‘”Don’t let the noise of others’ opinions drown out
your own inner voice. Have the courage to
follow your heart and intuition.”
My blog last week was on prostate cancer vis-à-vis diet and lifestyle. The lead article on the front page of yesterday’s New York Times reported on new United States Preventive Services Task Force (USPSTF) recommendations with respect to PSA testing (Prostate Specific Antigen). The bottom line is that this organization is counseling against the use of PSA testing in healthy men. They posit that the test does not save lives and leads to more tests and treatments that needlessly cause pain, incontinence and erectile dysfunction.
Two years ago, the same organization advised that women in their 40’s should no longer undergo routine mammography, setting off a blaze of controversy. Their proposals were met with great resistance by many cancer organizations, women, and their physicians, many of whom continue to ignore them.
It should be well noted that the chairwoman of the USPSTF is a pediatrician! It is obvious that prostate cancer is not a pediatric issue and should not be evaluated and managed by pediatricians. I, along with other members of the American Urological Association, ardently disagree with the assertions of the task force that prostate cancer testing with the PSA test provides no clear benefits. Urologists, radiation oncologists, and medical oncologists (those physicians in the know who are in the “trenches” and take care of prostate cancer on an everyday basis) understand how devastating prostate cancer can be, and the quintessential importance of early detection.
Confidently and unequivocally, I can state that when interpreted appropriately, the PSA test provides important information in the diagnosis, pre-treatment staging, risk assessment and monitoring of prostate cancer patients. Marginalizing this important test does a great disservice to those who may benefit from early prostate cancer detection; the recommendations of the task force will ultimately do more harm than good to the many men at risk for prostate cancer.
I have practiced urology for 23 years, in addition to 7 years of residency and fellowship training before entering practice. I am old enough to have served as a physician in both the pre-PSA era and the post-PSA era. In my early years of training at the University of Pennsylvania School of Medicine, it was not uncommon to treat men in the emergency room who could not urinate and on exam were found to have a rock-hard prostate and diffuse spread of prostate cancer to their bones…metastatic prostate cancer with a grim prognosis. In the post-PSA era, that scenario—fortunately—occurs on an extremely infrequent basis thanks to PSA screening. Essentially, annual screening with PSA and rectal exams has resulted in downward stage migration—picking up cases of prostate cancer in an early, curable stage before they spread and become incurable. I have little doubt that PSA testing saved my own father’s life, who underwent prostate surgery for cancer 15 years ago and is now a healthy, thriving and active 80-year-old…in ALL respects!
Importantly, prostate cancer is a remarkably heterogeneous disease with every single case being unique—literally as different as snowflakes—thus, the management of prostate cancer must be individualized. The major challenge for those of us who treat prostate cancer is to distinguish between clinically significant and clinically insignificant disease and to decide the best means of eradicating clinically significant disease to maintain both quantity and quality of life. Not all prostate cancers require active treatment and not all prostate cancers are life threatening. The decision to proceed to active treatment is one that men should discuss in detail with their urologists to determine whether active treatment is necessary, or whether surveillance may be an option for their prostate cancer.
What exactly is the PSA test? It’s just a simple blood test that is sent out to a laboratory with results available in a few days. Prostate-specific antigen (PSA) is a protein produced by the cells of the prostate gland. More specifically, it is an enzyme known as a protease that functions to liquefy semen following ejaculation. The PSA test measures the level of PSA in the blood and is the best tool currently available for detecting prostate cancer in its earliest— and most curable—stages. Although PSA is widely accepted as a tumor marker, it is prostate organ-specific but not cancer-specific. In other words, PSA can be elevated due to the presence of prostate cancer; however, not all elevated PSA tests mean that prostate cancer is present—benign prostate conditions can elevate it as well; the most common of these are prostatitis (inflammation of the prostate) and benign prostatic hyperplasia (BPH, an enlargement of the prostate gland).
Prostate cancer cells do not make more PSA, but rather less PSA than normal prostate cells. The elevated PSA that is detected in the blood associated with prostate cancer occurs because of a disruption of the cellular architecture of the prostate cells, the loss of this barrier of which permits the leakage of PSA into the circulation.
