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Vital Signs


Vital Signs

Summer 2009

Prostate - Specific Antigen (PSA) Questions & Answers with Dr. Mark Litwin


Mark S. Litwin, M.D., M.P.H

Professor of Urology and Health Services in the David Geffen School of Medicine at UCLA and the UCLA School of Public Health

There has been a lot of news, and some controversy, about prostate cancer lately.

UCLA Health Vital Signs publication - Summer 2009 issue: Q & A with Dr. Mark LitwinDR. LITWIN: In two large, randomized studies – one in the United States and one in Europe – half the men were screened regularly with prostate-specific antigen (PSA), which measures levels in the blood of a protein that is produced by the prostate in the presence of cancer, and half of the men were not screened regularly, and only received their usual care. The researchers were looking to see if there was any difference in prostate-cancer diagnoses or death rates in the two groups in the studies, in an attempt to answer the question, if we recommend routine screening, does it end up improving outcomes? And basically, what the two studies show is that if you are screened regularly, you’re more likely to be diagnosed with prostate cancer, but the question of whether you are less likely to die from prostate cancer is a lot less clear.

It seems like it would a no-brainer for most men – there’s this simple blood test available, and it’s easy to take and relatively inexpensive, so why wouldn’t I do it? The problem that arises, however, and the reason I don’t think it’s advisable to recommend this test to every single man who walks in off the street, is that, even though the test is pretty cheap, there’s a lot involved in working up a positive test. So let us say that a normal PSA for a typical man is between 0 and 4, and a man has result of 12, then it’s a pretty easy call of what to do to follow up on that – arrange for a biopsy of the prostate and see if there’s cancer there. But many men come in with a PSA of 4.3 or 4.9. It’s not so clear there, and there’s a lot of uncertainty about whether someone in that situation needs to have a biopsy or not.

Now let’s assume we’ve made a diagnosis of prostate cancer; we’re not entirely sure whether we should even treat it, never mind how to treat it. Because for the vast majority of men, prostate cancer is a slow-growing tumor and asymptomatic, and for many men it becomes a chronic condition.

Is the age of the patient a factor when making a determination whether or not to treat the cancer?

UCLA Health Vital Signs publication - Summer 2009 issue. Q & A with Mark S. Litwin, MD, MPHDR. LITWIN: Yes, it can be. For the vast majority of men, prostate cancer is diagnosed when they are nearing the final decade of life. The average life expectancy in this country is in the 80s, and if a prostate cancer is diagnosed, let’s say, in a 75-year-old, then this is where the difficulty in decision-making often comes in – what to do with that information? Because it is a slow-growing tumor, the likelihood is that something else is going to lead to that patient’s death before the cancer does. At that point in a man’s life, screening really confers no benefit.

What about younger patients?

DR. LITWIN: The studies do suggest that it makes more sense, if you are going to do prostate-cancer screening, to do it earlier in life when there is a potential for a lot more gain. Forty, which is the one common recommendation, is a little young to begin screening, I think, but if you find out at age 48 that you have prostate cancer, it probably does make a difference in terms of your decision-making and long-term survival. If there’s any group for whom at least a baseline screening makes sense, that would be for younger men.

When do you think it is good to get a baseline screening?

DR. LITWIN: Maybe at age 45, and if the PSA is not significantly elevated, then maybe get another one at age 50, and if it continues to be within normal limits then perhaps every two or three years until the mid-60s. Too many men go for screening every year into their 70s and 80s, and that’s too much. Even if prostate cancer is identified in a 48-year-old, it tends to be a slow-growing tumor. So now we are doing more of what’s called active surveillance; we are tracking the patient and doing PSA tests and prostate exams to monitor how the tumor is growing. If the patient is aging through his life faster than the tumor is growing, then we may not need to do anything about it. But if the tumor appears to have become an aggressive cancer, then it may need to be treated. Prostate cancer is like the cat family – there are housecats and there are tigers. The housecats will never bother anybody. The tigers, on the other hand, will get you.

How do you know if a tumor is a housecat or a tiger?

DR. LITWIN: The problem is we don’t immediately know which cat it is. It is true that we may have some idea – if we’ve got a high-grade tumor diagnosis with a PSA of 18 or 19, we have a pretty good idea that’s a tiger that needs to be treated. But for the vast majority of tumors, we really can’t tell which are the housecats and which are the tigers. We think most of them are housecats. And so even though we live in an age when the surgery and the radiation treatment for prostate cancer are outstanding and can be performed with minimal effect on quality of life, the treatment itself can still sometimes be worse than the disease.

How does a man trying to figure this out balance the risk-benefit equation?

DR. LITWIN: That’s an important and ultimately very personal question. Most men want to maintain their sexual function, their urinary function, their intestinal function. And many older men are already beginning to deal with age-related changes, and they want to maintain what they have. So for some men, it comes down to a choice: Do you want to potentially die from the prostate cancer or do you want to take a risk of losing sexual or urinary function? Mind you, the outcomes at a comprehensive, experienced and high-quality teaching institution like UCLA are much better than you might find elsewhere, but you still have the issue of why put yourself at any risk for side effects if the tumor is a slow-growing, low-grade housecat type?

This still leaves men with some confusion over the issue.

UCLA Health Vital Signs publication - Summer 2009 issue. Q & A with Mark S. Litwin, MD, MPHDR. LITWIN: Men need to sit down with their doctors – perhaps their primary-care physician more so than with an urologist because the primary-care physician has more comprehensive knowledge of the patient and his health history – and talk about these things, and have a frank discussion about the issues. The era of when patients were more passive about their healthcare decisions is gone. Today, patients need to be more actively involved in a variety of different healthcare decisions, including that of prostate-cancer screening. Studies can give us valuable information, but when the patient is behind the exam-room door with his doctor, all the decisions that have to be made are very personal and are informed by that patient’s life experience.

I don’t think that screening is necessarily a good idea for all men, but the men for whom it is a good idea, in my view, are those men who have a family history of prostate cancer, and those for whom there is a racial predisposition, i.e. African-American men, and particularly if they have a family history. On the other hand, Asian men tend to have much lower rates of high-risk prostate cancer, so for them screening may not be as important.

And then once a diagnosis has been made, or an elevated PSA has been obtained, then it’s really critical to seek out advice and consultation, usually from a urologist, who can provide thoughtful input on whether to have a biopsy, and if a diagnosis of cancer is made, whether to treat and if so, how to treat.

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