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.

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 – www.phillyburbs.com: 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 – www.phillyburbs.com: 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 Mortality at 11 Years of Follow-up — NEJM

After a median follow-up of 11 years in the core age group, the relative reduction in the risk of death from prostate cancer in the screening group was 21% rate ratio, 0.79; 95% confidence interval [CI], 0.68 to 0.91; P=0.001, and 29% after adjustment for noncompliance. The absolute reduction in mortality in the screening group was 0.10 deaths per 1000 person-years or 1.07 deaths per 1000 men who underwent randomization. The rate ratio for death from prostate cancer during follow-up years 10 and 11 was 0.62 95% CI, 0.45 to 0.85; P=0.003. To prevent one death from prostate cancer at 11 years of follow-up, 1055 men would need to be invited for screening and 37 cancers would need to be detected. There was no significant between-group difference in all-cause mortality.

via Prostate-Cancer Mortality at 11 Years of Follow-up — NEJM.

This NEJM published study is a 2 year update from the European Randomized Study of Screening for prostate cancer.  This is a timely article given the debate in this country as to the utility of prostate cancer screening.

Prostate cancer is a slow growing cancer that rarely cause mortality in months.  As more time goes by I would expect the updated version of this study to show a larger amount of people being helped by the treatment of their prostate cancer.

Organ-confined disease more common in screen-detected prostate cancer

Source: MedWire News

Prostate cancers detected by screening have a higher rate of organ-confined disease and a lower rate of extracapsular extension and positive surgical margins than non-screen-detected cancers, say researchers.
The widespread use of prostate cancer screening had led to stage migration, with more cancers detected at a lower stage, which has led to a reduction in the age-adjusted mortality rate. However, it is not clear whether some men are being treated unnecessarily, says the team.

Another study that shows men that are screened for prostate cancer with PSA bloodwork have cancers that are more likely to be contained to the prostate.

Active Surveillance for Prostate Cancer Patients

From Medscape

May 12, 2008 — The urine test for the PCA3 gene, already marketed for use in diagnosing prostate cancer, could also be useful in prognostication. It might have clinical application in selecting men with low-grade and low-volume tumors who would be suitable candidates for active surveillance, say researchers writing in the May issue of the Journal of Urology.
The PCA3 urine test, marketed in Europe by Gen-Probe, has been shown in previous studies to be more accurate in diagnosing early prostate cancer than serum levels of prostate-specific antigen (PSA).

I usually use the PCA 3 test for men who have had a negative biopsy and we are considering performing a second one. I usualy use it for men with high grade PIN after one biopsy. If the PCA 3 is positive, I usually perform a second biopsy. I have not looked at my data to see if the above correlation exists, but that would be interesting.
I also am not sure if you can use PCA 3 tests that are taken a few months apart to mean anything. For example, would a rise in PCA 3 be expected if a man develops cancer or the cancer is growing?

A Step Backward: The ACPM Recommendations on Prostate Cancer Screening

Medscape article summarizing PSA recommendations:
The most aggressive screening protocol is from the NCCN.

NCCN guidelines start from the premise that the patient has made a decision to seek early prostate cancer detection. They recommend beginning screening at age 40. The baseline PSA level, race, and family history are then used to determine the subsequent screening intervals. They recommend considering a biopsy for men with a total PSA level > 2.5 ng/mL, after further consideration of the PSA velocity, PSA density, and percent free PSA. They explain how these parameters can be used to lessen the possibility of confounding from benign prostatic hyperplasia. Furthermore, they describe how repeating PSA determinations with or without a trial of antibiotic therapy, as well as consideration of variability between different PSA assays, can reduce the likelihood of confounding from prostatitis or differences in PSA assay standardization. Moreover, they provide advice about whether or not repeat biopsies are needed and how to deal with the findings of high-grade prostatic intraepithelial neoplasia or atypical glands suspicious for carcinoma on an initial biopsy.

Screening for prostate cancer

The controversy over screening for prostate cancer will continue.

clipped from www.medscape.com

Information is not adequate to recommend screening men for prostate cancer with digital rectal examination or measurement of prostate-specific antigen (PSA), according to a position statement by the American College of Preventive Medicine (ACPM) published in the February issue of the American Journal of Preventive Medicine.

The American Urological Association recommends that men who are 50 years and older and who have an estimated life expectancy of more than 10 years should be offered PSA screening. The American Cancer Society recommends that men who are 50 years and older and who have a life expectancy of more than 10 years should be offered both DRE and PSA screening. The United States Preventive Services Task Force and American Academy of Family Physicians do not find sufficient evidence to recommend for or against PSA or DRE screening. The Canadian Task Force on Preventive Health Care recommends against routine screening with PSA.

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Testosterone and prostate size

Testosterone makes prostates grow larger and makes prostate cancer grow more quickly.
I came across a study that looks at prostate size and testosterone levels:

clipped from www.urotoday.com

Relationship between Serum Testosterone and Measures of Benign Prostatic Hyperplasia in Aging Men – Abstract

In our study, the serum testosterone levels in aging men did not correlate with the measures of BPH, including prostate volume and IPSS, regardless of whether total, free, or bioavailable testosterone was used. Age correlated with the measures of BPH, especially prostate volume. Additional large studies are needed to confirm these preliminary results.

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To my surprise, patients with higher testosterone levels did not have larger prostates. As expected, patients with higher PSAs and older patients had larger prostates.

PSA, free PSA, and the impact of intercourse on PSA

There was a good question asked on a prior entry:
Robotic Surgery Blog: Is Prostate Cancer Transmissible?: “Would you please comment on whether there is a connection between sexual activity and elevated PSA. Also, why would test results given to a patient not break down PSA into free and that with protein. Thank you.”

PSA can be done in many ways. Most often urologists including myself only order the total PSA, not the free and total test. If the free is ordered I usually do not give it to patients unless they ask. In general a low number (under 10%) gives you a higher chance of having cancer and a high number (over 25%) gives you a lower chance. Most patients would not understand the nuances involved in reading this test.

As for sexual intercourse, I do not think it causes a major jump in PSA. Patients who have intercourse the day before the test may have a slightly higher PSA value. When the studies were done to evaluate PSA values and risk of cancer patients were not asked to abstain from intercourse. Therefore I do not ask patients to modify their behavior.

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