and tests.
Still, prostate cancer is the second-leading cause of cancer death among American men after lung cancer. One in eight men will be diagnosed with the disease at some point in their lives.
A 2016 study found no difference in the death rate — which was very low overall —between men who chose treatment versus those who chose active monitoring, although the disease was more likely to progress and spread in men who chose monitoring alone.
“There’s confusion over the PSA test,” Pendleton said, “because you can have an elevated number and that doesn’t mean you have cancer, or you can have a low PSA and that doesn’t mean you don’t have cancer.”
The important number to follow, he said, is the “velocity” of the PSA, or the trend over time in terms of whether it rises.
The PSA test itself only came on the scene in 1994. Pendleton said that since then there’s been an ongoing debate in the “primary care world” about when, if ever, to screen for prostate cancer.
Not long after its debut, he said, PSA screening became commonplace among physicians and “what happened was there was a whole lot of over-diagnosis and over-treatment of minimally aggressive prostate cancer.”
Then a 2018 national task force recommended that men ages 55 to 69 should decide jointly with their physicians whether to test, based on a man’s preferences, values and risk factors. The pendulum swung back to, “We don’t even need to treat it,” Pendleton said.
But then emerging data suggested that many cases of high-grade prostate cancer were going undetected, and a 2022 study found a significant rise in metastatic prostate cancer among men aged 45 and older that coincided with the recommendation against routine cancer screenings.
So the pendulum may be swinging back again.
Pendleton said “in the urology world,” the current recommendation is routine PSA screening for men between 55 to 70 every one to two years. The same goes for men ages 40 to 65 if they have a positive family history for prostate cancer or if they’re African American, because Black men have a heightened risk for the cancer.
To lower the risk of over-diagnosing low-grade cancers that can be left alone, urologists now rely on more advanced tests — MRIs as well as a specialized blood test and also a new kind of fusion biopsy — on men with elevated PSAs to discern whether their cancer is intermediate or high-grade and likely in need of treatment.
“There’s been an increase in accuracy that is fourfold over [traditional diagnostic tests],” Pendleton said.
A number of experimental diagnostic and treatment models are in the pipeline that could end up being game-changers in the fight to end prostate cancer, Pendleton said.
Another piece of good news: The majority of men who have PSA levels that rise precipitously, like Chadwick’s did, will still end up having “indolent” forms of the cancer that are non-life-threatening.
But that wasn’t the case for Chadwick. He and his wife of 13 years, Teri Chadwick, a 58-year-old nonprofit executive, dealt with that grim fact the best they could.
After their move to Steamboat Springs — they’re both outdoorsy types who had bought a home in Colorado for their retirement before his cancer struck — Teri Chadwick threw herself into learning all she could about treatments and options.
“I tried to stay positive for him, but [his cancer] scared the bejesus out of me,” she said. “The surgery sounded horrendous, and it was, and I was freaked out about the hormone treatment.”
Chadwick would have to take a drug that reduced his testosterone, a male hormone that feeds the cancer. Chadwick, a former football player, had met his wife on Match.com: She has messaged him that she liked his big shoulders.
“The idea of him losing muscle mass, … I was just worried that he wouldn’t feel like himself, and that he would be freaked out by it,” she said.
In addition to the hormone therapy, Chadwick has undergone 11 rounds of radiation therapy and is in the midst of six cycles of chemotherapy.
For a while, his PSA and testosterone levels remained stubbornly high, and doctors added another cancer-blocking drug to his treatment regimen. He underwent a specialized scan called a PSMA Pet scan — which uses prostate-specific membrane antigen targeted tracers to hunt for diseased cells in tissues and organs — which found additional cancer that a traditional CT scan had missed, which doctors then treated with radiation.
After a time, his testosterone and PSA levels finally went down.
The chemotherapy — he’s about halfway done — makes his bones ache for three or four days. He struggles with fatigue and “chemo brain fog.” But recently his oncologist at the Shaw Cancer Center delivered some much-needed good news.
“She said I’m basically in remission,” Chadwick said. His original prognosis of only two years left to live has stretched to five years — the shiny brass ring in the world of cancer survival.
I got connected to Chadwick and learned his story through my husband — a colleague of Chadwick’s wife, remotely. I wanted to share his story with you because the issue is such an important one.
The couple is telling their story now because they want to get the word out that it’s the progression of the PSA test that matters — not just the benchmark — and they want to strongly urge all men to get tested.
“It’s a simple test, and it can save years of your life,” Teri Chadwick said.
They wonder if all the pain and worry and heartache could have been avoided if Chadwick had only gotten diagnosed sooner.
After he found out how bad his cancer was, Chadwick paid a visit to the primary care physician who had previously told him his rising PSA levels weren’t a concern.
“He literally said to me, ‘Well, if you’re going to have cancer, prostate cancer is the one to have,’’’ Chadwick said.
No, the doctor didn’t apologize for missing his cancer, Chadwick said. And no, he has no plans to sue for medical malpractice or otherwise seek recompense.
“Suing won’t make the cancer go away,” he said. “And, you know, doctors are human. Everything is advancing so rapidly in the area of prostate cancer, there’s no way primary doctors can keep up with it.”
This article has been updated to clarify the national task force’s recommendation in 2018.
