Homage to Tom Stamey, MD

BY RALPH BLUM

Looking back on my two-plus decades of coexisting with prostate cancer, I see my travels as an odyssey; or perhaps hegira comes closer to the mark, since it has indeed been “a flight to escape danger.” Either way, along the route, at meetings, consults, conferences, I have listened to the opinions and prejudices of eminent healers, men and women I would—all matters of disease aside—be pleased to count as friends.

Among them are a number of urologists and oncologists, all of whom had at least two things in common. First, at some point in their careers they had been either students or colleagues of Thomas Stamey, MD, a leading expert on prostate cancer and godfather and midwife to the PSA blood test. And second, a recognition of the modesty and humility with which Stamey regards his own achievement.

The literature of prostate cancer is hardly known for quotable remarks. Like a few lines you come away with after seeing a good play. But then the only “theatrical” aspect of prostate cancer is the OR. And while a compelling case can be made for too many urologists (aka surgeons) appearing far too frequently in those theaters, I have only one memorable quote.

It is something Dr. Stamey said, his terse prophecy that is pinned to the shelf above the desk where I work, and that has appeared on more than one occasion in my writing. It is this: “When the final chapter of this disease is written, it will prove that never in the history of oncology will so many men have been so over-treated for one disease.”

According to Stamey, prostate cancer is a disease all men get if we live long enough, so given an excuse to carry out a biopsy, doctors will likely find cancer.  “Our job now,” said Stamey, “is to stop removing every man’s prostate who has prostate cancer. We originally thought we were doing the right thing, but we are now figuring out how we went wrong. Some men need prostate treatment but certainly not all of them."

Stamey also reminds us that almost all men over 50 years of age start to develop benign prostatic hyperplasia, and that PSA is related today to the harmless enlargement of the prostate and not to cancer. Although the PSA test is still useful in monitoring patients after surgery, as an indicator of residual cancer, it is not a reliable predictor of the amount or severity of prostate cancer.  Stamey recommends a yearly digital rectal exam for all men over 50, and his group at Stanford is currently working on finding a blood marker that could indicate the more aggressive forms of cancer.

The most significant question is how to combat the fear factor. Many urologists will likely continue to perform biopsies based on PSA results, find early stage cancer, and recommend immediate—and as it turns out,  in most cases, unnecessary— treatment. So in what Stamey calls “this heavily screened country” it is up to each of us not to let fear dictate our decision making, not to yield to the emotional appeal of “cutting it out.”  If we decided to choose a Patron Saint of prostate cancer, you know who my candidate would be.

Consider that prior to the advent of PSA testing back in 1987, 1 of 41 men in the United States died of prostate cancer.  In 2009, with almost universal PSA screening and early treatment, the risk of dying from prostate cancer has improved, but not as much as you might think.  Presently the risk is 1 out of 53.

The cost of this progress is substantial: Prior to PSA testing 90,000 men were diagnosed with prostate cancer annually.  Now 200,000 men are told they have prostate cancer every year.  And, an additional 800,000 men undergo a prostate biopsy without being diagnosed with the disease.

So if your PSA is elevated, before you commit to irreversible and unpredictable bodily invasion, take a minute to consider the odds, and mull over Tom Stamey’s prophecy: “When the final chapter of this disease is written . . .”

Biopsy, Biopsy Everywhere

BY MARK SCHOLZ

A month ago I promised to expound more concerning our national passion for prostate biopsy. A million men are biopsied every year. Two hundred thousand will be diagnosed, the majority with Low-Risk disease, a condition that can be safely monitored without immediate treatment. Even so, most will undergo prompt radical treatment. Irrational fears drive most men into taking immediate action.

Since diagnosis overwhelmingly portends overtreatment, some experts have suggested that we put a stop to PSA testing. Practically speaking this will never happen. Patients and doctors alike are unwilling to forgo the information that PSA provides, imperfect as it may be.

