Prostate cancer screening event at Overlook Medical Center on October 3, 2013.


I am participating in a prostate cancer screening event for men over 50 years old that would like to be screened for prostate cancer. Men will have a PSA blood draw and a digital rectal examination. The target audience is for men not under the care of a physician currently.

The event will be held in the hospital from 6 to 9pm. Please call 1-800-247-9580 for pre-registration.

Dr. Krieger and Dr. Savatta discuss prostate cancer and PSA screening

In June of 2013 I joined my partner and president of UGNJ, Alan Krieger, MD to educate the public about prostate cancer.

Recently a governmental agency recommended against prostate cancer screening with PSA without recommending a replacement for PSA. We had a thorough discussion about the need to screen for prostate cancer and what men and their loved ones should know about the prostate.

Shared decision-making uncommon for PSA tests | Reuters

They found 64 percent of those men had not discussed the pluses and minuses of PSA tests with their doctors, or the scientific uncertainty of their effect. Of the rest, about half had talked only about the advantages of screening.

About 44 percent of study participants hadn’t been screened for prostate cancer in the past five years. The majority of those – 88 percent – reported no discussions regarding that choice, according to findings published in the Annals of Family Medicine.

via Shared decision-making uncommon for PSA tests | Reuters.

There was a study done in the Annal of Family Medicine that found that almost half of men have not been screened for prostate cancer in the last 5 years. Most of these did not have a discussion with their doctors as to whether they should be screened.

As a urologist who specializes in prostate cancer, I am concerned that we will have more men presenting with metastatic prostate cancer in the years to come.

AUA: Five tests, treatments may be unnecessary | Urology Times

The AUA’s list identified the following five recommendations:

A routine bone scan is unnecessary in men with low-risk prostate cancer.

Do not prescribe testosterone to men with erectile dysfunction who have normal testosterone levels.

Do not order creatinine or upper tract imaging in men with BPH.

Do not treat an elevated PSA with antibiotics for patients not experiencing other symptoms.

Do not perform ultrasound on boys with cryptorchidism.

via AUA: Five tests, treatments may be unnecessary | Urology Times.

The AUA has made recommendations on several areas.  There were two that were important for men in the area of prostate cancer.

Men with early stage prostate caner do not need a routine bone scan.  During my training at Indiana University from 1997-2003 this was the standard of care in my residency. Historically, all men with prostate cancer had a bone scan and CT scan.  Both of these are not necessary for men with low grade prostate cancer.  I have not ordered routine bone scans since coming to west Orange, NJ in 2003.

The other important recommendation was in the treatment of an elevated PSA with antibiotics.  This is the first time I have seen the AUA make the recommendation.  If men have stable urinary symptoms and no inflammatory (WBC) cells in the urine, antibiotics should not be prescribed.  I have been practicing in this fashion my entire career, but many physicians including urologists would often prescribe antibiotics to see if an elevated PSA  would return to normal values.

They got it wrong again – Reader Voices

While prostate cancer is still the second leading cause of death for American men, early detection and advanced treatments have combined to reduce the mortality rate from prostate cancer by nearly 40 percent in the last two decades. During that same time period, we have seen dramatically less metastatic disease than in my earliest days of treating men with prostate cancer in New Jersey 25 years ago before the PSA screening era.

via They got it wrong again – Reader Voices.

This editorial was written by a colleague of mine at Garden State Urology in response to the USPSTF Final Recommendation on PSA Screening states that men should not receive PSA testing.

As a urologist who deals with prostate cancer on a regular basis, this is an extremely disappointing recommendation.  The issue will remain in the forefront of health care debates in the months and years to come.

Prostate Cancer Screening: Moving Beyond PSA – Renal and Urology News

In nearly 1,000 men undergoing initial or repeat biopsy, these investigators found that urinary PCA3 prior to a prostate biopsy improved the prediction of PCa and high-grade disease with a high positive predictive value 90% in the initial biopsy setting and a high negative predictive value 88% in the repeat biopsy setting. The investigators conclude that counseling men undergoing prostate biopsy in the context of PCA3 would reduce the burden of prostate biopsies.

via Prostate Cancer Screening: Moving Beyond PSA – Renal and Urology News.


I have been using PCA-3 tests in a variety of ways.  I perform it yearly for men at high risk of prostate cancer, to determine if men need repeat prostate biopsies, and also in my active surveillance prostate cancer patients.

UroToday – Prospective evaluation of prostate cancer risk in candidates for inguinal hernia repair – Abstract

Prospective evaluation of prostate cancer risk in candidates for inguinal hernia repair

We found the incidence of concurrent prostate cancer with hernia to be low, but 51% of men had PSA values that suggested an increased relative risk of future development of prostate cancer. Men at increased risk of prostate cancer should be made aware of the impact that mesh might have on subsequent treatment options before mesh placement.

Many years ago it was thought that a prior laparoscopic hernia repair would be a major problem for a patient who had prostate cancer wanted a robotic prostatectomy.

Since 2003 the majority of robotic surgeons have performed robotic surgery through the abdominal cavity. With this approach, the bladder and blood vessels can safely be separated from the mesh with direct visualization.

I do not consider a prior hernia repair with mesh to be a significant concern prior to robotic surgery. The surgery should take a little longer, but removing the prostate is not a significant problem.

The only concern in patients that will undergo hernia repair is to make sure they do not have cancer at the present time. If they do and want surgery for prostate cancer, then a robotic hernia repair and robotic prostatectomy shoudl be done at the same time, avoiding 2 surgeries. I have performed over 100 of these combination hernia repairs and davinci prostatectomies.

