PSA Screening for Prostate Cancer

BY MARK SCHOLZ, MD

Most 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 them.

Random Biopsy, Not PSA is the Real Problem
When 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
Over-diagnosing 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?
Due 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
Most 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.

Therefore, 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
Only 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.

If 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 treatment.

Estimating Cancer Risk
If 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 Biopsy
Prior 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.   

“We Must do Better,” A Position Statement Regarding PSA Screening from Dean Foster, MD, PCRI Medical Director

Last May, the U.S. Preventative Services Task Force (USPSTF) triggered a firestorm of debate after issuing its recommendation against the use of the prostate-specific antigen (PSA) blood test to screen for prostate cancer. In her editorial responding to the controversy, Task Force Chair, Dr. Virginia Moyer summarized the committee’s findings with this sentence, “We can do better.” The Prostate Cancer Research Institute (PCRI), while disagreeing with the Task Force’s simplistic banning of PSA, does agree with Dr. Moyer’s conclusion: We can indeed do better.

“We can do better in educating men on the pros and cons of PSA,” explains Dr. Dean Foster, the PCRI medical director and prostate cancer survivor. “However, all the recent controversy is giving men an excuse to tune out about a disease that affects one in six of them. The subject of prostate cancer already makes men uncomfortable.  The controversy over the PSA test gives them one more reason not to pay attention.”

The PCRI encourages men to learn about PSA testing in consultation with their physician. When PSA screening is implemented and elevated levels are detected, further education is necessary before undergoing biopsy. For men with a high PSA, the PCRI currently recommends two additional tests prior to undergoing biopsy: PCA--3, a widely available urine test, and multi-parametric MRI. The PCRI offers free Helpline services to aid men in locating centers offering these services. 

Finally, Dr. Foster concludes: “Men can receive the benefit of PSA screening and still protect themselves from the risk of overtreatment, which is the main factor cited by the U.S. Preventative Services Task Force for giving PSA a “D” rating. The PCRI stands in agreement with Dr. Moyer and the USPSTF in that ‘we all must do better.’  However, PCRI does not recommend simply abandoning PSA screening. Through education, unnecessary overtreatment of the benign type of prostate cancer can be avoided while still using PSA to detect the aggressive form.”

Too Many Prostate Biopsies

BY MARK SCHOLZ, MD

Every year in the United States one million men undergo a prostate biopsy.  Biopsy has a number of potential complications including serious infections requiring hospitalization and bleeding severe enough to require transfusions. One-percent of urologists have had a patient die from a biopsy-induced infection.

Despite these daunting risks, the real danger men face is the diagnosis of cancer.  In the United States, ninety percent of men who are diagnosed with prostate cancer undergo radical treatment, even when they have the Low-Risk variety of the disease that can be safely watched.  Treatment for prostate cancer is hardly innocuous, commonly causing impotence and urinary incontinence.

Misguided but well-intentioned experts have cogently argued that the rampant overuse of unnecessary biopsies and radical treatment have become so egregious that PSA screening should be discontinued. However, evidence is strong that PSA screening does reduce prostate cancer mortality.

So how can this dilemma be resolved? Is there a way to spare the men with Low-Risk disease while still detecting High-Risk prostate cancer while it is still curable?

Historically, biopsy has been the only accurate method for detecting prostate cancer.  However, for every case of High-Risk cancer detected, four or five men get the unpleasant news that they have Low-Risk disease, a diagnosis that usually leads to unnecessary treatment.

Two reports at this year’s American Urology Associate meeting indicate that modern multi-parametric MRI detects High-Risk prostate cancer very accurately.

In Abstract #2051 Dr. Noboru reported his findings in 320 men with PSA levels less than 10. They compared MRI with a standard 14-core biopsy. Only one man with very low volume disease in the Gleason 8-10 category was missed by MRI.

