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Vital Signs

 
Summer 2009

Prostate - Specific Antigen (PSA) Questions & Answers with Dr. Robert Reiter

06/17/2009

DR. ROBERT REITER

Professor of Urology and Director of the Prostate Cancer Treatment Program at UCLA

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. Robert ReiterDR. REITER: The reason that prostate cancer is controversial is because of the difference between the number of men who are diagnosed each year – 220,000 to 230,000 – and the number of men who die from it – about 30,000 – which suggests that there are a large number of men who have this cancer who may not be destined to die from it. So a big issue is trying to understand who among these men needs to be treated, who might not need to be treated, as well as what is the best form of treatment. If used properly, PSA (prostate-specific antigen) screening is an excellent test to detect cancer and can help the doctor and the patient choose the best form of therapy, or whether therapy at all is the right thing to do.

How does it help to make that determination?

DR. REITER: If you have prostate cancer, PSA very often – not always, but very often – will increase as the cancer grows. A PSA that is rising usually is a sign that the cancer is growing, and how fast the PSA is rising can give the doctor and the patient a good sense of the threat that that cancer poses. So we believe that if the PSA doubles in three years or less, then those cancers are much more likely to be harmful than if a PSA changes or doubles every 10 years or so.

But there is some question about the efficacy of screening.

DR. REITER: There have been two large studies that were just reported in Europe and in the United States. Both studies evaluated more than 30,000 men who were randomized to either be screened yearly for prostate cancer with PSA testing, or not. The United States study reported results after 10 years and did not show any benefit to screening. However, the vast majority of men in that study who were not supposed to be screened actually were screened by their family doctors, and so there wasn’t a big difference between the screened and unscreened populations. Also, 10 years is probably too short a window of time to be able to determine the advantages of screening.

In Europe, however, the study very clearly demonstrated the benefit of screening. Screening was shown to reduce the risk of dying from prostate cancer by 25 percent. That was a very clear, positive result that should end the discussion about whether PSA can save men’s lives. The problem, though, even in the European study, is that to save one life, you needed to treat 10 or 15 or 20 or more men. So the controversy is not so much whether PSA screening can save men’s lives, but rather it involves the fact that many men need to be treated to save one life. The controversy is about the concept of over-diagnosis or over-treatment, and the reason that’s controversial is because, like many treatments for many diseases, treatment for prostate cancer, whether radiation or surgery, has complications. And so the question is:: What is the benefit verssus the risk that the average man may get from treatment?

If the issue, in essence, is one of cost-benefit – the cost of over-diagnosis and over-treatment versus the benefit of saving just one life – where does that leave us in the discussion of who should be screened?

UCLA Health Vital Signs publication - Summer 2009 issue: Q & A with Dr. Robert ReiterDR. REITER: The American Urological Association just revised its recommendations, that men should be screened at the age of 40. And the reason for that is that an elevation in PSA, even at that early age, can predict future likelihood of having prostate cancer. If a man has a PSA at the time that is completely normal – let’s say, less than 1 – then he probably should have the test again at ages 45, and then at age 50. Once you hit age 50, the recommendation still is either every year or every two years – I generally recommend every year. If you have a family history of prostate cancer or are African American, the recommendation is to start screening earlier, perhaps even at the age of 30 or 35.

And, with this concept of cost-benefit in mind, if a man’s PSA level is elevated, what should he do?

DR. REITER: He should talk with his doctor. Most urologists are attuned to the issue of screening, and they should be able to discuss these issues with their patients. But if a man doesn’t feel that he’s getting answers or an opportunity to discuss the risks and benefits of treatment, then it is reasonable to get another opinion or to seek the opinion of a urologist who specializes in cancer.

There also are screening tools that are very good adjuncts to PSA testing. Testing for the presence of PCA3, which is a molecule that is produced by prostate cancers but not by normal glands, can be very efficacious. Studies have shown that when PCA3 is found in the urine after a prostate exam, it almost always indicates the presence of cancer. We have begun to use it as a test for men about whom we have a high suspicion of prostate cancer but whose biopsies are negative.

If treatment is required, are there new directions in the approach to treating prostate cancer?

DR. REITER: Because of the results from these screening trials that suggest that we may be treating more men than need to be treated, there is greater interest in what we call active surveillance or watchful waiting, and we have initiated protocols for active surveillance to follow our patients who are good candidates for this approach in the early stages of their disease. And we are one of the first centers to integrate magnetic resonance imaging, ultrasound and other imaging technologies into our practices. So if surgery is necessary, that helps me to better determine whether I can preserve a man’s sexual nerves or not, and it has improved the results of the surgery accordingly.

In the later stages of the disease, advances in management and drug management have evolved that are very exciting. At UCLA, we developed one of the new drugs for advanced prostate cancer that’s now in clinical trials, Medivation 3100. Another drug, Abiraterone, is also being tested in multiple groups of men. There are also dietary programs – UCLA is the leading center exploring the use of pomegranate juice in managing prostate cancer – and there are vaccine trials that have reported positive findings.

What is the outlook for the future?

DR. REITER: I think there’s more reason for optimism than ever before. When I came to UCLA, in 1995, we really only offered conventional radiation therapy and open radical prostatectomy, and we had maybe one or two people working in the field. Since then, we have grown the program. The National Cancer Institute has designated us as a specialized program in prostate cancer, which signifies that we have unique skills and experience in the management of prostate cancer. We have a comprehensive program, with medical oncologists, radiation oncologists, surgeons, radiologists, nutritionists, therapists, all working together to manage this disease. So there’s a huge reason for optimism for the future that we will identify men who need treatment and that we will treat them appropriately, potentially even in the most advanced stages of the disease.





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