Johns Hopkins Health Alert
Recent PSA Studies: What You Need To Know
The recent contradictory studies of more than 240,000 men published in the New England Journal of Medicine (NEJM) about the effectiveness of using the prostate specific antigen (PSA) test for reducing death from prostate cancer left many men and physicians confused, upset, disappointed, and wondering what they should now do. One study reported that PSA saves lives, while the other noted no benefit whatsoever. To help our readers with this confusing data, we asked H. Ballentine Carter, M.D., Director of Adult Urology at the Brady Urological Institute at Johns Hopkins, to provides his thoughts. Here are Dr. Carter's remarks …
Granted, while both studies had their particular limitations, the PSA test has its own limitations. For example, an elevated PSA can be a tip-off to a lethal cancer, but it can also detect less aggressive cancer that may never cause harm. Since we don't yet have a definitive test that can tell the difference, and may not for many years, most prostate cancer experts believe that this cancer is now not only over diagnosed but also over treated.
Does the PSA test save lives -- according to the American Cancer Society, 28,000 men died from prostate cancer in 2008 -- or does it merely subject a large number of men with elevated PSAs to unnecessary surgery or radiation with side effects that can include urinary incontinence, erectile dysfunction, and irritative urinary and bowel symptoms? Doctors and patients alike have always wanted to know the answer for years, and they were hoping that these randomized trials would provide them. Unfortunately, they did not.
According to H. Ballentine Carter, M.D., Director of Adult Urology at the Brady Urological Institute at Johns Hopkins, the studies will not end the controversy surrounding the PSA test, a blood test that millions of men have been taking since it was first introduced in the late 1980s. It's currently estimated that 25 million PSA tests are performed annually in the United States."I am not sure that we learned a tremendous amount from the NEJM studies," admits Dr. Carter. "We already knew that we were over diagnosing and over treating this disease. Now we have numbers to document the extent of over treatment."
The studies published in the NEJM, from large randomized studies performed in North America and Europe, yielded contradictory results. An early analysis of the North American study of 77,000 men aged 55 to 74, which is still ongoing, showed no reduction in death from prostate cancer attributable to prostate cancer after seven to 10 years of follow-up.
However, the European study of 182,000 men aged 55 to 69, which is also ongoing, showed a 20% reduction in death among men who had PSA testing. For every life saved, however, 1,400 men need to be screened and 48 would need treatment following a positive PSA and digital rectal exam to result in one fewer death during a 10-year period.
Another way to look at it: 47 men who had a PSA test followed by surgery or radiation for their cancer may not have needed it, and many might go on to have urinary and erection complaints. In harming their quality of life while ostensibly protecting them from cancer, some men might say that this is too high price to pay for a disease that was not going to cause harm.
However, further follow-up could demonstrate a greater benefit of PSA screening and reduced harm as we learn more about the ability of PSA testing to prevent other outcomes, such as the development of metastatic disease and local progression of cancer that requires treatment. In addition, since prostate cancer takes a long time to progress, the 20% reduction in prostate cancer mortality found after 10 years could be higher with longer follow-up.
"PSA screening is certainly not perfect, but it is clearly saving some lives," says Dr. Carter. "If an individual is thinking about being tested, we now have some numbers to give him and he can make up his mind whether or not to be tested. If a man wants to continue to be tested, that's certainly reasonable. "
Once a man knows the risks and the trade-offs, he may or may not want to have a PSA test. "Americans are not like Europeans," concedes Dr. Carter. "We tend to be aggressive about wanting to know more. In spite of these new reports, I still think most men will still want to have the PSA test."
In light of these new studies, what should a man do? Says Dr. Carter: "I like what Dr. Michael J. Barry, M.D., medical director of the John D. Stoeckle Center for Primary Care, said in his NEJM editorial about the studies. He wrote, "The implications of the trade-offs reflected in these data, like beauty, will be in the eye of the beholder. Some well-informed clinicians and patients will still see these trade-offs as favorable; others will see them as unfavorable. As a result, a shared decision-making approach to PSA screening, as recommended by most guidelines, seems more appropriate than ever."