Prostate Biopsy: Side Effects and Risks

UroToday – EAU 2007 – Session on Prostate Biopsy 1

The 7,074 biopsies were performed in 5,153 men. Minor complications included hematuria >1 day (13.8%), hematospermia (35.8%), and rectal bleeding (2.1%). Major complications were prostatitis, epididymitis, fever >38C, rectal bleeding >2 days, and urinary retention, all <1.0%. This study validates the safety of TRUS biopsy of the prostate.

This is a lower number than I would have guessed for blood in the semen (hematospermia), but a nice study to advise patients of possible side effects from a prostate biopsy.

This is what we need to consider when I asked the question of doing biopsies on everyone.

Lowering PSA and PSA velocity: Are we doing the best thing

2 recent studies recommend lowering the psa velocity.
UroToday – Age Adjusted Prostate Specific Antigen and Prostate Specific Antigen Velocity Cut Points in Prostate Cancer Screening

beige_quote.bmpTraditional recommendations for prostate biopsy have included a total serum PSA of 4.0 ng/ml or greater and a PSA velocity of 0.75 ng/ml per year or greater. While recent trends have moved towards a PSA threshold of 2.5 ng/ml or greater in men younger than 65 years, specific recommendations for PSA velocity thresholds in younger men have not been agreed upon.
In the February issue of the Journal of Urology, Moul, Albala, and colleagues from Duke University report the results of a cohort of 33,643 men who formed part of a prostate cancer early detection study. Of these men, 11,861 patients were identified with 2 or more serum PSA values over a 2 year period. Total PSA and PSA velocity threshold values with the highest sensitivity and specificity for prostate cancer detection were identified for men 50 to 59 years old.
In men age 50 to 59 years, a serum PSA threshold for biopsy of 2.0 ng/ml or greater achieved the highest sensitivity (84%) when compared to thresholds of 2.5 ng/ml, 3.0 ng/ml, and 3.5 ng/ml with sensitivities of 82%, 79%, and 77%, respectively. The specificity of a PSA threshold of 2.0 ng/ml in these men was acceptable at 74.4%, which was not significantly different from the specificity of using a threshold of 2.5 ng/ml (80%).
Using a PSAv of 0.4 ng/ml/year in men age 50 to 59 years achieved a specificity of 84% and sensitivity of 72%, compared with a PSA threshold of 0.75 ng/ml with sensitivity and specificity of 70% and 84%, respectively.

UroToday – Prostate Specific Antigen Velocity Threshold for Predicting Prostate Cancer in Young Men:

beige_quote.bmpUsing a PSA velocity of 0.4 ng/ml/year or greater may enhance prostate cancer early detection especially in men with a total PSA lower than 2.5 ng/ml. A PSA velocity threshold of 0.4 ng/ml per year or greater was independently predictive of cancer irrespective of age, total PSA, family history of prostate cancer, or race. What was most dramatic was that this criterion had the strongest association to cancer in multivariate analysis, even in patients with a total PSA less than 2.5 ng/ml. Using a PSA velocity threshold of 0.4 ng/ml/year was found to have a sensitivity of 67%, specificity of 81%, positive predictive value of 16%, and negative predictive value of 98%.
This study suggests that using a PSA velocity biopsy threshold of 0.75 ng/ml/year for men younger than 60 years may be inappropriate. Using a PSA velocity of 0.4 ng/ml/year or greater may enhance prostate cancer early detection especially in men with a total PSA lower than 2.5 ng/ml.

Urologists at Georgetown, Northwestern, Washington University, and Duke have been advocating lowering the PSA velocity which should trigger the recommendation for a biopsy. I admit that I often perform a prostate biopsy on young healthy men with a PSA of 2.5 or a lower PSA velocity of 0.4. I am performing more biopsies and finding more cancers. You certainly can make the argument that waiting for a higher PSA may not diminish the cure rate and may find cancers that are more clinically significant.
I understand that some urologists do not believe in PSA as a screen for prostate cancer at all.
I am sure that one day we will have better screening tests that are more specific and probably more sensitive.
I wonder what people think of a prostate biopsy done as a baseline study. I would compare this to a screening colonoscopy which likely has a similar rate of complication (low), can be done under local anesthesia, and will find some prostate cancers that we are not finding now.
The major obvious downside would be putting most men through a biopsy which will not reveal cancer and finding cancer that may not need to be treated for months to years.
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Quality of life after a negative biopsy

UroToday – “False-Positive” Prostate Cancer Screenings Assessed

“Men can discuss the pros and cons of getting a PSA test with their
doctors. However, once a man decides to go ahead and get a PSA test, if
its results are abnormal, he typically should have ongoing follow-up and
surveillance for prostate cancer,” Katz said.

Katz said that a strength of the UI study was that it did not rely on
volunteers. “Volunteers who sign up for a prostate cancer screening
study represent a different type of population than that comprised by
the individuals in our study, who were patients seen in the usual course
of care,” he said.

However, Katz noted, a limitation of the study is that the researchers
were not able to obtain baseline data on how the men originally felt
about their health prior to screening. In addition, the study focused
primarily on Caucasian men.

This is an interesting study, but I think it needs further investigation prior to making any definitive conclusions.
I think that a man who has a low PSA may have a better sexual outlook than a man who is offered screening and refuses. You would have to also follow the consequence of bringing up PSA screening with patients and look if just the discussion of prostate cancer is a detriment since it is usually picked up prior to there being any symptoms.

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