Paul LaFontaine, MD, a urologist with Emerson Urology Associates in Concord, answers questions on the role prostate-specific antigen (PSA) screenings play in detecting prostate cancer.
There were headlines in the spring about new guidelines for prostate-specific antigen (PSA) testing. Was this newsworthy?
Yes, because the announcement from the U.S. Preventive Services Task Force (USPSTF) brought its recommendation more in line with what other major professional groups have been saying for some time: that a decision about PSA screening for prostate cancer should be made after discussion between a patient and his physician.
Now the USPSTF, American Urological Association and American Cancer Society (ACS) all pretty much agree that men between ages 55 and 69 might benefit from having a PSA test.
The ACS recommends that PSA testing be considered beginning at 50 and in men in their 40s if they have a strong family history of prostate cancer. I’ve diagnosed patients in their late 40s with advanced prostate cancer, so I agree with this.
Have your patients been confused about whether or not to have the PSA test?
Yes, because it was the standard screening for a number of years. Five years ago, the USPSTF, an independent panel of experts, recommended against routine PSA screening. The fact is, the PSA test has limitations. The higher the score, the more predictive the test is. Certainly a lot more men are diagnosed with prostate cancer than die of prostate cancer — only one in six do — and there are men with prostate cancer who don’t require treatment.
For example, in performing a biopsy, we use the Gleason grading system, with scores of 2-10 to determine a patient’s prognosis. Many men with Gleason 6 or lower prostate cancers will have very slow-growing cancers that don’t require aggressive treatment.
What needs to be covered during the patient-physician discussion about PSA testing?
We discuss the patient’s family history. If someone has a strong family history of prostate cancer, or if they are African-American, we direct them toward screening beginning at age 45. Once the PSA test has been performed, we tend to categorize patients according to the most current data. If a man’s PSA number is between 4 and 10, there is a 25 percent chance that he has prostate cancer. If a 65-year-old man has a PSA of 9.9, he might want to be proactive, and we discuss further screening and possibly a biopsy. If that same guy had a PSA of 4.1, it may be more reasonable for him to take a conservative approach to his PSA and monitor it over time.
For some men, is active surveillance the right approach?
It usually is for low-risk guys. Active surveillance, also known as “watchful waiting,” typically consists of PSA testing, an examination and possibly a repeat prostate biopsy to make sure that his cancer hasn’t progressed. One of the problems with PSA screening in the past is that we over-diagnosed people and, as a result, over-treated them. That’s because the test originally was developed as a way to follow men who had been diagnosed with prostate cancer; we later determined the test had limitations.
Today, many men avoid radiation or surgery in favor of active surveillance, which can help them decide to delay treatment. The more fortunate men will never require treatment.
Are there any new ways of diagnosing or monitoring prostate cancer?
There is an alternative to the PSA test, called the 4Kscore, which combines four biomarkers with clinical information to stratify a man’s risk. The Prostate Health Index consists of three blood tests that produce an overall score that helps interpret a high PSA test score. Today MRI scans are being used to evaluate men who have an elevated PSA. If a man says, “my PSA is high, but I don’t want a biopsy,” we can consider performing an MRI. If the results look good, we assume he is fine. If not, we obtain a biopsy.
I believe that, eventually, there will be a molecular test that analyzes a man’s DNA to determine the presence of specific proteins or a sequence of proteins. Based on that information, we will be able to answer the question: treat or don’t treat?
For more information on Emerson Urology Associates or to schedule an appointment with Dr. Paul LaFontaine, call 978-287-8950.