September 30, 2015
Shades of Grey with the PSA

Prostate specific antigen (PSA) is an enzyme that is produced by the prostate and serves to liquefy ejaculate. There are a number of conditions that may cause an increase in the production of PSA including benign prostatic hyperplasia (BPH) and prostatitis, and in general, the higher a man’s PSA level, the more likely it is that he has prostate cancer. Sounds pretty cut and dry doesn’t it? We have a marker that is specific to the prostate that we can test in serum and is elevated in prostate cancer patients - what a perfect screening test!

Unfortunately, the situation isn’t quite that black and white. First of all, it turns out that PSA isn’t specific to the prostate, or even specific to men for that matter. Furthermore, only a quarter of men who have elevated PSA levels are diagnosed with prostate cancer upon biopsy. Unnecessarily subjecting 75 men to the possible side effects of biopsy to detect 25 cancer cases would possibly be worth it except that nearly all prostate cancer cases are slow growing and unlikely to have a significant impact on mortality. That’s right, several large studies have found that men who have annual prostate cancer screening are more likely to be diagnosed with prostate cancer, but not more likely to die from the disease than men who are not screened. This indicates that screening may lead to additional diagnostic procedures or unnecessary treatments, many of which can have significant side effects, but not contribute to a longer life. Simple needle biopsy of the prostate has been reported to result in difficulty urinating and increased urinary urgency as well as erectile dysfunction, with increasing incidence directly correlated with number of samples taken. And for men who are diagnosed with prostate cancer, most are treated with surgery or radiation which often results in erectile, urinary and bowel problems for decades after treatment.

While this information may sound controversial, a large number of busy practitioners still routinely run screening PSA levels because they either believe that it is a simple screening test or that it is required for liability purposes. However, most of the organizations that make recommendations for cancer screening are no longer recommending PSA screening. The U.S. Preventative Task Force Service has given PSA screening for prostate cancer a grade D, meaning that not only do they not support this practice, but they recommend that physicians actively discourage its use. The American Urological Association recommends against PSA screening in men under 55 and over the age of 70, or in any men who have an expected life expectancy of less than 10-15 years. In the 55-69 group, they recommend that the potential harms associated with additional screening and treatment be discussed with the patient for shared decision making. The American Cancer Society has similar advice, stating that men should not be screened until they have been informed about the uncertainties and risks as well as the potential benefits of screening.

Like many areas of medicine, this topic offers a great opportunity for educating the patient on the risks and benefits of PSA screening and more importantly the potential side effects of additional diagnostic procedures and treatment options. Unfortunately, many patients are frightened when they hear the C-word and may react rashly out of fear. In the case of prostate malignancies, the time should be taken to fully explore all of the treatment options, including the option of not treating.

There are many resources that can be recommended to these patients including the documentary Surviving Prostate Cancer, the trailer for which can be found at www.survivingprostatecancer.org And for more information on what can be done to optimize prostate health in general, including the influence that hormones have on the growth and proliferation of prostate cells, please join us for the two day Labrix Advanced Workshop in Las Vegas on January 16th and 17th; registration is available at www.labrix.com.

References:
  • Diamandis EP, Yu H. Nonprostatic sources of prostate-specific antigen. Urol Clin North Am. 1997 May;24(2):275-82.
  • Barry MJ. Clinical practice. Prostate -specific antigen testing for early diagnosis of prostate cancer. N Engl J Med. 2001 May 3:344(18):1373-7.
  • Andriole GL, Crawford ED, Grubb RL, et al. Prostate cancer screening in the randomized prostate, lung, colorectal and ovarian cancer screening trial: mortality results after 13 years of follow-up. J Natl Cancer Inst. 2012 Jan 18; 104(2):125-32.
  • Klein T, Palisaar RJ, Holz A, et al. The impact of prostate biopsy and periprostatic nerve block on erectile and voiding function: A prospective study. J Urol. 2010 Oct; 184(4): 1447-52.
  • Resnick MJ, Koyama T, Fan KH, et al. Long-term functional outcomes after treatment for localized prostate cancer. N Engl J Med. 2013 Jan 31;368(5): 436-45.
  • Final Update Summary: Prostate Cancer: Screening. U.S. Preventive Services Task Force. July 2015. Prostate Cancer Screening website
  • Carter HB, Albertsen PC, Barry MJ, et al. Early detection of prostate cancer: AUA guideline. J Urol. 2013 Aug; 190(2):419-26.
  • Prostate Cancer Website

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