The PSA test is extremely helpful to monitor patients with a history of prostate cancer to check the status of the cancer. If the PSA level begins to rise, it may be the first sign of recurrence. Such a biochemical relapse typically precedes clinical relapse by months or years. Refinements in PSA testing include the following:
PSA velocity: It is very useful to compare the PSA values from year to year. Generally, the PSA will increase by only a small increment, reflecting benign prostate growth. If the PSA accelerates at a greater rate than anticipated—a condition known as accelerated PSA velocity—an ultrasound/biopsy is indicated.
PSA density: PSA density (level of PSA divided by the volume of the prostate) considers the relationship of the PSA level to the size of the prostate. In other words, an elevated PSA might not arouse suspicion if you have a very enlarged prostate.
Age-adjusted PSA: Age is an important factor with respect to PSA levels. It is now recognized that PSA will increase with the aging process in accordance with the increasing size of the prostate gland that occurs with growing older. For this reason, age-adjusted PSA levels can be useful to determine when further diagnostic tests are needed.
Free/Total PSA: Essentially, PSA circulates in the blood in two forms: a “free” form in which the PSA is unbound to any other structures, and a “complex” PSA in which the PSA is bound to a protein. The free PSA/total PSA ratio can offer a predictive value, in similar fashion to the way the HDL cholesterol/total cholesterol can be helpful in a man with an elevated cholesterol level.
In 2009, there were two studies published in the New England Journal of Medicine with respect to screening for prostate cancer. The results were summarized on the front pages of many newspapers, resulting in confusion for many patients. Dr. Andriole, in the United States, reported no mortality benefit from combined digital rectal exam and PSA screening after 7-10 years. Schroeder et al in Europe reported that PSA screening alone (without rectal exams) resulted in a 20% decrease in the death rate at a median follow up of 9 years. It is the consensus of many urologists that these studies were published prematurely, with ambiguous results.
The hard facts:
• 95% of male urologists and 80% of primary care physicians older than 50 have PSA screening—clearly those in the know feel that screening is beneficial.
• USA death rates from prostate cancer have fallen 4% annually since 1992, five years after introduction of PSA testing.
• Generally, urologists do not screen or treat men who have a life expectancy less than 10 years for the very reason that prostate cancer rarely causes mortality in the first decade after diagnosis and that other competing medical issues will cause death before the prostate cancer has a chance to.
• Prostate cancer is a slow-growing process and early detection and treatment is directed at extending life well beyond the decade following diagnosis!
• The aforementioned studies will not prove meaningful until carried out for 15, 20, 25 years and beyond—the time reference in which we expect treatment to make a meaningful difference.
Another controversial subject is at what age to stop screening for prostate cancer. According to the United States Preventative Services Task Force update, the “harms of screening outweigh the benefits in men 75 years old or older.” Studies have shown that at age 75 if you have a PSA less than 3, the chances of later developing high-risk prostate cancer are minimal. My opinion is that all 75-year-olds are not the same, functional age trumps chronological age, and that an individual’s preference regarding screening is of great importance.
I end with an important quote from Dr. Willet Whitmore, M.D., from way back in 1973, but still so relevant (Dr. Whitmore served as chief of urology at what is now Memorial Sloan-Kettering Cancer Center and died in 1995 of prostate cancer.)
“Appropriate treatment implies that therapy be applied neither to those patients for whom it is unnecessary nor to those for whom it will prove ineffective. Furthermore, the therapy should be that which would most assuredly permit the individual a qualitatively and quantitatively normal life. It need not necessarily involve an effort at cancer cure. Human nature in physicians, be they surgeons, radiotherapists, or medical oncologists, is apt to attribute good results following treatment to such treatment and bad results to the cancer, ignoring what is sometimes the equally plausible possibility that the good results are as much a consequence of the natural history of the tumor as are the bad results.”
For more information:
click on “patient education” and then on “Prostate Cancer: Second Opinion” to read my monograph.
To watch my video on PSA screening:
Andrew Siegel, M.D.