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Should Prostate Cancer Screening Stop at Age 75?

         

Aug. 25, 2008 — Siteman Cancer Center urologist Gerald Andriole, MD, discusses prostate cancer treatment advances, including a brand-new "male lumpectomy" procedure, and reacts to a recent study suggesting men over 75 shouldn’t receive PSA screenings.

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TRANSCRIPT OF AUDIO FILE

On this edition of Cancer Connection, we’ll talk about prostate cancer, who should get a PSA test and new procedures that are helping men beat the disease.

Host: Thanks for downloading this podcast from the Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine in St Louis. I’m Jason Merrill. In August, the U.S. Preventive Services Task Force said men over 75 should avoid PSA screening because it leads to unnecessary anxiety, surgery and complications. The decision led to some controversy with men over 75 who are now prostate cancer survivors. To talk with us about the recommendations and also the future of prostate cancer treatment is Gerald Andriole. Dr. Andriole is chief of urology at Barnes-Jewish Hospital and Washington University School of Medicine. Dr. Andriole, thank you for joining us.

Andriole: It’s a pleasure to be here today.

Host: So what do you think of the task force recommendation?

Andriole: Well, I think the task force was put in a pretty difficult position. You have to understand that the group of people involved in the task force are actually wearing the hats of health economists more so than the hat of a doctor taking care of an individual patient. And why do I think that’s significant? Well, they’re sort of right to say, boy, the average 75-year-old man probably won’t live very long, and the average 75-year-old man, if he gets prostate cancer, it’s probably not going to be an aggressive one that’s going to be lethal in a short period of time. So when you sort of crunch the numbers in that way, it’s easy to say, you know, 75-year-old men shouldn’t be screened for prostate cancer.

But every doctor who’s taking care of patients knows that there are 75-year-old men who are in terrific shape. I have several patients in the area here who are avid annual participants in the Senior Olympics, and these guys are going to have a better chance of living 15 and 20 years than I do, quite frankly, because they’re in such tip-top shape. So I think that to be fair, you know, the task force was sort of looking at the averages at a societal level at a group of men, and what they said is true to that extent. But boy, when it comes time to dealing with an individual patient, I think the doctor and the patient must individualize what they do because men who are healthy and have a long life expectancy at the age of 75 should in fact be screened for prostate cancer.

Host: So as not all 75-year-old men are unhealthy people, what has the patient reaction been? Have you had patients who said this doesn’t make any sense to me?

Andriole: Absolutely. I mean, I’ve had plenty of patients say that they don’t want to stop being screened, that they have a lot of reassurance when their PSA levels are low. By and large, most of the men who see their doctors are very conscious of their health, and they probably are on average, as we say, above average in terms of their life expectancy because they’ve probably been taking care of themselves for many, many years.

Host: Well, let’s start at the beginning for a lot of people. What is a PSA?

Andriole: Well, PSA is a protein that’s made by the prostate, and if you don’t have prostate cancer, only a small amount of PSA gets into the bloodstream. Most of it comes out normally in the semen when the man ejaculates. But if you have prostate cancer or if you have some other things going on in your prostate, like a big prostate or infections in your prostate, all of those things result in a fair amount of that PSA getting into your bloodstream. And that’s why when we measure it by drawing a tube of blood, the PSA levels tend to be higher in men who have prostate cancer than in men who don’t.

Host: So if you have an elevated PSA, what number is that and what normally happens after that?

Andriole: Well, that’s a rolling target. So if you’re a man in your 60s or 70s, a PSA is probably OK if it’s up to about 4, but if you’re younger than that, a PSA above 2.5 should be considered abnormally elevated and should prompt a visit to your urologist to discuss, gee, why is this PSA higher than normal for that age group and should we go ahead and do a biopsy to look for prostate cancer.

Host: At what age should people start thinking about getting their PSA?

