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PSA very accurate guide to finding prostate cancer spread to your bones

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Jim Marshall (not a doctor) said ...

In brief, what a bone scan will likely find before you have any kind of treatment for prostate cancer:

PSA greater than 100

Prostate cancer very likely has spread to several places in your bones. (multiple metastases)


PSA greater than 20

Likely prostate cancer has spread to at least one place in your bones.


PSA less than 20

Quite unlikely prostate cancer has spread to your bones.


The PSA blood test is getting bad press lately. There have been calls to limit its use.


This paper is not about PSA levels after treatment. The paper below confirms the usefulness of PSA in telling whether prostate cancer may have spread to your bones before you are treated.


It reports on the most commonly used 'bone scan' (a radionuclide bone scan) where you are injected with short-life radioactivity, and then scanned to see where it sits. The radioactivity prefers bone damage, especially prostate cancer bone damage. 


The men had no symptoms of bone metastases (e.g. pain), and no previous treatment for prostate cancer.


... end Jim

Indian J Nucl Med. 2012 Apr-Jun; 27(2): 81–84.

doi:  10.4103/0972-3919.110683

PMCID: PMC3665151

Predictive value of serum prostate specific antigen in detecting bone metastasis in prostate cancer patients using bone scintigraphy


Koramadai Karuppusamy Kamaleshwaran, Bhagwant Rai Mittal, Chidambaram Natrajan Balasubramanian Harisankar, Anish Bhattacharya, Shrawan Kumar Singh,1 and Arup K Mandal1

Department of Nuclear Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India

1Department of Urology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Address for correspondence: Dr. Bhagwant Rai Mittal, Department of Nuclear Medicine, PGIMER, Chandigarh - 160 012, India. E-mail: brmittal@yahoo.com

Copyright : © Indian Journal of Nuclear Medicine

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.




Radionuclide bone scan (BS) used to be the investigation of choice for detecting osseous metastases in prostate cancer. Now, with the availability serum prostate specific antigen (PSA) testing, clinicians do have a timely, cost-effective method to determine those patients who are highly unlikely to have osseous metastases. We determine the utility of PSA for predicting the presence of skeletal metastasis on BSs in prostate cancer patients.


Materials and Methods:


Retrospective analysis of medical records of 322 consecutive prostate cancers patients subjected to BS during the last 3 years was done. 52 cases were excluded due to following reasons: Serum PSA not available, hormonal or other therapy given prior to serum PSA measurement, and/or BS, and symptomatic for bone metastasis. In remaining 270 cases, PSA value and BS were evaluated. BS was performed with Tc99m methylene diphosphonate (MDP) as per the standard protocol.




BS was found to be positive in 153/270 (56%) and negative in 117 (46%) patients. Of the 153 positive cases, 108 (70%) had serum PSA > 100 ng/ml, 42 (28%) had PSA of 20-100 ng/ml and only 3 (2%) had PSA < 20 ng/ml. All the patients with PSA > 100 ng/ml had multiple skeletal metastasis. Of the 117 negative cases, 110 (94%) had a PSA < 20 ng/ml, 5 had between 20 and 100 ng/ml and only 2 (1.8%) had PSA > 100 ng/ml. Of the 113 patients with serum PSA < 20 ng/ml, 110 (97.4%) did not show any bony metastasis. 150/157 (95.5%) patients with PSA > 20 ng/ml had bone metastasis. Using this criterion, 110 (40.7%) scans would have been omitted.




Serum PSA < 20 ng/ml have high predictive value in ruling out skeletal metastasis. Our data are in corroboration with results from previous studies that BS should be performed only if PSA > 20 ng/ml. Using this cut-off, unnecessary investigation can be avoided. Avoiding BS in this group of patients would translate into a significant cost-saving and reduction in their psychological and physical burden.


Keywords: Bone scan, prostate Ca, prostate specific antigen, Tc99m-methylene diphosphonate

This extract is in the public domain.


Any highlighting (except the title) is not by the author, but by Jim Marshall.

Jim is not a doctor.

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Hi Jim Jim Jim,


I read your comments on this topic with particular interest, especially regarding the accuracy of the PSA measurement in relationship with the spread of prostrate cancer to the bones.


