Q&A

On Cancer: Department of Surgery Chair Peter Scardino on Smarter Screening for Prostate Cancer

Pictured: Peter Scardino Department of Surgery Chair Peter Scardino

Update: Recent news headlines have raised questions about the value of the PSA test, a blood test used to screen for prostate cancer. The debate over PSA and its usefulness can leave men who are at risk for the disease wondering who to listen to and what course of action to take. Does the PSA test lead to overdiagnosis, or does it help detect cancer at an early stage? 

At Memorial Sloan Kettering, we’re always in pursuit of the most accurate information and latest treatment updates. Our doctors and researchers continue to be at the forefront of research into PSA screening, utilizing the most precise data and information available. Below is a blog post that addresses the debate over PSA and MSK’s balanced approach when incorporating these test results into the whole picture of a patient’s health. Stay tuned to our blog for the latest news on prostate cancer screening and treatment.  The long-standing controversy about the value of the prostate-specific antigen (PSA) blood test for the detection of prostate cancer intensified last year when the US Preventive Services Task Force (USPSTF) recommended against it, despite evidence that PSA screening saves lives.

Memorial Sloan Kettering urologist Peter T. Scardino, Chair of the Department of Surgery, recently coauthored an article with research methodologist Andrew Vickers for the American Urological Association’s AUANews, which suggests taking a balanced approach to prostate-cancer screening and treatment.

We spoke with Dr. Scardino to learn more.

What is the prostate-specific antigen?

PSA is a protein made by cells of the prostate gland. Although it’s normal for men to have low levels of PSA in their blood, prostate cancer can increase a man’s PSA levels. Doctors may recommend a biopsy – the removal of cells or tissue from the prostate gland for examination by a pathologist – for men with an elevated PSA level (greater than or equal to 3 ng/mL) or a rising value over time.

However, an elevated or rising PSA level alone does not always mean that a man has prostate cancer. In fact, most of the time an elevated PSA level also comes with age, and with the onset of other, noncancerous conditions such as benign prostatic hyperplasia, in which the prostate is enlarged, or prostatitis, an inflammation of the prostate gland.

Why has PSA screening been criticized?

The problem is that an elevated PSA test may trigger a biopsy that incidentally finds a low-risk cancer that poses little danger to a man’s health and is very unlikely to become life threatening. Most men with such cancers are treated, even though their cancer is not aggressive and might not cause symptoms during the course of their natural lives. These treatments can lead to long-term health issues that impact quality of life. False-positive test results can also result in an unnecessary biopsy that has its own side effects, such as bleeding or infection.

What are the advantages of using PSA testing to detect prostate cancer?

A number of clinical trials have demonstrated that PSA screening can reduce the risk of prostate cancer death by 20 to 44 percent over ten to 14 years when compared with not screening. If testing substantially decreases, deaths from the disease are likely to rise to the high levels seen prior to the widespread use of PSA screening.

Instead of abandoning PSA testing altogether, we should consider better, smarter ways to use the tool to continue to give patients the benefit of early detection and effective treatment for dangerous prostate cancers, while reducing the risk of harm from overdiagnosis and overtreatment.

How can we strike a balance between the harms and benefits of PSA screening?

We can achieve this balance by using a more-selective and targeted approach to screening. Screening efforts should be focused on men who are at the highest risk of developing a life-threatening prostate cancer. This includes men with a family history of the disease, men with a genetic predisposition to prostate cancer, and African American men. 

Older men stand to benefit the least from PSA testing. Research has shown that screening men over age 70 is not likely to be beneficial, but they continue to be screened at high rates.

Memorial Sloan Kettering’s prostate cancer screening guidelines recommend that men have an initial PSA test at age 45. Based on the results of that test, men at low risk for developing prostate cancer can be tested every five years, but men at an intermediate to high risk should receive more frequent evaluations every two years.

How can doctors further reduce the risk of harm from overtreatment of low-risk prostate cancers?

A diagnosis of prostate cancer requires a biopsy, and men should not have a biopsy without a good reason. In fact, most men with an elevated PSA level do not have prostate cancer. PSA levels vary considerably and should be confirmed with a repeat test in six to 12 weeks before a doctor recommends a biopsy.