In Abstract # 1444 Dr. Emberton found that MRI accurately predicted the absence of any High-Grade cancer (Gleason score of 3 + 4 = 7 or above) with 95% accuracy.  Both Dr. Emberton and Dr. Noboru used a standard 1.5 Tesla MRI.  Enhanced, more accurate three Tesla MRI is available select centers.

High-quality prostate imaging is the only potential solution to the PSA screening conundrum.  Imaging detects High-Risk cancer that needs treatment. Men with Low-Risk disease can use the same technology for ongoing monitoring.

PSA screening is not the culprit for overtreatment in the U.S.   The policy of performing an immediate random, multi-core biopsy on every man with a PSA above 4.0 is the real problem. Fortunately, MRI imaging offers a viable alternative.

The Screening Paradox? Or Is It Just a Dilemma?

BY RALPH BLUM

Maybe it’s shabby of me to immediately think: It’s all about money. The pot of gold at the end of the prostate cancer rainbow. Well, the first dip into that pot is billing for all those PSA tests, DREs and biopsies. Standard screening procedures, right? Only it’s not that clear cut. More and more these days, I tend to consult with Dr. Google. Turns out there is disagreement in high places.

The American Board of Family Practice regards screening as less than effective; they don’t recommend it for prostate cancer. Meanwhile the American Urological Association staunchly maintains that screening saves a lot of lives—even if, as one urologist told me, “Thanks to screening, I may end up doing 38 unnecessary radical prostatectomies to save one life.”  When you get a specialty board at odds with a family practice group, it makes you think.

Then you have both the American Urological Society and the American Cancer Society discouraging screening for men whose life expectancy is 10 years or less. Why? Because the cancer, in most cases, is so slow growing that it can take that long for screening to prove useful. And besides, those men will probably die with it, not from it. Gina Kolata, science reporter for the New York Times, published an article “Screening Prostates at Any Age.” The piece opened with the question: “When, if ever, are people just too old to benefit from cancer screening?” Apparently never.

A recent study published in The Journal of Clinical Oncology reported that men in their 70s are being screened at almost twice the rate of men in their 50s. What’s that all about, given the life expectancy at that age? The study also found that men from 80 to 85 are screened as often as men in their 50s. Can you hear the chorus of clanging cash registers in the background?

Perhaps there is a more tolerant way to look at what, at first glance, appears to be blatant over-screening. Is it possible, Kolata wonders in her Times article, that late and continued screening provides a psychological “boost” for older men? A kind of placebo effect in the form of “evidence that death is not waiting in the wings?” (Some kind of Botox treatment for us sagging old geezers?) Obviously the cancer industry profits handsomely from that “delusive obsession.”

Fact: Some 50-year-olds do not require screening; some 75-year-olds may benefit from it. Certain prostate cancers are highly aggressive but do not produce much PSA. At the same time, since prostate cancer is usually asymptomatic until well advanced, plenty of doctors I respect consider it  dereliction of duty not to screen for and detect it when it is still curable. Hard to argue with that logic. The burden is on the doctor to prove the guy doesn’t have cancer. Which is why he orders the screening tests just like he orders a cholesterol test or CBC (Complete Blood Count) for anyone over 50. And then there are all the “diagnostic tests. . .” Still, as the saying goes, ‘Better safe than sorry’.” Your doc doesn’t want to hear from the lawyer for your estate.

As my departed friend, NBC White Paper producer Fred Freed never tired of saying, “There are no easy answers.” To confirm the truth of that dictum for this cancer, you ought to attend a monthly meeting of the Prostate Cancer Club at Michael Milken’s Santa Monica Headquarters, and listen to 30 or more of LA’s top urologists, prostate and radiation oncologists and diagnostic radiologists arguing over a dozen or so current papers on all aspects of prostate cancer, none of which command widespread consensus.

Why should screening be an exception? Keep it simple: If you have reason to think you may be at risk for prostate cancer, get screened. If not, go fishing. Or buy yourself a new putter. If you’re rising 80 and off having fun with your sweetie, ignorance may not be bliss, but it sure can contribute to your quality of life.