Posts Tagged ‘PSA test’

Takeaways from Dr. Sanda’s Chat on Prostate Cancer

Thank you for attending the live chat with Dr. Martin Sanda on prostate cancer. (Link to: ) Your questions and participation were terrific. Below are additional Q&As that we didn’t have time to get to during the live chat portion.

As you know, prostate cancer is the second most common cancer in men, second only to skin cancers. Emory Healthcare is privileged to partner with you in your health and is ready and able to assist if needed. Please use the resources on this page and this website to contact us if we can help in any way.

Question: What are today’s best prostate cancer diagnosis methodologies?
Answer: Despite a lot of advances in imaging tests such as MRI or higher-resolution ultrasound, there is still a need to biopsy the prostate in order to determine whether or not prostate cancer is present. The biopsy provides important information, not only as to whether there are cancer cells, but if so, how aggressive or how fast-growing those cancer cells appear to be. Bone scans and CT scans are useful to look for spread of prostate cancer elsewhere. Also, new PET (positron emission tomography) scans or other diagnostic studies that image molecules which are taken up by cancerous tissue and not by normal tissue are emerging. But, their role in standard care is not yet sorted out. MRI can provide valuable information about the size and configuration of tumors in the prostate itself and the immediate vicinity, as part of a watchful waiting monitoring plan, or as a guide for treatment planning.

Question: What are the dangers of conventional biopsy?
Answer: The main risk of prostate cancer biopsy is infection, which can be seen in approximately one out of 50 to one out of 100 cases and can require hospitalization for treatment. More commonly, some men may feel faint after a biopsy and should plan on taking the day off or taking it easy if they undergo a prostate biopsy procedure. Rarely, men might experience bleeding from where the needle is inserted into the prostate and this, too, can require hospitalization. Common after prostate biopsy is having blood in the semen or ejaculate; however, this does not pose any danger or risks and will typically resolve in a matter of a few weeks.

Question: Are there new drugs and and prostate cancer treatments on the near horizon?
Answer: Major scientific discoveries have taken place over the past five to 10 years and many more are underway. This has led to a half-dozen new treatments for advanced prostate cancer that have become available in the past several years. A broad range of new treatments are being developed, including more refined types of hormonal therapy, including immune therapies or therapeutic vaccines and also targeted therapies that are aimed at molecular differences between the cancer cell and normal tissue.

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About Dr. Martin Sanda

Dr. Martin SandaMartin G. Sanda, MD, an internationally recognized prostate cancer surgeon and scientist, was appointed chair of the Department of Urology at Emory University School of Medicine and service chief for Emory Healthcare. He also serves as director of the Prostate Cancer Center, which will be established within Emory’s Winship Cancer Institute.

Sanda joins Emory from Harvard Medical School, where he was professor of surgery in urology, and from Beth Israel Deaconess Medical Center, where he served as director of the Prostate Cancer Center. He was also the co-leader of the Prostate Cancer Program at the Dana Farber Cancer Center.

 

PSA Screening for Prostate Cancer: A Healthy Debate

Prostate cancer is the second leading cause of cancer death among American men. In 2013, nearly 250,000 men will be diagnosed with prostate cancer and more than 32,000 men will die from prostate cancer across the United States. In Georgia, it is estimated that 7,360 men will be diagnosed and 1,080 will die.  With alarming statistics such as these, we want every advantage possible in our fight with this disease.

Over the last few years, the topic of PSA testing as a screening tool for prostate cancer has been under heavy debate in the medical community. PSA (prostate specific antigen) is a protein produced by the prostate gland and its levels can be measured by a simple blood test.  A higher number could indicate prostate cancer, but the test doesn’t differentiate between an aggressive, fast-growing cancer, and one that is so slow-growing it wouldn’t threaten a man’s life.

On January 8, Emory University School of Medicine’s Department of Medicine Grand Rounds took on an unusual format: a debate between Otis Brawley, MD and John Petros, MD on the validity of PSA testing as a prostate cancer screening tool.

Dr. Otis Brawley

Dr. Otis Brawley

Dr. Otis Brawley is a professor of hematology and medical oncology and chief medical officer for the American Cancer Society. He kicked off the debate asserting that research demonstrates PSA testing to be unreliable, possibly leading to too many diagnoses and unnecessary treatment for prostate cancer.

Dr. John Petros

Dr. John Petros

Dr. John Petros is a professor of urology who treats prostate cancer patients, and he argues that after looking at other studies (more details below), the PSA test is a tool that has helped save lives by detecting prostate cancer in its early stages.

Less than a year ago, a “grade D” rating for PSA screening was issued by the U.S. Preventive Services Task Force, stating that PSA testing offers more harm than good due to complications from PSA-test-driven treatment such as incontinence and blood clots. Despite not ruling out its use, Dr. Brawley is in agreement with the assessment of the U.S. Preventive Services Task Force and says he’s not convinced the PSA test saves lives. As he puts it, “Pretend you are offered the choice of taking a pill that will double the risk of prostate cancer diagnosis from 10 to 20 percent, but could decrease risk of prostate cancer death by one fifth: from 3 to 2.4 percent. [...] Do you feel lucky?” Brawley quipped.

To counterpoint Dr. Brawley’s assertion, Dr. Petros cited the National Cancer Institute’s epidemiology data, which indicates the rate of metastatic prostate cancer has substantially dropped over the last few decades due to prostate cancer being diagnosed earlier on. Dr. Petros also discussed research conducted in Sweden and Austria, which shows significant drops in prostate cancer-related mortality as a result of PSA testing.