In the future, new blood markers now in development such as free-to-total PSA ratios, the 4K score,* and the Prostate Health Index may be able to increase the accuracy of PSA testing in predicting the presence of cancer, especially aggressive disease.

When should prostate cancer be treated?

Prostate cancer treatments such as surgery and radiation therapy can lead to long-term problems with urinary, bowel, and sexual function. At Memorial Sloan Kettering, we don’t recommend treating prostate cancer unless it is aggressive.

Many cancers detected with PSA screening are at low risk for progressing and do not need immediate treatment. Men found to have a low-risk cancer should consider active surveillance, or watchful waiting, which involves regular monitoring of the cancer for any signs of progression or aggressiveness.

Active surveillance would also be an appropriate option for elderly men with intermediate-risk cancer, as it has been shown that surgery and radiation are usually of little benefit for men over 70, unless a man is unusually fit and otherwise healthy. Such patients should be carefully evaluated, given a repeat biopsy to rule out more-aggressive cancer, and then followed regularly with periodic biopsies.

If treatment for prostate cancer is indicated, studies show that outcomes are better when it is delivered by high-volume practitioners or at high-volume centers such as Memorial Sloan Kettering, in order to reduce the risk and severity of side effects that may adversely affect a man’s quality of life.  

Urologists and primary care physicians who adopt this overall balanced approach and modify the way they counsel their patients about prostate cancer screening and treatment could help countless men in their care. 

*Disclosure: Drs. Scardino and Vickers are inventors of the 4K score and are involved in its commercial development. Dr. Scardino is a paid consultant to the company to which the 4K score is licensed.

Comments

I was very skeptical of the recommendation to severely limit PSA screening when it was made last year. In my situation, I had a 3.9 PSA score from my 40th birthday physical. Over the next 10 years, I watched my PSA rise every year. I had several biopsies and was diagnosed just short of my 50th birthday. Dr Scardino did my surgery in 1999 after seeing an aggressive rise in the PSA score in just a few months.

Under the "new" guidelines, my cancer probably would not have been caught before it metastasized. Scardino's and Vicker's "smart" recommendation to the USPSTF standards seems like a much more intelligent approach that would reduce cost, avoid unneeded procedures yet use the PSA test in a a way to continue to save lives. Today, I'm prostate cancer free and living a normal life. Other men have that right as well.

I had yearly PSA screenings and 8 years ago my PSA went up from a normal 1.3 to a 3.9. My local Urologist suggested we wait and monitor but I insisted on a Biopsy which revealed Cancer. I went to SK and had surgery by Dr James Eastham and I am now cured. I recommend PSA test every year , especially for those men over 50 years old.

Dear Professor Scardino,
I am Urologist in Spain. What do you think is the right treatment for a high risk patient, diagnosed with PSA of 580 ng/ml but without imagen of metastasis? A local treatment is justified?
Thank you in advance

Hi Cesar, we are not able to answer individual medical questions on our blog. If your patient would like to get a second opinion from a Memorial Sloan-Kettering doctor, we recommend that he goes through our International Center. You can find more information at http://www.mskcc.org/cancer-care/international-patients. Thank you for your comment.

Dr. Scardino,
I have read that performing a 3 Tesla multiparametric MRI with spectroscopy
will pinpoint areas of concern for cancer in the prostate.
After the areas are identified a limited TARGETED biopsy
is performed instead of the usual 12 sample TRUSS biopsy.
Is the above suggested by and performed at Memorial Sloan.
If you have time to answer - your opinion would be appreciated.

John, we have forwarded your question to Dr. Scardino and will post a response if we receive one. Thank you for your comment.

