PSA and Prostate Cancer: A Fool with a tool is still a fool? I am an advocate of getting one as a baseline in the man about 40 or so, then every two years with the GP’s exam.

You might disagree about PSA’s and when and who they are done on…but about 5 times a year a 50 year old man comes into my office for his “first” rectal exam and PSA and it determined that he has asymptomatic advanced prostate cancer. Is it cost effective, are some being checked that are normal. No and yes. But what’s a man to do? This is what all the hub bub is about in the discussions that follow. I am also reminded of my patient who was 38 and got a PSA by accident with a job physical, it was elevated, his biopsy was positive with mod risk parameters. Anecdotal? Maybe…But what’s a man to do?

Mr. PSA speaks out…

Debate has been ongoing about the use of the PSA test in the detection of prostate cancer but the question may not be whether we use the test but, rather, how we use it,” said Christopher Amling, MD

Prostate Cancer: To Treat, Not To Treat And When To Treat?

16 May 2011

As physicians and researchers debate the merit of the prostate-specific antigen (PSA) test, questions have arisen about the test’s ability to accurately identify the presence of prostate cancer, as well as how the test may be interpreted and better used to determine which prostate cancers require treatment and which do not. New research presented at the 2011 AUA Annual Meeting will bring light to the innovative possibilities for the use of PSA. A special panel, to be held on Monday, May 16, 2011 at 9:00 a.m., will discuss with members of the media the following studies:

How Soon Can We Identify Men at High Risk for Prostate Cancer Death? An Early Surveillance Strategy for Prostate Cancer (#986): A single blood test before the age of 50 could predict a man’s long-term risk of prostate cancer death, according to research from Memorial Sloan-Kettering Cancer Center in New York and Lund University in Malmo, Sweden. Using data from the Preventive Project, a cardiovascular study enrolling men ages 33 to 50 between 1974 and 1986, and a combination of case-note review or death certificate data, researchers identified 141 men in the study who had subsequently died of prostate cancer. Nearly half (44 percent) of the deaths occurred in men whose PSA score fell in the top 10 percent (≥1.5 ng/ml). Researchers expanded their analysis to the top quartile of men, measuring free PSA and human glandular kallikrein 2 (hK2), and found that these markers helped to identify an additional 2.4 percent of deaths in the top 10 percent of risk. These data suggest that early analysis of PSA, free PSA and hK2 may provide critical insight into a man’s risk of developing aggressive, life-threatening disease, enabling urologists to better assess when early intervention may be necessary.

Can a Single PSA Measurement at Age 60-70 Years Identify Men Who Need No Further Prostate Cancer Testing? (#2025): Eliminating prostate cancer testing after the age of 60 may be an option for some men, but others could benefit from continued testing, according to new data being presented by Johns Hopkins researchers. Using data from the Baltimore Longitudinal Study of Aging, researchers identified 448 men with PSA measurements between the ages of 60 and 70, including 199 with a PSA less than 1 ng/ml. They reviewed PSA trajectory and its relationship to later diagnosis of prostate cancer (including high-risk disease, defined by PSA greater or equal to 20 ng/ml, Gleason 8-10 or confirmed prostate cancer death). In the 199 men with low PSA (median age of 61.9 at time of test), 13 were later diagnosed – four with significant disease. These data indicate that it may not be advisable to apply a universal cut-off point for PSA testing.

Possible Pitfalls in Using Prostate-Specific Antigen Velocity for Detection of Prostate Cancer (#2032): Prostate-specific antigen velocity (PSAV) can be a strong derivative in improving the performance of the PSA blood test as a marker for prostate cancer but has limited sensitivity and specificity, according to new data from researchers at Northwestern University. Researchers examined patients in two categories: those with elevated PSAV and no cancer on biopsy, and those with low PSAV with biopsy-detected cancer. Of those patients with low PSAV with biopsy-detected disease, 4.6 percent had a Gleason 8-10 tumor, 30 percent had slow-growing tumors with a Gleason score less than 6 and 54 percent had Gleason 7 tumors. Of those patients with elevated PSAV and negative biopsy, 58 percent were later diagnosed with biopsy-detected disease, suggesting a need to closely follow a patient’s PSA despite an initial negative biopsy.