- Bottom line: What the studies point out is that right now we still don't have a one-size-fits-all type test. While Dr. Carter believes that the value of the PSA test is still debated, until we have a better biomarker test that can differentiate inconsequential from lethal tumors, the PSA test needs to be used more judiciously. "I think a lot of the overtreatment we see has to do with using PSA as an absolute cutoff. I think PSA velocity, how fast the PSA moves over time, may be a better measure of the presence of lethal cancer.
"Doctors can get a lot more information if there is a PSA history, which is why I believe getting a baseline PSA at a younger age is a reasonable thing to do.," says Dr. Carter. "I recommend that all men should have an initial PSA test starting at age 40. A follow-up test should be given at age 45 and then again at age 50. Combining that information with the patient's age, size of the gland, and the free PSA test, should improve the accuracy of the PSA test. This will indicate their risk of developing prostate cancer.
"While not precise, it offers the best indication we have so far about the presence of cancer and what should be done," he says.
Posted in Prostate Disorders on March 27, 2009
Reviewed September 2011
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I thought that a needle biopsy followed by finding the gleason score would "differentiate inconsequential from lethal tumors:. Why is that not mentioned in the article?
Posted by: grc | March 28, 2009 11:25 AM
The article is extremely stupid and it amazes me that the very hospital that diagnosed me with cancer last year and the hospital that leads everyone in urology would be so ignorant. I was only 46 years old last year when my PSA reading jumped 4.2 points in one year. My previous annual readings were 1.9, 2.1, 2.3, 2.3 then 6.5. My alarmed primary care physician sent me to a urologist, tried antibiotic hoping it was an infection, then 12 needle biopsies, you diagnosed me with cancer. I had it removed in Vanderbilt Hospital on April 17th, 2008. Found out at my 6 week followup that it was an agressive cancer, my prostate was 10% cancerous, and yet it was contained and they removed it before it got outside. Praise God! My life was saved by a simple PSA test each year as a beginning barometer then going ahead with the surgery. Had I waited until 50 to get checked my physician said I would be dead. In closing, be careful what stupid articles you print, when it comes to a deadly disease like cancer. I for one am glad I went through with it and 1 year later I have no side affects at all, a happy marriage and that cancer will not ever kill me.
Posted by: Jim Anderson | March 28, 2009 1:51 PM
I have gone beyond disappointment to anger toward Johns Hopkins, and organization that touts itself as the "world expert on prostate cancer."
This article, and the last one, is nothing more than a scare tactic to further confuse the patient and/or potential patient.
What happened to the needle biopsy? What treatment decisions need to be made until the results of a reliable biopsy lead the way?
In my sitation, a slow increasing PSA result lead to a biopsy, which found "abnormailties." Following the biopsy, the PSA level lowered and began a slow increase again. Four years later, the PSA was at 4.8 and another biopsy. Cancer was found in three quadrants with Gleason 7,7,6 numbers.
Then, and only then did I have to make any decisions. Until then, there were no " unneccessary or overtreatments."
I had a robotic radical prostatectomy and have had some of the not-so-desirable aftereffect. But I am alive, happy and, after almost two years, cancer free.
If Johns Hopkins wants to continue to create revenue with their heavily marketed reporting documents, the organization should be required, by medical ethics and law, to provide their clients with the most honest and accurate information available.
Posted by: Ed L | March 28, 2009 3:43 PM
My husband had a 4.1 psa and turned up to have an aggressive gleason 9 or 10 post biopsy. I worry more about men like him who may lose their lives as opposed to losing their bladder control.
Posted by: lbi103 | March 29, 2009 6:49 PM
Personally, I think the PSA is being asked to do more than originally intended...which was to indicate the "possibility" of prostate cancer. Prior to PSA testing (using only the DRE), I think the diagnosis of curable pc was about 20-25%. With the use of PSA testing, I think it is now around 70-80%. Urologists are getting smarter with interpreting the PSA scores and also have utilized other PSA information to help them..."free" PSA and PSA "velocity." I'm sure (unscientifically) that as a result of these additional bits of information the number of overdiagnosed and overtreated men have been reduced (dare I say "measureably"). I agree with other comments posted here questioning the absence of the Gleason Score when looking for aggressive pc. The PSA simply gives us "cause for concern." In my case, it wasn't moving upward, hence the importance of the DRE. Fortunate are those men who find their cancer by the PSA test up to a decade before I found mine (radical prostatectomy with capsular penetration and perineural invasion followed with radiation 6 years later). I recall Dr. Stamey saying a few short years ago that we should go back to the DRE because (paraphrasing here) [if the disease is found by the DRE, we know it needs treating]. Of course, that also meant the vast majority of men would not be cured. And, why is there so little confidence that men can handle PSA testing and a biopsy when needed...and...then make a reasonable and intelligent decision of what they want to do. Some of us value our lives over the "possibility" of incontinence or impotence. PSA testing DOES NOT automatically start us down the road to treatment and living with terrible side effects. We ALWAYS have the option of saying "NO" to further testing and treatment. By the way, I facilitate a Man to Man Prostate Cancer Support group and have lost 9 men from my group in the last 7 years. Someone please tell me that their families don't wish their prostate cancer had been detected when curable.