Despite their differing views on the validity and use of PSA testing as a prostate cancer screening tool, there are five things Dr. Brawley and Dr. Petros agree on:

  1. The PLCO study, a NCI-sponsored randomized clinical trial to examine the effects of screening on cancer-related mortality, was flawed. In particular, the “control” arm had a substantial rate of PSA testing.
  2.  Brawley said: “Some cancers that are detected early do not pose a threat and do not need to be treated.” Similarly, Petros said: “Prostate cancer can be low risk if safely observed, but high risk forms are lethal. We need to focus on cancers that matter.”
  3. PSA testing should be performed in the context of a physician-patient relationship, with men making an informed decision about the value of the information they will receive and the associated risks.
  4. Vans in supermarket parking lots – more broadly, community- or employer-based screening  — are not the ideal setting for PSA testing.
  5. Biomarkers that are better than PSA alone are needed. Brawley said: “We need a 2013 definition of prostate cancer, informed by genomics, rather than going by what Virchow decided prostate cancer looks like under the microscope 160 years ago.”

In regards to the last point, Dr. Petros added that more sophisticated tests than PSA have already been developed. The prostate health index, which measure levels for three types of PSA and is also more cancer-specific is a good example. Research is currently being conducted at Emory by Carlos Moreno and Dr. Petros to help further this goal. To build on the research they’ve already performed around a panel of biomarkers that can predict prostate cancer outcomes after prostatectomy, Moreno and Dr. Petros will seek to evaluate in coming months whether the same biomarkers could be useful on prostate biopsy samples. The results of this research are expected to help inform treatment option decision making regarding the use of surgery versus radiation.

For now, Petros is an advocate of initiating a conversation about PSA screening with patients 50 and older, or younger if they are at risk for the disease. He believes the decision to have routine PSA testing, follow-up tests and prostate cancer treatments, is a very individualized process.

“It comes down to, what do you tell the man standing in front of you?” he said. “You have to consider where they are in life and what their goals are, and that varies with every man.”

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Questions on Validity of PSA Test as Prostate Cancer Screening Tool?

Prostate Cancer PSA ScreeningViraj Master, MD Prostate cancer is the second leading cause of cancer death among American men.  Nearly 250,000 men will be diagnosed with prostate cancer this year.  More than 32,000 men will die from prostate cancer this year.  In Georgia, 7,360 men will be diagnosed and 1,080 will die.  With statistics like that, we want every advantage possible in our fight with this disease.

Since the early 1990s, the Prostate Specific Antigen (PSA) test has been the primary screening tool used to detect prostate cancer. The PSA is a simple blood test, non-invasive and easy to administer and process.  The US Preventive Services Task Force has recently recommended, however, that the PSA test no longer be offered to men as a screening tool.

This task force is a federally funded independent panel of experts in prevention and evidence-based medicine.  It is comprised of primary care providers such as internists, family practitioners and pediatricians, but not oncologists or urologists.  Their job is to evaluate the benefits of preventive services like screening and make recommendations about which services should be routinely incorporated into primary medical care.

Screening, or early detection, for prostate cancer is a complicated issue.  Unlike the colonoscopy, which provides clear evidence of early detection and has been determined to have saved lives in multiple studies, the PSA test has been contradictory, with some studies showing a benefit, while others did not.  There are many reasons, including the fact that most forms of prostate cancer are relatively slow-growing cancers.  Generally, a man with prostate cancer may live for many years without ever having the cancer discovered.  In fact, many men with prostate cancer will not die from it, but with it.  In addition, high or increasing levels of PSA can indicate an increased risk for prostate cancer, but can also indicate an infection or an enlarged prostate.  So, the USPSTF determined that because of these uncertainties, the risk of over treatment is greater than the benefit, and their recommendation states that PSA tests should no longer be offered as a screening tool.

The biggest issue in prostate cancer that confronts patients, their families and their healthcare providers is to delink screening with treatment.  Not all forms of prostate cancer require active therapeutic interventions, but some do.

While the PSA test is imperfect, it is – at this time – the best tool we have at our disposal for early detection of prostate cancer.  The Winship Cancer Institute of Emory University aligns with the American Urological Association, the American Cancer Society, American College of Physicians and the American College of Preventive Medicine and recommends informed decision-making.  Our recommendation is that men at average risk should receive information, including a PSA test if they want it, at an appropriate middle age, although African American men or men with a family history of prostate cancer should receive information at an earlier age, such as 40, or 45 years.

So, what do we mean when we say “informed decision-making”?  This means that doctors should discuss the potential benefits and harms of PSA screening with their patients and consider their patients’ preferences, overall health, and family history when making decisions regarding screening with a PSA test.

Unfortunately, there is no easy answer.  Each patient comes to us with his own distinctive characteristics, and those characteristics must be taken into consideration when deciding whether to have the PSA test.

About Dr. Viraj Master
Dr. Master specializes in the treatment of adrenal cancer, bladder cancer, kidney cancer, prostate cancer, testicular cancer. He is also an expert in laparoscopic surgery. Dr. Master received his Medical Degree in the University of Chicago in Chicago, Illinois, in 1997. He completed his Internship at University of California, San Francisco in 1999, where he also completed his Fellowship in 2003.