The PSA Controversy...continues

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The PSA Controversy
By Cheryl McEvoy
Posted on: October 28, 2009


By Cheryl McEvoy

My dad worries. Mostly about his wife, two daughters and aging Labrador, but every now and then, thoughts turn to himself. His mother beat colon cancer, his brother died from pancreatic cancer, so he takes signs and symptoms seriously. That's why I was surprised when he casually mentioned his elevated prostate-specific antigen (PSA) level.

The PSA test was part of a routine exam conducted at the firehouse, where he's volunteered for nearly 40 years. My dad's not keen on waiting in a doctor's office just to hear he should drop a few pounds, so the firehouse physical is an easy way to check in.

My dad's PSA had been high before; he got a biopsy 2 years ago, but--after much fretting--it came back negative. This time, his PSA was even higher, but he wasn't concerned. The test has a reputation for faulty results (both healthy and cancerous cells can produce the chemical), so my dad was confident he was cancer-free.

Then he got the call. The urologist apologized for having to tell my dad over the phone, but even he was surprised by the results. Turns out, my dad had early stage prostate cancer--about as early as you can catch it. There was no immediate danger, but my dad decided to undergo surgery.

Some would consider his actions smart; others, excessive. That's because PSA testing isn't fool-proof. Doctors often err on the side of caution, but research findings have patients questioning whether the test is worth it.

The PSA test has been criticized for inducing Henny Penny panic in men when results are abnormal. Even when a biopsy confirms the diagnosis, it's not always a death knell; some forms of prostate cancer never progress, or grow at such a slow pace they never become life-threatening, according to research. The European Randomized Study of Screening for Prostate Cancer (ERSPC) found that PSA screening every 4 years reduced prostate cancer deaths by 20 percent; however, the test also led to overdiagnosis, with 48 additional cancers detected for every death prevented. Similarly, the National Cancer Institute's Prostate, Lung, Colorectal and Ovarian Cancer (PLCO) Screening Trial identified "excess" cancer diagnoses--the screening group had 23 percent more diagnoses than the control group. But unlike the ERSPC, the PLCO trial did not find any reduction in deaths as a result of screening.

The results prompted some skeptics to slough off the test, but according to Mark Kawachi, MD, chair of the National Comprehensive Cancer Network Guidelines for Prostate Early Detection and associate professor of surgery, urology and urologic oncology at City of Hope Comprehensive Cancer Center, Duarte, CA, early detection shouldn't be understated. "I don't think anybody would be willing at this point in time to simply turn their back on PSA, because it is in the single most powerful blood test for identifying the presence of prostate cancer at a time when the cancer is curable," he says

According to Dr. Kawachi, the problem isn't overdiagnosis; it's overtreatment. PSA testing and biopsies can confirm a man has cancer, but they can't distinguish between life-threatening and non-threatening cases. Large population studies, like the ERSPC and PLCO, indicate that more often than not, the cancer will be too slow-growing to prove fatal. But when you're the one on the exam table, numbers provide little comfort. "We know some men will die, we know some men won't die, but we can't apply the statistics to a particular patient and necessarily say it's cut-and-dry this is what you should do," Dr. Kawachi says.

Even when odds are in their favor, many men nip cancer in the bud, electing to get surgery or radiation therapy before it has a chance to get worse. But treatment carries its own set of risks. Surgery can lead to incontinence or impotence, and sufferers may regret their treatment decision. Bowel dysfunction, loose stools and other side effects get less press, mostly because they're difficult to discuss, Dr. Kawachi notes, but they're nonetheless unpleasant.

To reduce such risks, researchers are developing treatments and tools that are more effective and precise. Dr. Kawachi cites robotic surgery and image-guided radiation therapy as preferred treatment options, but says experience is often what makes the difference. "The key now is to make sure patients are being offered treatment not simply based on convenience but because of the experience and outcomes of those providers," he explains.

Recently, interest has been drumming around "active surveillance." The option is just as its title implies; patients get periodic PSA tests and may undergo re-biopsy to track the cancer's progression. If levels haven't changed, surveillance continues; if the tumor has grown, doctors can take action. Prostate cancer patients with characteristics of slow progression--meaning they have a Gleason grade (a measure related to the tumor's tissue pattern) of 3+3 or less, a PSA level of 10 or less and a normal prostate upon digital examination--are the most common candidates.

"Active surveillance" can help patients avoid the nasty side effects of unnecessary treatment, but it also means dealing with the constant "What ifs?" There's no way to tell when the cancer might spread, but once it crosses into the danger zone, survival odds plummet. For many, "wait and see" is too distressing, and they opt for treatment instead.

My dad probably is a candidate for active surveillance, but like I said, he worries. As do I. Our family isn't great with odds, either, so I'm glad he elected for surgery. It'll be about 9 months since his diagnosis when they wheel him into the operating room, and even in that short time, he's gone for additional PSA tests to make sure his cancer hasn't progressed.

There will always be "What ifs?" What if the surgery goes wrong? What if he would have been fine without treatment? But, according to Dr. Kawachi, those questions are inevitable. "That's where the human piece of the puzzle, our expectations, enter in," he says. "If our expectations are met, we're happy, and if our expectations are not met, we're unfortunately dissatisfied."

Well, I'll be keeping my fingers crossed.

Cheryl McEvoy is an assistant editor with ADVANCE, the parent company that publishes this patient resource center.

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