Posted by: maribob38 | March 30, 2009 1:52 PM
I think reports like this circulating all over the internet could mislead a lot of mean to avoid testing, to their detriment. No mention is made of PSA score acceleration or biopsy results.
My score went from a consistant 1.8 to 3.2 in one year. A retest came back at 3.5, so I had a biopsy last December. Results were cancer with a Gleeson score of 3-3 in one of 12 samples. The original Urologist said prostate cancers are multifocal so there could be more tumors that the biopsy missed. After much research, and considering my age of 65 and good health, I chose to have a radical prostatectomy at UCLA, which happened last week.
Came thru surgery fine, post biopsy showed cancer in all 4 quadrants with Gleesons of 3-3. IMHO, these would only have been a source of trouble later, so I am glad I did the RPP.
Now, if I could just lose this %$#@@#$% catheter, life would be good. Only 6 more days, but who's counting?
Posted by: Peterlech | April 1, 2009 3:48 PM
The purpose of this article is to indicate how PSA testing saves lives by detecting PC in its early stages. Biopsies and any subsequent treatments are typically performed based on various PSA values such as PSA density and velocity (PSAV). Because of a recent annual PSAV of 0.9, I have researched this topic using the internet and through the use of testbooks(including Dr. Walsh's) for over a month and found that the information in this article is totally correct. It was interesting to note during my research how many MD's still think that a PSA value under 4.0 is still acceptable, regardless of PSAV. I have a biopsy scheduled in the next couple of weeks at a facility other than JH but I will use this facility if the results are positive.
Posted by: 12oreo | April 30, 2009 7:03 AM
Peterlech wrote- I think reports like this circulating all over the internet could mislead a lot of mean to avoid testing, to their detriment. No mention is made of PSA score acceleration or biopsy results. My score went from a consistant 1.8 to 3.2 in one year. A retest came back at 3.5, so I had a biopsy last December. Results were cancer with a Gleeson score of 3-3 in one of 12 samples. The original Urologist said prostate cancers are multifocal so there could be more tumors that the biopsy missed. After much research, and considering my age of 65 and good health, I chose to have a radical prostatectomy at UCLA, which happened last week.
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Peter, the article addressed PSA score acceleration in this sentence:
"I think a lot of the overtreatment we see has to do with using PSA as an absolute cutoff. I think PSA velocity, how fast the PSA moves over time, may be a better measure of the presence of lethal cancer".
Posted by: 12oreo | April 30, 2009 7:37 AM
had 42 radiation treatments 2 years ago. psa number was .29, tHEN WENT TO 1.25 AND AS of last week it is 3.0. have an appointment with a uroligist and my other doctor will do blood work in 30 days. the colonoscopy six months ago show everything is good. i am confused and concerned ; the radiation dr. suggested "we still have chemo.:" This is scary when there is no sign of cancer other thanthe increase in psa #
Posted by: rhett1934 | February 12, 2011 7:15 AM
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I read with great interest your report on psa testing etc etc and perhaps the overkill of treatments for prostate cancer. Ironically just last week a close friend of mine, a retired Professor of BioChemistry at Boston College and I were discussing psa scores and he emphatically stated that a low psa reading meant nothing, stating that even with a low reading things could be going on in the prostate that were not to the benefit of an individual. As your article stated, bottom line, their is much more studies to be conducted before a positive handle on prostate cancer can come to the forefront of detection and treatment. The article was interesting and simply reinforced what my Professor Friend articulated.
Posted by: nick cercone | March 28, 2009 7:38 AM