“Ought to I get a PSA?”
It relies upon. Who’s asking, and why?
If the query is being requested by a 45-year-old man, the reply goes to be completely different than if it’s being requested by a 75-year-old. If a main care clinician is asking, he/she could also be confused about present suggestions relating to screening for prostate most cancers. The reply is difficult and fraught with bias. Sadly, the controversy over PSA screening for prostate most cancers nonetheless persists after 40 years of expertise.
I practiced urology for 35 years. I began my residency in urology at Oregon Well being Science College in 1979, eight to 10 years earlier than urologists started utilizing PSA.
I’ve witnessed the evolution of prostate most cancers “screening” utilizing PSA. I used to be there earlier than the controversy began, and I’m nonetheless right here in the course of the struggle. The “struggle?” Sure, the struggle. In a single nook are the doubters, the “non-screeners,” physicians who take their cues from the US Preventive Job Pressure’s 2012 Degree D advice (since revised to Degree C in 2018) – “we don’t must display for prostate most cancers by doing PSAs on our sufferers as a result of most prostate cancers are indolent and slow-growing, and males aren’t going to die from prostate most cancers. The remedy (surgical procedure, radiation, hormones) is worse than the illness.”
Within the different nook are urologists, oncologists, and radiation oncologists who imagine that early detection of prostate most cancers utilizing PSA as an preliminary marker just isn’t solely attainable but in addition saves lives. Extra importantly, early detection prevents morbidity from superior and/or metastatic illness.
In 1980, PSA was nonetheless in analysis labs. By the mid-80s, docs realized that PSA was a extra delicate take a look at for detecting prostate most cancers than acid phosphatase (a blood take a look at). Acid phosphatase was elevated in superior/metastatic prostate most cancers however not as delicate for prostate most cancers as PSA. Previous to PSA, the one strategy to detect localized prostate most cancers was by a digital rectal examination (DRE) or by investigating signs of bladder outlet obstruction or signs of superior/metastatic illness.
Earlier than the mid-80s, if a nodule was felt, a blind biopsy utilizing solely finger steerage was carried out. A optimistic biopsy, regular acid phos, destructive bone and CT scan meant “localized prostate most cancers.” That affected person was normally provided surgical procedure (a radical retro-pubic prostatectomy) or exterior beam radiation remedy. This was uncommon. From 1979 to 1982, I assisted in two radical prostatectomies. After PSA had been round for 15 years, I used to be concerned in performing two radical prostatectomies per week, roughly 100 a yr.
Half of the prostate most cancers sufferers within the early 80s had superior or metastatic illness. If the affected person had regionally superior illness however no metastases (Stage ‘C’), he can be handled with radiation. 25% of sufferers had been discovered to have prostate most cancers after a TURP, stage A1 (fewer than 5% of chips +) or A2 (larger than 5% of chips +). On the Portland VA, usually half of our sufferers on the ward had been being handled for metastatic prostate most cancers with IV stilphosterol and/or radiation remedy for distant mets, or painful bone mets in peril of pathologic fracture.
What occurred over the subsequent 4 many years with respect to PSA within the US (issues are completely different in different international locations) is each phenomenal and tragic. With thousands and thousands of PSAs and prostate biopsies being finished, the incidence of prostate most cancers elevated. Nonetheless, the share of sufferers presenting with superior and metastatic illness fell from 50% to lower than 10%. Mortality from prostate most cancers declined.
We realized that PSA was a superb take a look at to evaluate response to remedy. An undetectable PSA after remedy was indicative of a superb response to remedy (surgical procedure, radiation, even hormone ablation for the remedy of metastatic illness). A rising PSA after remedy was indicative of recurrence.
We realized about PSA velocity (change in PSA over time), PSA density (PSA/prostate quantity), % free PSA, PCA3 (prostate most cancers antigen urine take a look at), isoPSA, and not too long ago newer checks like ExoDx (urine biomarker). All of those variations and checks have been useful in refining the sensitivity and specificity of PSA-based screening. Add to these instruments multi-parametric MRI.
Prostate most cancers incidence will increase 10% every decade. A 50-year-old man has a 50% probability of getting “prostate most cancers” in his prostate, a 60-year-old, 60%, and so forth. Clearly, not all prostate cancers are “clinically vital,” which means they’re slow-growing, indolent, and can by no means trigger any issues all through that man’s life. Because of this many docs will inform sufferers, “You usually tend to die with prostate most cancers than from prostate most cancers.”
