As you may have been reading over the last year or so, there is a continuing controversy about the utility of PSA when used as a screening tool for prostate cancer. Almost exactly one year ago, we discussed PSA in this blog. Given the continuing questions and arguments, I thought it would be prudent to revisit the issue.

The following is a letter sent to all of the members of the American Urologic Association. I thought that our followers of the Men’s Health Blog would be interested in reading what our association is saying about PSA.

“Dear AUA Member,

As you know, the American Urological Association (AUA) has been monitoring the recent debate about prostate-specific antigen (PSA) testing and actively inserting our position on the topic as needed. On Tuesday, March 9, an op-ed in The New York Times, written by Dr. Richard J. Ablin, inaccurately asserted that the AUA supports routine PSA screening. The article has received significant attention from news outlets around the country and the AUA is working with media outlets to respond.

The AUA stands in support of prostate cancer testing. However, the AUA does not advocate universal annual PSA testing for all men, nor does it support routine biopsy. Research has shown that a PSA above a certain level at age 40 is a stronger predictor of prostate cancer risk than family history or race. The AUA recommends that men ages 40 and older talk to their doctors about prostate health and the pros and cons of establishing a baseline PSA score. Establishing a baseline PSA at age 40 empowers patients and doctors to make informed decisions about future testing. The AUA also clearly states that follow-up should be determined based on a patient’s individual risk and discussions with his doctor.

We feel that the recent debate is inappropriately focused on the PSA test itself, when we should be focusing on how test results are being interpreted and impacting treatment decisions. The 2009 AUA Best Practice Statement on Prostate-specific Antigen presents a balanced assessment of the test’s strengths and weaknesses and provides comprehensive guidance on how to appropriately interpret test results based on a patient’s individual risk factors.”

This is essentially the way that I have been practicing for the last number of years and I suspect that most of my colleagues have a similar practice as well. In medicine, much as in many other places, the pendulum tends to swing in arcs that are rather large. At first PSA was thought to be the “wonder lab,” and now there are many doctors (mostly primary care) who feel that PSA is not a particularly good test. Truth as always, lies somewhere in the middle. There is no question that the use of PSA has helped to identify prostate cancer in many at a much earlier stage and the evidence shows that because of this prostate cancer death has decreased. But like anything, PSA is not perfect and it is best utilized by a knowledgeable physician and an informed patient.

Have a great weekend. Go Terps!

We (Sinai Hospital Radiation Oncology in conjunction with Advanced Urology Associates) have now been performing Cyberknife Stereotactic Radiosurgery (CK SRS) for prostate cancer for just over 18 months. There have been over 50 men in that time that have had their prostate cancer treated by CK SRS. And while it is too early to make any judgements about the long term efficacy of the treatment, there are a number of observances that can be made.

The first is that overall, there are less side effects with CK SRS than the other options for radiation therapy. It appears that the percentage of men having profound symptoms from radiation are far fewer in number than with seed implantation or even IMRT. Most men have transient frequency and urgency of urination that is well controlled with medications such as flomax or uroxatrol. Bowel issues such as diarrhea or rectal bleeding are present in small numbers, again less than the other modalities of treatment. This parallels what has been seen in other centers performing CK SRS for prostate cancer.

Secondly, in terms of PSA response, we have seen a pattern similar to what we see with seed implantation. The majority of men have their PSA reduced by 50% at their first check which is typically three months after treatment. This pattern has persisted at their six, nine, and twelve month checkups as well.

In terms of erectile dysfunction, as with other modalities, it depends on the quality of the function prior to the treatment. Good erectile function prior to treatment has been rewarded with good function afterward. For the men that have marginal function to begin with, they have seen some declination of their function afterward which is consistent with the seed implant and IMRT experience.

Overall, the large majority of men who have undergone CK SRS to treat their prostate cancer have been gratified with the results. Remember that there are significant biases in this group. One is the group of men that self select for the treatment, because that is what they want. The second group is the men with significant urinary symptoms prior to the institution of treatment so we would expect a higher post treatment symptom rate. Almost all of my patients have stated that they would select CK SRS again to treat their cancer now knowing what they know.

The jury is still out on CK SRS. It is a Medicare approved modality to treat prostate cancer. How it is going to look in five to ten years against seed implantation, IMRT and surgery is anybody’s guess. What we do know so far is that we have seen a good PSA response with a minimal and generally acceptable side effect profile. I suspect that over the next few years better data will accrue and more men will want the treatment as they hear about from their friends. One thing is for certain. This is a treatment that finds its way by word of mouth and advertising. Many urologists either don’t know about CK SRS or refuse to discuss it with their patients for a myriad of reasons. Hopefully that will change over the next few years as patient choice drives the train. That is assuming patient choice in the future matters. Given the legislation passing through the Congress, choices in treatment of many disease processes may be limited to what some “panel of experts” deems is financially advantageous to the government rather than efficacious for the patient. And while I don’t want to generate negative comments from my readers who support this legislation, this is an aspect that is little discussed by the media but one that is very concerning in the medical community.