John, Dr. Scardino provided this response to your question:

MRI is a valuable test to identify cancer within the prostate, but it is not perfect, and we generally do not use it before doing the first biopsy in a man with an elevated PSA, especially if the digital rectal exam is abnormal. I would suggest an MRI if you've already have one or more biopsies negative for cancer, but your PSA is persistently elevated. It is still a controversy whether to biopsy only the abnormal areas on MRI, i.e., targeted biopsies, or to do systematic biopsies as well. We generally do both to avoid missing an aggressive cancer.

i am 76 and recently my psa was 4.68 and 4.00 in 2012 i have bhp for a long time my free psa is 43. do you recommend a biopsy

Richard, unfortunately we are unable to answer specific medical questions on our blog. If you would like to make an appointment with a Memorial Sloan Kettering physician, please call our Physician Referral Service at 800-525-2225 or go to http://www.mskcc.org/cancer-care/appointment. Thanks for your comment.

When is "saturation biopsy" under anesthesia indicated and how do patients recover?

Allan, for more information about this procedure we recommend you call the National Cancer Institute's Cancer Information Service at 800-4CANCER. If you'd like to speak to a doctor at Memorial Sloan Kettering, you can call 800-525-2225 or go to http://www.mskcc.org/cancer-care/appointment for more information on how to make an appointment. Thank you for your comment.

Is the 4k score available?

Allan, Memorial Sloan Kettering is not offering the 4k score test at this time. Thank you for your comment.

Dear Dr.Scardino, what about new test which save from,same times, unnecessary biopsy operation--PROLARIS TEST or DCA 3 ? Are they performing in Memorial Cancer Center? Thank You for Your answer.

Vladimir, we passed this question on to MSK prostate surgeon James Eastham (Chief of the Urology Service) who responds: The PCA3 test is used in the setting of a man with an elevated PSA with a prior negative biopsy to determine if a repeat biopsy is warranted; we do offer this test at MSK. Prolaris is a genetic test (not yet FDA approved) used in the setting of a prostate biopsy that shows low risk cancer to determine if the genetic profile is consistent with low-risk cancer. This is offered at our center.

Dear Dr. Scardino,
The PCA3 test has been criticized for detecting the level of likelihood of prostate cancer in men with negative biopsies because 1) the test does not differentiate between non aggressive cancer and aggressive cancer and 2) there are urologists who use PCA3 test results to encourage patients with a history of negative biopsies to have a saturation biopsy which may simply confirm non aggressive cancer but create a serious risk of infection from such a biopsy. How do you react to such criticism? Secondly, given the fact that the new 4Kscore Test is also a predictive test, do you recommend a saturation biopsy if a patient with prior negative biopsies, but an elevated PSA and a 4K score indicating a risk of aggressive cancer has a fusion biopsy using the guidance of a multriparametric MRI where the biopsy is again negative? In summary then, is there not a risk that the 4Kscore test could actually lead to needless biopsies, especially a saturation biopsy, which prove negative and do not confirm what is essentially a predictive algorithm? Thank you very much for your time and consideration.

Dear Peter, we forwarded your inquiry to Dr. Scardino and he responded:

"Dear Mr. Levine:

Thank you very much for your comment regarding the PCA3 test. I agree that the PCA3 test distinguishes between the presence and absence of cancer, but is not very good at characterizing the seriousness of the cancer. It should be taken in context of all the other data, including the PSA changes over time, the free PSA, the physical examination, and MRI results. We rarely recommend a saturation biopsy today.

The 4K score, I believe, is quite different. It has been shown to be much more predictive of the presence of a high-grade (Gleason 7 or higher) cancer than the presence of any cancer, and can actually help distinguish between the two. When one sets a threshold for the presence of a high-grade cancer, such as 10%, one can reduce the number of biopsies indicated by an elevated PSA alone by about 50%. I would not recommend a saturation biopsy in someone with an abnormal 4K score and an elevated PSA who had prior negative biopsies, but I would recommend an MRI of the prostate with guided biopsies of any suspicious abnormal areas. A saturation biopsy is rarely indicated.

Consequently, I think the 4K score would not lead to more saturation biopsies with consequent risk of bleeding or infection, but to fewer biopsies overall.

I hope this information is helpful

Sincerely,
Peter Scardino, MD"

Thank you for your comment.

Does Sloan Kettering use the 4K score test?

Dear Stuart, we checked with Dr. Scardino and he said that the 4k score test is still in development and not being used clinically at this time. Thank you for your comment.

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