This created issues as a result of many clinically insignificant cancers had been unnecessarily handled. With overtreatment got here vital issues – impotence, incontinence, and post-surgical and radiation issues.
The USPTF issued a Degree D advice towards PSA-based screening (2008 and 2012). The advice was primarily based on three research (PLOC, ERSPC, and Gothenburg). All three research are flawed for quite a lot of causes and had been misinterpreted by the USPFT. Not one urologist or oncologist was on the USPTF committee. The USPFT advice has confronted in depth criticism within the literature. Morbidity from metastatic illness and remedy just isn’t a part of their evaluation. Because of the flawed advice by the USPTF, there was a rise in superior/metastatic illness, which prompted a revision of their advice to Degree C in 2018.
At present, the 2 camps are nonetheless far aside on the early detection of prostate most cancers. Like different conflicting beliefs in 2023, this battle is senseless and doesn’t should persist. Hundreds of males are nonetheless presenting with superior and metastatic prostate most cancers. It’s estimated that 35,000 males will die of prostate most cancers in 2023.
“Who’re these males? Have they ever had a PSA or digital rectal examination?” Within the mid-90s, we reviewed 100 consecutive sufferers who introduced with superior or metastatic prostate most cancers. Many had PSAs over 100. We requested, “What number of had well being care insurance coverage in the course of the ten years previous to presentation?” 85. We then questioned, “What number of had a PSA and/or a DRE inside ten years of being recognized with metastatic/superior illness?” Zero! (0!). And, “What number of had a documented ‘shared decision-making’ dialog relating to the ‘potential harms/dangers vs advantages’ of getting a PSA?” Once more, zero.
The April 2023 AUA Guideline Early Detection of Prostate Cancer: AUA/SUO Guideline (2023) states, “Clinicians ought to interact in shared decision-making (SDM) with individuals for whom prostate most cancers screening can be applicable and proceed primarily based on an individual’s values and preferences (Scientific Precept).”
From the Could 2018 USPTF recommendation: “Primarily based on a evaluate of the proof, the Job Pressure recommends that males aged 55 to 69 years make a person determination about whether or not to be screened after a dialog with their clinician concerning the potential advantages and harms. For males 70 years and older, the potential advantages don’t outweigh the anticipated harms, and these males shouldn’t be routinely screened for prostate most cancers.”
Most clinicians would not have the time to conduct a strong, factual, non-biased “shared decision-making” dialog. Furthermore, it’s not the affected person’s duty to learn sufficient to interact in a dialog about whether or not or to not have a PSA.
The disconnect between main care and urology needn’t persist. Urologists aren’t focused on performing biopsies on sufferers with PSAs (and different indicators – MRI Pi-RAD of 3-5, ExoDx > 15, and extra) indicative of low-risk, indolent prostate most cancers. Urologists aren’t focused on treating cancers that don’t want remedy. In actual fact, a full third of sufferers who’ve optimistic biopsies are provided energetic surveillance. Likewise, main care physicians aren’t focused on conducting quite a few PSAs, which results in pointless biopsies and pointless remedy inflicting impotence, incontinence, and worse, solely to learn a small variety of these males.
We all know sufficient about PSA (and DRE) to tell a person of his danger of getting clinically vital versus indolent CaP PRIOR to TRUS/bx. Danger calculators are available, and a person can then resolve, primarily based upon his danger, whether or not or to not have a biopsy.
If the biopsy is optimistic, urologists have the required info to have a strong SDM dialog about whether or not or NOT remedy is indicated, primarily based on particular person preferences, and what every remedy (potential harms, dangers, advantages) entails.
For 4 many years, urologists have improved the specificity of PSA as an preliminary early detection device. The times of a standard PSA being < 4 have lengthy handed. Each man has a person danger of growing clinically vital and doubtlessly harmful prostate most cancers primarily based on tons of fine research and proof (mpMRI, enhanced PSA interpretation utilizing % free PSA, PSA density, PSA velocity, isoPSA, urine biomarkers (PCA3, ExoDx), genetic markers, and extra! If you wish to know your danger, get a PSA after which discover somebody who can inform you what your danger is.
Stephen Lieberman is a urologist.