  

Realistically speaking, PSA testing per se is not the real problem.  The problem is doctors and patients overreacting to the information PSA supplies. The solution is not less frequent PSA testing, but rather convincing physicians to slow down the rush to immediately biopsy men with slight PSA increases. Diagnosing every single case of prostate cancer is of highly questionable value. Many men would rather be spared the unnecessary knowledge that they have a non-threatening Low-Risk prostate cancer.

Rushing into an immediate biopsy only makes sense when aggressive cancer is present and that is much less common.

So where is the middle ground between immediate biopsy of every PSA elevation and forgoing PSA testing and biopsy altogether?

Before deciding to do a biopsy, the prostate gland should be measured with an ultrasound scan to determine whether it is abnormally enlarged.  If the amount of PSA elevation is proportionate to the degree of prostate enlargement, then the PSA elevation is due to benign cause. Rather than proceeding with an immediate biopsy, additional PSA monitoring and a urine test called PCA-3 may be helpful. 

PCA-3 is a relatively new test that measures ribonucleic acid (RNA) secreted by the cancer cells into the urine following manual massage of the prostate. Studies show that the amount of PCA-3 in the urine increases in proportion to both the size and aggressiveness of a man’s prostate cancer. Unlike PSA, PCA-3 is unaffected by the size of the prostate. Low amounts of PCA-3 in the urine, say less than 40, indicate that the presence of an underlying aggressive cancer is less likely.

If the PCA-3 and PSA density are favorable, further monitoring with some form of imaging offers additional insurance against missing the diagnosis of aggressive cancer.  Modern 3-Tesla endorectal MRI and high-resolution color Doppler ultrasound, while not perfect, are reasonably accurate methods for detecting aggressive cancers. 

So in summary, biopsy should be reserved for men with elevated PSA levels that can’t be explained by a prostate infection, laboratory error or recent sexual activity. Here are some signs that a biopsy may be needed:

1.                  A PSA elevation out of proportion to the size of their gland or

2.                  Abnormally elevated PCA-3 levels or

3.                  An abnormality felt on digital rectal examination or

4.                  Imaging studies suggestive of underlying aggressive cancer.

PSA is a remarkable tool that has transformed the management of prostate cancer over the last 20 years. Rather than triggering an immediate biopsy, an elevated PSA should lead to further investigation. Rushing to a biopsy simply because PSA is elevated frequently leads to unnecessary radical treatment with detrimental lifelong consequences.

The First Decision: Screening for Prostate Cancer with PSA

BY MARK SCHOLZ

Prostate cancer is highly curable when it is identified at an early stage. The PSA blood test, although not foolproof, improves the chance of arresting cancer while it’s still contained within the prostate. Detecting prostate cancer early gives men the power to choose a variety of treatment alternatives.

Surprisingly there are arguments against PSA testing.  Since some types of prostate cancer are low-grade, and therefore slow growing, diagnosing them, especially in older men, may only cause unnecessary fear and anxiety. Even more disturbing, men with this low-grade, non-aggressive type may be encouraged to undergo unnecessary treatment that in many cases leads to urinary incontinence or impotence.

PSA elevations also can occur from non-cancerous conditions. Prostate infections, prostate enlargement and even recent sexual activity may cause the PSA to rise temporarily.  If none of these reasons can account for an abnormally elevated PSA level, an assortment of scans, blood and urine tests may be required to ferret out what is actually causing the elevation.

So we have a dilemma. Many men are given a PSA blood test without first being educated about its limitations. Advance discussions about the implications of an abnormal PSA, and prostate cancer diagnosis almost never occur. This is no small issue. Even though low-grade prostate cancer is incredibly common, many doctors are still unaware that recent studies show that low-grade prostate cancer can safely be monitored. Instead, when the diagnosis is made, most men are carted off to have radical surgery.

Despite all these daunting issues, I still believe that PSA screening is appropriate so long as men are informed about its limitations, and so long as the doctors who administer the test are well versed in the latest studies. In my next blog I will be addressing an even bigger question—whether to have a prostate biopsy when an elevated PSA occurs.