I have multiple metastases and have never had a PSA level of higher than 4. The spread is in my spine, ribs, hips and possibly elsewhere (currently undergoing xrays etc to determine if spread has advanced to shoulder). My latest PSA reading was less than 2 and has been for several years. I am receiving hormone injections in an attempt to control the spread as radiation or operations are not an option.


Although I believe my very low readings are very uncommon for someone like me who has multiple metastases, it does prove however, that we should be aware that the PSA reading can be misleading. For you information, my Gleeson score is 5+4.





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For Eamon,


In view of androgen deprivation therapy your treatment option, and in view of your advanced Gleason Score 4+5/9, you might find information helpful in this paper: http://tinyurl.com/3s76t6x.


I have come across several men whose PSA levels never gave evidence of anything out of the order, and for those it was the digital rectal exam (DRE) that determined the presence likely cancer development that lead to the eventual biopsy.  This is, of course, troubling since too often, as in your case, the cancer has had time to become aggressive to the point of metastasis and the side effect of that metastasis that leads to the eventual recognition of prostate cancer presence/development.


Charles (Chuck) Maack

Prostate Cancer Activist/Mentor



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Apologies...I just noted that I indicated your Gleason Score was 4+5/9 when actually 5+4/9, and all the more reason the url provided may provide you better understanding of testing, imaging, treatment considerations, particularly the consideration of triple hormonal blockade....also explained here: http://tinyurl.com/3ulagd2 supported by this http://tinyurl.com/74bkzam

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Hi Jim,


Hope you are as well as can be expected.  I also read with great interest the recent topic regarding PSA and bone metastases.  My PSA situation is very much the same as Eamons.  A quick summary of my journey thus far is as follows:


- April 2008 - TURP

- June 2012 - another TURP + BNI (bladder neck incision)

- July 2012 - 12 biopsies, Gleeson score 4 + 5 = 9

- July 2012 - CT scans

- 6/08/2012 - advised of metastitic disease in right & left sides of pelvis

- August 2012 - commenced hormone injections (Zoladex) every 3 months and have been advised that I will be receiving this injection for the rest of my life

- February 2013 CT scans

- results confirm that cancer now also residing in back of right hip

- from 8/05/2013 to 14/06/2013 attended 25 sessions of radiotherapy

- monthly PSA results over the last 12 months have been as low as 'unrecordable' to 5.5. At for a few months the results were doubling every month.

- September 2013 CT scans

- results confirm that cancer now also residing in lower spine

- 29/10/2013 commenced the 1st of 10 chemotherapy infusions (Docetaxel-Prednisolone), at 3 weekly intervals

- after the 6th infusion I'll be having more CT scans to ascertain current situation

- I'm a candidate for Abiraterone (Zytiga), but this will depend on the results future CT scans and completion of chemotherapy / radiotherapy

- had the 5th infusion today (21/01/2013) - PSA 4.4

- I have been informed by my Palliative Care Specialist that a study is either being planned or is underway (can't remember which - chemo brain!), looking at low PSA results / resultant multiple metastases experienced by a 'small' percentage of advanced prostate cancer patients.


I provide the above information in support of Eamon's comments as we are 'A-typical' - my results were a shock for all involved - my Urologist, Radiation Oncologist, Medical Oncologist, Palliative Care Specialist, Pathologists and support personnel.


All the best and I hope to catch up with you at the next 'face to face' lunch.




Brian Hammerton

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I would hope that both Eamon and Brian are including appropriate supplements in their daily intake to support bone issues that accompany the medicines prescribed to treat advanced prostate cancer.  May I suggest opening my paper on Diet and Supplements http://tinyurl.com/6z5l8fm and scrolling down to page 7 that begins


FOLLOWING" explaining particularly the supplement developed by one of the top Medical Oncologists in the world, Stephen Strum, who has specialized specifically in research and treatment of recurring and advanced, high grade, prostate cancer since 1983 - Dr. Strum’s Intensive Bone Formula.
You both may also consider reviewing Bisphosphonates and Dental Considerations regarding bone issues: http://tinyurl.com/3m78ymg since more often than not, by the time men are diagnosed with prostate cancer, and especially advanced prostate cancer, osteopenia or osteoporosis are also in development.  


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