What is the role of prostate-specific antigen screening in your practice?

Urology Times Journal, Vol 50 No 03, Volume 50, Issue 03

"I use PSA testing to make sure patients with high-risk prostate cancer, specifically, and advanced prostate cancer, or even metastatic prostate cancer, don’t go undiagnosed," says 1 urologist.

“I like to get a baseline PSA [prostate-specific antigen] for patients in their 40s, particularly if they’re seeing me for a prostate issue. As patients gets into their 70s, I start the conversation about stopping PSA testing because it loses value.

If a PSA level goes up and, as importantly, if there’s a change in PSA velocity, we may do a course of antibiotics then recheck the PSA. It may come down because inflammation was involved. If it doesn’t, the patient has time to adjust to the idea of a biopsy.

We don’t want to go back to the days before PSA testing because then we clearly saw much more advanced disease with much less we could do about it. The PSA has been valuable, but as with any other tool it may be overused at times or misunderstood.

The PSA screenings we used to do in September—big events getting men who…wouldn’t come in otherwise—have fallen by the wayside, reasonably so, because in the last years of those screenings, many men already had had [their PSAs checked] and were just coming for a second one.

There’s been a shift in the individuals getting treated for prostate cancer. They’re living a better quality of life, provided we catch them early enough.”

Sherman M. Hawkins, MD

Goldsboro, North Carolina

“I use PSA testing to make sure patients with high-risk prostate cancer, specifically, and advanced prostate cancer, or even metastatic prostate cancer, don’t go undiagnosed. Prostate cancer remains the No. 2 or No. 3 cancer killer of males in America. So PSA is an important adjunct to DRE [digital rectal exam] in efforts to give those patients a diagnosis earlier. We don’t get as clear a benefit with intermediate- and low-risk prostate cancer.

Every patient with urinary issues should have a physical exam, including a DRE. The PSA should be considered at age 40, even in the absence of risk factors, and absolutely at 40 with risk factors—positive family history, African-American individuals, genetic predisposition. Then we can talk about monitoring frequency.

I follow the guidelines. Being mindful, a really healthy 70-year-old man may live to age 95. Anybody in practice 25 years knows our patient demographic has changed. Patients used to be in their 60s. Now they’re routinely in their 70s and 80s, if not 90s. I would like consensus among urologists that high-risk prostate cancer in otherwise healthy males should be treated.

Do I do PSAs on patients older than 70? Yes. Annually? As a rule, no.

PSA shouldn’t be considered simply a screening test; it’s actually part of the diagnostic work-up. If a patient is 80 years old and has trouble urinating, PSA helps ensure it’s not advanced prostate cancer that I might have missed as a result of not doing PSA testing.

I’m using PSA as I always have. I followed patients with lower-risk cancer before it was recommended. Simple math showed that most of our patients weren’t dying of prostate cancer.”

Mark K. Plante, MD

Burlington, Vermont

“Most men are being referred to me because their PSA levels started increasing. Anyone with prostatic symptoms, voiding symptoms, etc, warrants a PSA check. If the PSA falls within range for the age group, I may recheck it right away or in 3 months to determine the trajectory of the PSA levels and whether there’s a need for further investigation.

Nowadays, if some of our primary care doctors see an elevated PSA or abnormal DRE, they’ll order an MRI. It’s not common among primary care doctors, but ours do it because they know the MRI is being utilized more in prostate cancer screening. Often patients come to me, as a robotic surgery specialist, already prescreened with a PSA level and/or an MRI.

MRIs help catch intermediate- to high-risk prostate cancers more likely to benefit from treatment vs lower-risk [cancers] you should probably just watch with active surveillance.

We still follow patients with a negative MRI or biopsy, just not as closely, to make sure their PSA isn’t increasing at an alarming rate. I’ll probably do a PSA test every 6 months for a couple years, then push it out farther if the PSA stabilizes.

Typically, if someone comes in with an elevated PSA, I recheck to make sure it’s a true value, then get PSA levels every 3 months to determine data points to check the trajectory of the PSA’s velocity, whether it’s increasing at an alarming rate or it’s steady and their PSA is always high.

Coupled with their physical examination, family history, race, those are all factors included in determining how to manage people.”

Layron Long, MD

Corvallis, Oregon