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

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.

Add a Comment

We welcome your questions and comments. Because this is a public forum, please do not include contact information or other personal details. Also, keep in mind that while we can provide general information and resources, we cannot offer personal medical advice. To make an appointment with one of our experts, contact our Physician Referral Service at 800-525-2225 or online.
Your e-mail address is kept private and will not be shown publicly.

More information about formatting options