Johns Hopkins Response to 2 Recent PCa Studies

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Date Joined Sep 2008
Total Posts : 4271
   Posted 3/27/2009 6:31 AM (GMT -6)   
Hello All:
Shown below is the response from one of Hopkin's most respected docs.  As you will see, the bottom line suggests continued PSA testing.

The recent contradictory studies of more than 240,000 men published in the New England Journal of Medicine (NEJM) about the effectiveness of using the prostate specific antigen (PSA) test for reducing death from prostate cancer left many men and physicians confused, upset, disappointed, and wondering what they should now do. One study reported that PSA saves lives, while the other noted no benefit whatsoever. To help our readers with this confusing data, we asked H. Ballentine Carter, M.D., Director of Adult Urology at the Brady Urological Institute at Johns Hopkins, to provides his thoughts. Here's are Dr. Carter's remarks.

Granted, while both studies had their particular limitations, the PSA test has its own limitations. For example, an elevated PSA can be a tip-off to a lethal cancer, but it can also detect less aggressive cancer that may never cause harm. Since we don't yet have a definitive test that can tell the difference, and may not for many years, most prostate cancer experts believe that this cancer is now not only over diagnosed but also over treated.

Does the PSA test save lives -- according to the American Cancer Society, 288,000 men died from prostate cancer in 2008 -- or does it merely subject a large number of men with elevated PSAs to unnecessary surgery or radiation with side effects that can include urinary incontinence, erectile dysfunction, and irritative urinary and bowel symptoms? Doctors and patients alike have always wanted to know the answer for years, and they were hoping that these randomized trials would provide them. Unfortunately, they did not.

According to H. Ballentine Carter, M.D., Director of Adult Urology at the Brady Urological Institute at Johns Hopkins, the studies will not end the controversy surrounding the PSA test, a blood test that millions of men have been taking since it was first introduced in the late 1980s. It's currently estimated that 25 million PSA tests are performed annually in the United States."I am not sure that we learned a tremendous amount from the NEJM studies," admits Dr. Carter. "We already knew that we were over diagnosing and over treating this disease. Now we have numbers to document the extent of over treatment."

The studies published in the NEJM, from large randomized studies performed in North America and Europe, yielded contradictory results. An early analysis of the North American study of 77,000 men aged 55 to 74, which is still ongoing, showed no reduction in death from prostate cancer attributable to prostate cancer after seven to 10 years of follow-up.

However, the European study of 182,000 men aged 55 to 69, which is also ongoing, showed a 20% reduction in death among men who had PSA testing. For every life saved, however, 1,400 men need to be screened and 48 would need treatment following a positive PSA and digital rectal exam to result in one fewer death during a 10-year period.

Another way to look at it: 47 men who had a PSA test followed by surgery or radiation for their cancer may not have needed it, and many might go on to have urinary and erection complaints. In harming their quality of life while ostensibly protecting them from cancer, some men might say that this is too high price to pay for a disease that was not going to cause harm.

However, further follow-up could demonstrate a greater benefit of PSA screening and reduced harm as we learn more about the ability of PSA testing to prevent other outcomes, such as the development of metastatic disease and local progression of cancer that requires treatment. In addition, since prostate cancer takes a long time to progress, the 20% reduction in prostate cancer mortality found after 10 years could be higher with longer follow-up.

"PSA screening is certainly not perfect, but it is clearly saving some lives," says Dr. Carter. "If an individual is thinking about being tested, we now have some numbers to give him and he can make up his mind whether or not to be tested. If a man wants to continue to be tested, that's certainly reasonable. "

Once a man knows the risks and the trade-offs, he may or may not want to have a PSA test. "Americans are not like Europeans," concedes Dr. Carter. "We tend to be aggressive about wanting to know more. In spite of these new reports, I still think most men will still want to have the PSA test."

In light of these new studies, what should a man do? Says Dr. Carter: "I like what Dr. Michael J. Barry, M.D., medical director of the John D. Stoeckle Center for Primary Care, said in his NEJM editorial about the studies. He wrote, "The implications of the trade-offs reflected in these data, like beauty, will be in the eye of the beholder. Some well-informed clinicians and patients will still see these trade-offs as favorable; others will see them as unfavorable. As a result, a shared decision-making approach to PSA screening, as recommended by most guidelines, seems more appropriate than ever."

