When news broke last July of the American Society for Clinical Oncology’s recommendation against PSA screening in many groups of men, Alan J. Wein, MD, professor and chief director, Division of Urology, shared his insight for the Penn Medicine News Blog. Wein noted that the test is worthwhile for some groups and not for others.
Now, almost a year later, new prostate cancer screening methods are garnering national attention, and a Reuters article earlier this week discusses the cautious approach towards PSA testing taken by the American College of Physicians. A recent New York Times article suggests that these new tests can decrease the number of “false alarms” from elevated PSA readings and prevent thousands of men from receiving unnecessary biopsies, surgeries, and radiation treatments. Some of the new tests look at the genetic workings of a cancer to identify dangerous tumors that need treatment, rather than slow-growing ones that may be best to monitor only.
Considering these new discoveries, I checked in with David Lee, MD, FACS, assistant professor of Surgery in Urology, to see if any of these new tests influences the treatment he provides for patients.
News blog: What do you think of these new screenings that are gaining more attention now? Is the PSA test still a useful tool for some groups?
Lee: The PSA is still extremely useful for all men. It is still the best blood test for screening for a particular type of cancer. It is not a perfect test, but wholesale abandonment of PSA screening will certainly result in many more men dying of prostate cancer. Because PSA can be elevated for a number of reasons, screening for prostate cancer as a whole can still be improved upon and new technologies may help us in this regard. I absolutely agree with the need for improved screening methods but all of these tests will likely never replace the PSA but be used in conjunction with it.
News blog: Have you implemented any of these new tests in your treatment of prostate cancer patients?
Lee: We have been using PCA3, a urine based assay, occasionally to help us screen some men who have a higher risk for prostate cancer based on a slightly elevated PSA and a biopsy that shows no cancer. This may help us decide when and if we need to offer another biopsy at a future time for these men. There is a test called the Prolaris test that we are in the process of implementing that can help to determine whether a particular prostate cancer is more quickly growing than another. This test uses RNA analysis of biopsied tissue to determine expression of certain markers that are associated with cell division.
News blog: What’s the difference between watchful waiting and active surveillance?
Lee: Watchful waiting is the process of diagnosing someone’s prostate cancer and then offering no active treatment or follow up until symptoms from spread appear. These men would then get treated with hormonal or chemotherapy agents. Active surveillance (AS) is the process by which urologists closely follow men with prostate cancer with serial PSA’s (usually every 3 months) and a periodic biopsy of the prostate (typically every year). However, the idea that active surveillance is more careful option than active treatment is quite dangerous. I think it is quite the opposite.
In some cases, a patient’s overall health suggests they are more likely to die of another cause before their prostate cancer spreads. Alternatively, “if the patient has a long life expectancy, say greater than 10 years, then even a very small and slow growing prostate cancer ought to be treated,” Lee adds.
News blog: So how accurate is the PSA test in regard to active surveillance?
Lee: Methods for surveillance of someone with prostate cancer, consisting mainly of PSA and prostate biopsies, have been controversial due to their less than optimal ability to detect prostate cancer. Why then would someone undergoing active surveillance feel totally comfortable relying on these tests then to determine when treatment is necessary? At least 30-40% of men that we perform radical prostatectomy on for Gleason 6 prostate cancer have a Gleason 7 at time of surgery. This reflects the inability of the prostate biopsy to adequately sample the prostate cancer so that we understand what type is really within the prostate. Additionally, prostate biopsy or PSA gives us no idea of how close to the edge of the prostate a particular cancer is growing. Therefore, a patient may have a small cancer, but if it’s close to the edge, the cancer needs to grow only a small distance before it is growing through the edge. When we find someone with an early prostate cancer, I think it is very reasonable to think that this is fortunate opportunity to perform surgery because this is time that such a treatment can cure someone permanently and if surveillance is performed then we might miss that window. Therefore, even our surveillance methods need improvement. So, if someone is considering surveillance this must be thoughtfully discussed realizing the inadequacies that are present in this method of treatment.
Much like any other condition, patients are encouraged to speak with their urologist on all available care options. “For the correctly selected patient, active surveillance may be the best treatment,” Lee says.