The Worst Cancers Send Early PSA Signals that Would Allow Early Detection if Monitoring Focused on Increasing PSA (#1197): PSAV and its rate of increase over time may be a key marker in identifying aggressive disease and could provide valuable insight in how to interpret the PSA test, according to researchers from Medical University Innsbruck in Austria and the University of California, San Francisco. Study authors analyzed pre-diagnosis PSA history from 94 prostate cancer patients who, following surgical treatment, suffered extra-capsular extension (EE) or recurrence, and calculated annual growth rate in cancer PSA for each. Of the men with EE or recurrence, 98.9 percent had an increasing or constant PSAV and 95 percent had a PSA annual growth rate of 10 percent or more, suggesting that, in men with a current PSA less than 4.0 ng/ml, increased scrutiny of annual growth rates of 1.0 ng/ml or more may be warranted.

“Debate has been ongoing about the use of the PSA test in the detection of prostate cancer but the question may not be whether we use the test but, rather, how we use it,” said Christopher Amling, MD, who moderated the briefing for media. “These studies shed important light on how we might refine our use and interpretation of the PSA test.”

American Urological Association

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a good physician recommends the bark of the quinquennia while the patient would be obliged to eat the whole tree…..

4 Replies to “PSA and Prostate Cancer: A Fool with a tool is still a fool? I am an advocate of getting one as a baseline in the man about 40 or so, then every two years with the GP’s exam.”

  1. What do you use instead of a PSA? Nothing?
    Come on lets be realistic PSA may be an imperfect tool but really is nothing better?
    Until a better replacement is found PSA is it.


  2. Please describe significant PSA numbers. Pre and post surgery. I’ve read just about everything, still seems up for interpretation.



  3. Here in the UK we do not have screening for prostate cancer.

    I was diagnosed too late in feb 2006 my PCa was already metastatic so now I practice intermittent hormone therapy (a kind of active surveillance I suppose)and it seems to be working for me.

    I think the problem is the way that Doctors and consultants interpret the PSA reading.

    If many of the doctors were better informed about which patients need to be followed closer and the consultants were less willing to offer radical treatment instead of active surveillance, the PSA test would I believe have more significance.

    Of course we would all like a better diagnostic test but until it comes along lets use the PSA test.

    The chances are that any new test will work alongside the PSA test.
    There have been endless debates about the merits of the PSA test for over 20 years and all end in confusion.

    I dont see any debates conducted by PCa patients to see what they think.

    I know that if you were to give a wish to the 11,000 UK men who will die of prostate cancer this year, they would wish theyd have had a PSA test earlier when their cancer could most probably have been cured.

    Expectation and Quality of Life are massive issues.

    More money for research into PCa diagnostics would eventually save many lives as well as saving the health service a massive amount of the money that is and will increasingly have to be spent on treatments such as PROVENGE and ABIRATERONE (excellent as they are).

    Keith (red sock)


    1. In the US we have “prostate screening” days in which doctors and hospitals provide the exam and PSA for free. It is a marketing plan of sorts. Although we do not have a national policy for screening, screening occurs every day every time a family practicioner adds a PSA to his yearly physical of blood work for his patient, that patient has been “screened.” I wonder if in the UK the national health care system won’t let the family doctor even order the test…i.e. if they do, it won’t be done or paid for. The story about the guy from Kenya, Jerrry Okunga was interesting. There he was diagnosed late with prostate cance and all the while complimenting his friend who was an advocate of national health care and nicer medical facilities. He did not need that…he needed to be aware of the need to be checked for prostate cancer. In a way, it’s the doctors that are seeing patients for colds and such, who should be “getting the word” out about awareness. I recently saw a 50 year old who had never had a rectal exam or a PSA who was found to have metastatic disease. You are right…the 11,000 wish they’d had a PSA earlier. The bottom line is that the powers that be feel it is not worth the money to check and pay for 100 men to find the one with early or aggressive prostate cancer. And that…sadly is the real debate. I wish you well and thanks for your excellent comments. JM


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