Bottom line: What the studies point out is that right now we still don't have a one-size-fits-all type test. While Dr. Carter believes that the value of the PSA test is still debated, until we have a better biomarker test that can differentiate inconsequential from lethal tumors, the PSA test needs to be used more judiciously. "I think a lot of the overtreatment we see has to do with using PSA as an absolute cutoff. I think PSA velocity, how fast the PSA moves over time, may be a better measure of the presence of lethal cancer.

"Doctors can get a lot more information if there is a PSA history, which is why I believe getting a baseline PSA at a younger age is a reasonable thing to do.," says Dr. Carter. "I recommend that all men should have an initial PSA test starting at age 40. A follow-up test should be given at age 45 and then again at age 50. Combining that information with the patient's age, size of the gland, and the free PSA test, should improve the accuracy of the PSA test. This will indicate their risk of developing prostate cancer.

"While not precise, it offers the best indication we have so far about the presence of cancer and what should be done," he says.

Age 62
Gleason 4 +3 = 7
PSA 4.2
2 of 16 cores cancerous
Brachytherapy December 9, 2008.  73 Iodine-125 seeds.  Procedure went great, catheter out before I went home, only minor discomfort.  Regular activities resumed, everything continues to function normally as of 3/6/09.

Steve n Dallas
Veteran Member

Date Joined Mar 2008
Total Posts : 4848
   Posted 3/27/2009 7:10 AM (GMT -6)   
Nice article.

Age 54   - 5'11"   205lbs
Overall Heath Condition - Good
PSA - July 2007 & Jan 2008 -> 1.3
Biopsy - 03/04/08 -> Gleason 6 
06/25/08 - Da Vinci robotic laparoscopy
Catheter in for five weeks.
Dry after 3 months.
10/03/08 - 1st Quarter PSA -> less then .01
01/16/09 - 2nd Quarter PSA -> less then .01
Surgeon - Keith A. Waguespack, M.D.

Elite Member

Date Joined Oct 2008
Total Posts : 25393
   Posted 3/27/2009 7:17 AM (GMT -6)   
Sounds like a balanced opinion from a good source
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5
3rd Biopsy Sept 08: Positive 7 of 7 cores, 40-90%, Gleason 7, 4+3
Open RP surgery 11/14/8, Right nerves spared, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9 .05, 6 month on 5/9

Regular Member

Date Joined Nov 2008
Total Posts : 65
   Posted 3/27/2009 10:50 AM (GMT -6)   
Thanks for bringing this article to our attention. It brings some sanity to the argument. My local urologist had an opinion about these articles and stated "The doctors providing opinions do not have a face to face relationship with patients and are the moral equivalent of bean counters".

In a litigious society such as ours it behooves the physician to err in favor of over-treatment. Although basic prostate cancer treatment is full of patient options, not enough want to take full responsibility for their selection and prefer the first physician (urologist) choose for them. It is difficult for many to read, digest, and make an educated choice that does not include an X factor. I suppose your crystal ball is as cloudy as mine. If you were the physician, what would you do ?
Dx'd 1999, Age 60, PSA 43, Gleason (3+4=7), T3c
42-3d EBRT w/Lupron/Casodex for 24 months and PSA remaining to be <0.1 for the entire 24 month period.
July 2001 - 2nd opinion required to go intermittent ADT.
MDAnderson biopsy revised Gleason (4+5=9).
Intermittent ADT, Lupron only, with PSA threshhold established at 1.0.
March 2007 - Diminishing returns with Lupron, conferred with MDA urologist for bilateral orchiectomy. Uro asked for biopsy of prostate again. Biopsy resulted in tumors found with Gleason (5+4=9).
August 2007 - RRP and bilateral orchiectomy. PSA <0.1
99% continent immediately
September 2008 - PSA 0.45
November 2008 - PSA 0.67
December 2008 - Resume Casodex
December 2008 - Stricture in bladder neck requiring surgical removal. 99% incontinent immediately.

Life is not waiting for the storm to pass, it's learning to dance in the rain.

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