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  • Men's Health
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  • Prostate Cancer

Risk Assessment in Prostate Cancer: The PSA Test


Key opinion leaders in urology provide an overview of the prevalence of prostate cancer and discuss the importance of screening and risk assessment tools like the Prostate-Specific Antigen (PSA) test.

David Albala, MD: Hello, and welcome to this UroView™ video series titled “The Role of Liquid Biomarkers for Early Detection for Prostate Cancer.” I’m Dr David Albala, the chief of urology at Crouse Hospital in Syracuse, New York, and a physician at Associated Medical Professionals. Joining me in this discussion is 1 of my former partners and a good friend and colleague, Dr Judd Moul, who’s a urological oncologist at the Duke Cancer Center in Durham, North Carolina. In today’s discussion, we’ll discuss the need for risk-assessment tools and the availability of liquid biomarkers for early detection in prostate cancer. Dr Moul, thank you for joining us. It’s great to see you again. This will be a nice, lively discussion as we talk about the role of biomarkers in prostate cancer.

To kick off and lay a little groundwork for some of the audience, what’s the prevalence of prostate cancer in the United States? Maybe you could give us some insight on what the standard of care is for prostate cancer risk assessment.

Judd W. Moul, MD: Thanks so much. It’s really a pleasure and an honor to be working with you and doing this program together. Before I talk about prostate cancer, we worked together at Duke from 2004 till 2011. As it relates to prostate cancer, that was really the era before risk assessment. I can remember you and me in the operating room; we did tons of radical prostatectomies in a lot of low-risk men. Things have changed since that time. As far as prostate cancer today, if we look over the last 15 to 20 years, the incidence in the United States has ranged from a high of 330,000 cases a year down to 200,000 cases a year when the US Preventive Services Task Force gave the PSA [prostate-specific antigen] test a D rating. Now it’s on the upswing. As you probably see in Syracuse, as we do in Durham, we have more primary care physicians re-embracing the PSA test and screening. But during the pandemic—and we’ll talk about that—it’s been all over the map, and we’re all waiting to see how the pandemic is going to play out on prostate cancer.

David Albala, MD: Judd, just a couple of quick questions. There are a lot of advantages and disadvantages when we talk about prostate screening. When you and I trained, the PSA era came in the late 1980s, 1990s, and the incidence of prostate cancer was 1 of 6 and 1 of 7 men, but we were still seeing 200,000-plus deaths. But we did see a drop in the types of patients we were seeing. When I was at the VA [Veterans Affairs Medical Center], we’d see many metastatic patients come in. The PSA era really changed that. There was a real pendulum switch, and then the patients were coming in. Obviously those patients with early disease we were treating much more aggressively than we do today with perhaps active surveillance. Tell us what you view as the advantages and disadvantages of screening.

Judd W. Moul, MD: First, the PSA test is not going away. Obviously it needs to be refined, and we now use secondary tests many times to fine-tune decisions before we do a biopsy. But the PSA test has been amazing in that it’s a very good basic screening test. The PSA was criticized widely, but I’m not sure it was the PSA test that was bad. It was how we collectively in the medical profession used the test, or used the information. Early on, 1 of the main advantages was decreased metastatic prostate cancer rates, because it does a great job of picking up metastatic disease when you have a high PSA. We went from, back when you and I were in training, 1 of 5 men typically presented with metastatic disease. I’m sure you remember the days where we’d go to the ER [emergency department] and see a guy with cord compression—a terrible situation. In the PSA era, that dropped to 2% or 3%, meaning that only 2% to 3% of guys presenting with prostate cancer had metastases. Now it’s ticking up a little during the COVID-19 era. We’ll see how that plays out. But no question, PSA has done a great job of decreasing the rates of metastases. Where we fell short early on was not really recognizing that many lower-volume Gleason 6s don’t need to be treated. We as a urological profession have responded to that, and certainly among colleagues there’s an embrace of active surveillance. There’s better risk assessment. But I would never bash the PSA test, because overall it has saved countless lives. It needs to be fine-tuned, and over the last 30 years we’ve learned how to fine-tune it.

David Albala, MD: I agree completely. PSA was a significant contribution to our armamentarium of picking up prostate cancer. Over the years we’ve used it in various forms, looking at free to total PSA, PSA velocity, PSA density. But it isn’t a cancer-specific test, and as urologists we recognize it has limitations.

Transcript edited for clarity.

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