Prostate Awareness Foundation

Prostate Self Help

Monthly Bulletin

April 2009

To PSA or Not To PSA, That Is The Question:

Are you glad you had an initial PSA test or do you wish you never had taken one? If you are like most of us, that’s a question men all over are asking themselves. But it’s a difficult one to answer.

Two recent research studies in the New England Journal of Medicine are creating a debate among health professionals and men all over about the efficacy and validity of PSA as a diagnostic tool. These recent reports on the interim results from two of the most rigorous studies to date on prostate cancer screening (PSA testing) have failed to bring any clarity to one of the most contentious issues in men’s prostate health.

The two studies, one on 182,000 European men and the second on 77,000 men in the United States yielded a host of contradictions and have done nothing to clear up this issue. The North American study (See March 18, 2009 NEJM – Mortality Results From a Randomized Prostate Cancer Screening Trial) of men between the ages of 55 and 74 showed no reduction in death from prostate cancer attributable to PSA screening during a ten year period. The European study (See March 26, 2009 – Screening and Prostate Cancer Mortality in a Randomized European Study) of men between the ages of 55 and 69 showed a 20% reduction in death among those who had a PSA test. However, the European study highlighted the concern that for every life saved, 1,400 men needed to be screened and 48 men would need aggressive treatment to result in reducing the death rate by one individual during a ten year period. Another way to look at this study would be that 47 men who had a PSA test followed by radical prostatectomy or radiation may not need it. These men would have to undergo the possibility of impotence and incontinence. Many men feel this is too high a price to pay for a disease that was not going to cause any harm!

PSA testing has been a controversial subject at least since the early part of this century. Thomas Stamey, MD, at the Stanford Medical Center is considered one of the founding fathers of PSA testing going back to the 1980’s. He has said for the past few years that the PSA era is over. He feels that the disease is age related and the PSA test is no longer a valid assay for prostate cancer diagnosis. (See his article on this subject archived at in the Clinical Information section). Dr Stamey does feel however, that the PSA test is still an important tool in gauging disease progression once diagnosed and also to determine whether a treatment has failed.

Peter Carroll, MD is the chief of Urology at UCSF Medical Center in San Francisco and is a well respected expert on prostate cancer. He has been saying for the past few years that we are over diagnosing and over treating prostate cancer. (See his article on the subject at the PAF website, also in the Clinical Information section).

At last September’s PCRI Symposium on Prostate Cancer, the most prominent and highly respected prostate cancer specialists agreed that between 27% and 56% of men are being over treated for a disease that probably will not progress. Another alarming statistic reported by Dr Carroll is that upwards of 92% of men diagnosed with prostate cancer that probably would not progress, still opt for aggressive treatment. Why? Most likely because of their personal fear, and the fears of their family in regard to the possibility of disease progression and death.

The major problem with prostate cancer screening tests, including the PSA test is that there is no test at this time that can clearly determine which men will progress and which men will not. Until a test of this nature is available the controversy will continue.

The Combidex test is not approved by the FDA, but available in Holland. This test does appear to offer more conclusive information on disease progression. Prominent prostate cancer specialists agree that this test needs to be fast tracked by the FDA and made available here in the United States.

Here at the PAF, we have had concerns about PSA for a number of years. At the foundation, we regularly talk to men with PSA scores over 10, and in some cases over 100 who do not appear to be progressing. Correspondingly, there are many men with supposedly low PSA scores under 4.00, who seem to have aggressive prostate cancer. Could it be that every man has his own “normal” PSA level and that it’s doubling time (PSA velocity) is the real key?

Ken Malik and Robert Gumpertz, the co-founders of PAF and both fourteen year veterans of prostate cancer have said for some time that the longer they look at PSA testing the less is clear. PAF has recommended for some time that men need other markers besides PSA in order to make a valid decision about how to proceed after diagnosis. These markers and other tests, at the minimum should include: DRE (digital rectal exam), Color Doppler Ultrasound test, Free PSA and personal PSA velocity.

(most pc specialists agree that if a PSA value doubles in less than 2 years, that something is going on and further tests are necessary.)

Personally, Ken is glad he had a PSA test in 1995, even though it led to a prostate cancer diagnosis. Without this information, Ken would not have made the lifestyle changes he did and feels that there is a good chance that he might have succumbed to prostate cancer. Instead he has been able to avoid conventional therapy and retain his quality of life.

With the new controversy generated by the recent NE Journal of Medicine clinical studies, PAF has been regularly addressing the subject with its membership. Many men we’ve talked to feel that PSA testing, although not perfect, continues to have value in keeping the prostate cancer death rate low. Many others tell us they wish they had never had a PSA test and undergone treatment with its quality of life changing side effects.

Rick Mohovich is a prostate cancer veteran of almost 12 years, he is a regular participant in the annual Cancer Climb for Prostate Awareness expeditions and a knowledgeable proponent of PSA testing. Rick feels his prostate cancer diagnosis after a high PSA reading was a wake-up call and instrumental in his decision to take a more participatory part in his prostate health. Rick has adopted the PAF strategy of life style changes as an adjunct to his conventional prostate healing.

Jan Zlotnick, RN a long time prostate cancer veteran and a member of the PAF board of director’s feels that the PSA number itself is not as important as what one does with the results. He feels that this process should include due diligence on one’s options before plunging into a protocol, if at all.

We believe that H. Ballentine Carter, MD, Director of Adult Urology at the Brady Urological Institute at Johns Hopkins, offers a sane approach to PSA testing. It is his feeling that PSA velocity is really the key to a more realistic treatment path decision. To best determine one’s personal PSA velocity his recommendation is that one establish a baseline for their PSA starting at age 40. A follow-up test should be given at age 45 and again at age 50. He feels this is a sensible way to establish the PSA velocity. Combining that information with age, size of the gland and the free PSA test will indicate more conclusively the risk of developing prostate cancer and help determine if one should undergo a biopsy. So approach would reduce the number of unnecessary biopsies.

So what’s a man to do? PAF’s experience, after talking to so many men over the past ten years is that PSA does save lives! We’ve talked to far too many men that waited too long to be diagnosed before they found out that they had advanced prostate cancer.

PAF feels that health professionals specializing in prostate cancer need to spend time explaining the ramifications of a high PSA test to all men before having them undergo the test. A shared decision making approach to PSA screening between doctor and patient appears to be a sane approach to this ongoing controversial test.

Your view and feedback on this controversial issue is encouraged and appreciated.