Andriole: Well again, that’s sort of changed a lot. If you back up 10 years ago, it was said, well, start at the age of 50. Then we sort of recognized that there are, again, subpopulations of men who have a higher-than-average risk of prostate cancer. So African-American men and men with a strong family history of prostate cancer should get screened starting at the age of 40. And that’s pretty much a standard guideline.

But if I had a crystal ball and looked into it and said, hey, what are we going to be saying about PSA testing a few years from now? Well, we’re going to just say all men should start getting their PSAs starting at the age of 40, and that will allow them to have a long PSA track record so that we can look not just at the level of the PSA in the blood, as we were talking about before, but also the rate at which that PSA is rising. Because we’re kind of learning that even if a man has a fairly low PSA level, like 2, if it got there over the course of just a year or two, rising from .5 to 1.7 to 2, that’s concerning because the rate of rise was so rapid. And in the future, we’re going to make decisions to do biopsies of the prostate based on the rate of rise of the PSA.

Host: About a year ago, we had talked about another test that was on the horizon that could be a challenger to the PSA. What other test do you see in the future that people should know about that could be a prostate cancer detection tool?

Andriole: Well, there are probably three good ones that we have to keep our eye on. A year ago, there was a lot of excitement about EPCA2, and that excitement is actually still held, and that is still currently under investigation. You have to realize, it takes quite a long time to satisfy the requirements of the FDA and so forth to validate a test. So keep EPCA2 in mind.

The second test is actually a urinary test. So there’s a test called PCA3, which is done on urine that’s collected after the man has a digital rectal exam. The concept of this test is that if there are abnormal DNA molecules in that urine that look like they could have only come from cancer, then you sort of raise your suspicion that that man has prostate cancer and would probably need to undergo a biopsy of the prostate. That test is again not yet FDA-approved in the United States, although the similar organization in Europe has approved it, and it’s really useful for men who initially have an elevated PSA. They might have a biopsy of the prostate that does not show prostate cancer. If this PCA3 test, however, is also abnormal and suspicious, then it gives the patient and the doctor enough concern that they should do another biopsy of the prostate.

And the third test to keep in mind is called proPSA. You probably remember a few years ago there was a lot of excitement about a thing called free PSA or unbound PSA. Well over the years, we’ve kind of figured out that there are several different subtypes of free PSA, and there’s one of them called proPSA that’s probably prostate-cancer specific. This is in the mid-stages of evaluation as well. So I would say for the folks out there, there are these three exciting tests and stay tuned.

Host: If someone is diagnosed, you have minimally-invasive options to help them through the process, correct?

Andriole: Absolutely. You know, there has really been a substantial improvement in how we take care of men who have small prostate cancers that are confined to the prostate. Surgery has certainly gotten a lot better now that there are laparoscopic and robot-assisted laparoscopic approaches, but we’re also looking at just what we’ve been calling a male lumpectomy. In other words, just destroying the cancer in the specific region of the prostate where it is found. All of these approaches are minimally invasive and a substantial improvement over what was offered five to 10 years ago.

Host: A male lumpectomy?

Andriole: Right. We’re sort of coining that term as analogous to women who have breast cancer, where, you know, often you can see the lump on a mammogram or you can feel it when you examine the breast. The surgeons who care for those patients don’t necessarily take off the entire breast. They will do a lumpectomy. We haven’t been able to do that in the prostate until now because our techniques of knowing exactly where the prostate cancer is within the prostate were not sufficient. But we’ve recently developed some biopsy strategies that allow us to have confidence that we know precisely where the cancer is within the prostate. It’s our view that if you have good information on where the cancer is, you can then ablate or destroy that region of the prostate as an outpatient and, in so doing, very likely destroy the entire cancer in that man’s prostate.

Host: Dr. Andriole, thank you very much for joining us.

Andriole: My pleasure, Jason. Thank you very much.

Host: For more information on prostate cancer, you can visit the Siteman Cancer Center online at www.siteman.wustl.edu or call 800-600-3606. Thanks for downloading. Until next time, I’m Jason Merrill.