BY MARK SCHOLZ, MD
elderly men already have prostate cancer—they just don’t know they have it. And they
might be better off remaining ignorant. Newly-diagnosed men are thrown into an
eight-billion-per-year medical world that extols radical treatment. Over-treatment is so out-of-control that
a New England Journal of Medicine study estimates that forty-eight men are getting
unnecessary surgery or radiation for each individual who truly benefits from
Random Biopsy, Not PSA
is the Real Problem
PSA is elevated, primary care physicians usually refer to a urologist for an
immediate 12-core random prostate biopsy. One
million men are biopsied annually in the United States. Few people realize
that even when the PSA is normal, the biopsy will be positive 20% of the time. The
problem is that a diagnosis of any prostate cancer, even the Low-Risk type, almost invariably leads
to surgery or radiation.
Biopsies Are Not Benign
Low-Risk prostate cancer, and the
attendant risk of over-treatment, is not the only problem caused by random
biopsy. Consider the emotional devastation caused by a cancer diagnosis. Men
are literally frightened to death by
the discovery of prostate cancer: The first week after diagnosis, the risk of
suicide and heart attacks jumps dramatically. In addition, 3% of men suffer biopsy-induced
infections resulting in hospitalization. Fatal infections are estimated to occur
in approximately one-thousand men undergoing random biopsy per year.
Stop PSA Screening?
to all these mounting negatives, the US Preventative Services Task Force now recommends
that routine PSA testing cease altogether. The Task Force’s conclusion was that
unnecessary treatment to over a
hundred thousand men annually is too big a price to pay even though PSA
screening saves lives. The Task Force fails to understand that overtreatment
isn’t caused by PSA, it’s what physicians do with the information PSA provides—they
automatically refer every patient for immediate random biopsy.
PSA Is Heavily
Influenced by Prostate Size
PSA originates from the prostate gland, not from cancer. Therefore, when the
cancer is relatively small, PSA is a reflection prostate gland size. In a man without cancer, PSA
normally averages one-tenth of the
prostate volume. For example, the average PSA for a 30cc prostate is 3; five
for a 50cc prostate and 10 for a 100cc prostate with size determined by
ultrasound or MRI.
PSA can only be termed “abnormal” if it’s 50% higher than expected, based on a
man’s prostate size. For example, an abnormal PSA for a 30cc prostate is 4.5, a
50cc prostate, 7.5 and a 100cc prostate, 15. Additional extraneous factors such
as low-grade infections, lab variations and recent sexual activity can also cause
PSA to vary. Repeat testing helps
average out these variations so the “real” PSA can be determined.
Primary Care Doctors Are
the Source for Balanced Counsel
the primary care physicians can stop the mindless rush to random biopsy. Instead
of referring for random biopsy they can send their patients with elevated PSA
for prostate imaging with multiparametric MRI or Color Doppler Ultrasound.
Imaging can put the PSA elevation into context by determining the prostate
size. Also, in the hands of an experienced radiologist, using state-of-the-art,
three-Tesla MRI, high-grade cancer can be ruled out with 95 to 98% accuracy.
imaging detects a high-grade lesion, primary physicians can then counsel their
patients about whether a targeted
biopsy directed at the abnormal lesion should be performed. Alternatively they
can recommend simple monitoring with a repeat imaging study six to twelve
months down the road to determine if the lesion is growing. Lastly, if a
targeted biopsy shows cancer, rather than being guided by a urologist, who is,
after all, a surgeon, patients can obtain counsel from their primary physician,
a non-surgeon who can provide unbiased assistance in selecting the best
Estimating Cancer Risk
men are concerned about the risk of forgoing an immediate random biopsy they
can estimate the percentage likelihood of harboring low-grade or high-grade
disease with an online calculator by googling, “risk of biopsy-detectable prostate cancer.”
Imaging Rather than
to PSA screening men should be informed that if PSA is high, the first step
should be imaging rather than random biopsy. Random biopsy can cause serious
infections. It also diagnoses Low-Risk
prostate cancer, a harmless condition that nevertheless, often leads to unnecessary
treatment. PSA screening, while saving lives by detecting High-Risk cancer at an early stage, can also, if handled
improperly, lead to unnecessary treatment with many lifelong side effects.