The detection and treatment of prostate cancer is a major focus of most general urologic practices. The Urology Wellness Center at Lake Mary is no different in this regard. The cornerstone of PSA screening is the PSA blood test. Prostate Specific Antigen (PSA) is a protein secreted by the prostate, its level in the serum is used as a measure of a man's risk of prostate cancer. In spite of it's widespread use, PSA levels as a screening tool for prostate cancer remains controversial.

 

Disagreement in the medical community over the utility of PSA screening is not new. While the American Cancer Society and the American Urological Association have endorsed the use of PSA in prostate cancer screening; it's acceptance is by no means universal. The U.S. Preventive Services Task Force has stated that that the balance of risks and benefits remains undetermined. More recently several studies addressing these issues were publicized in the lay media. Andriole et al recently published initial results from the PLCO (Prostate, Lung, Colorectal, and Ovarian) Cancer Screening Trial on prostate cancer mortality. They concluded that at 7-10 years there was no difference between the annually screened group and the control group. This is in contrast to other studies including the ERSPC (European Randomized Study of Screening for Prostate Cancer) which reported a 27% reduction in death from prostate cancer. While I believe there is solid evidence to support PSA screening for prostate cancer, there is also evidence to suggest there is over diagnosis.

 

Autopsy studies show the presence of prostate cancer in a third of men over age 50 and almost half of men over age 70. However, the lifetime risk of death from prostate cancer is only about 3 %. Clearly, not all prostate cancers are life threatening and therefore do not need diagnosis and treatment. The challenge for us as physicians is to avoid overtreatment where possible without missing the opportunity to cure a patient of a potentially lethal disease.

 

The recently updated AUA Best Practice Policy statement recommends that PSA testing be offered to well informed men starting at age 40. I am already seeing this trend among primary care providers from the Seminole and Volusia county areas. A man in his 40's should have a PSA less than 2.0 ng/dl. Acceptable "normal" values incrementally increase with age. Patients who present for PSA screening should be made aware of the risks (including diagnosis of clinically insignificant disease) as well as benefits of this protocol. I try to comfort patients at their initial visit as less than 30 % of patients with a PSA under 10 ng/dl will turn out to have cancer. Patients need to understand that there is no test which will predict with certainty the presence (or absence) of prostate cancer. It should be stressed that the PSA value is only one piece of information used to asses a man's risk of prostate cancer. The PSA trend over several years (PSA velocity), family history, ethnicity, free PSA and findings of the digital rectal exam (DRE) are other important clues. A PSA which has risen more than 0.5 ng/dl  over a year, a first degree relative with prostate cancer, sub Saharan African ancestry, a free PSA less than 25% and a prostate nodule or any asymmetry on digital exam portend a higher risk. My initial recommendation for men with a newly found elevated PSA is to repeat the test in one month and to make every effort to find prior values to allow calculation of a PSA velocity. On recheck both the free and total PSA should be checked. Once all desired information is obtained the findings are discussed with the patient and a biopsy is recommended for any abnormal finding suggesting an elevated risk of prostate cancer.

 

The other side of this controversy is the patient who is unlikely to benefit from prostate cancer screening. It must be stressed that these guidelines do not apply to symptomatic patients. ACS guidelines suggest that screening is appropriate for men with a 10 yr life expectancy. I always find these guidelines somewhat nebulous. Clearly, the 90 y.o. patient in hospice does not need prostate cancer screening. But when is it appropriate to stop screening? Schaeffer et al evaluated the BLAS data and found that men aged 75-80 with a PSA under 3.0 ng/dl were unlikely to be diagnosed with high risk prostate cancer during their life. I offer these men the option of less aggressive screening and will often simply observe elevated PSAs in this group. Such decisions require full discussion with the patient as to the risks and benefits of such an approach.

 

The advent of PSA testing is credited with a reduction of mortality from prostate cancer of up to 30%. There can be little doubt however that there has also been significant over diagnosis. Our challenge as physicians is to use the tools at our disposal to assess each patients risk individually. Not every patient with an elevated PSA needs a biopsy. Not every patient with prostate cancer needs to proceed immediately to radical treatment. At the Urology Wellness Center, our goal is to diagnose and treat clinically relevant cancers early enough to allow a cure while minimizing the over treatment of clinically insignificant cancers which are unlikely to ever impact a patients life.