By Leslie Deane, MD
As a young boy growing up, I saw two of my grandfather’s brothers be diagnosed with prostate cancer and develop metastases from it, and ultimately succumb to this disease. This was in the pre-prostate specific antigen (PSA) era. This was at a time when men were still treated with diethylstilbestrol, and treatments for advanced prostate cancer were not available. Had screening been an option at that time, they may have been diagnosed earlier and possibly not suffer the way they did.
PSA is an enzyme that is present in prostatic tissue, and its level in the blood can be measured by simple blood test. It is used to estimate a man’s chances of having prostate cancer based on its level.
In 2012, the U.S. Preventive Services Task Force issued a statement based on the available evidence, that PSA should not be recommended for screening men for prostate cancer, as its results can cause harm to the men be evaluated. Having personally seen family members deal with prostate cancer in its most advanced form, and having treated many patients who were diagnosed very late, I am on a quest to prevent others suffering in this way.
Shared decision making
The American Urological Association and the American Cancer Society took a different stance and recommended a shared decision-making model that recommends that men have a discussion about the advantages and disadvantages of having the test done. This would result in men who have risk factors for cancer being screened,and those who do not have any identifiable risk factors potentially being excluded from screening.
This latter situation will undoubtedly allow some men with significant cancers to go undiagnosed and miss an opportunity for early detection and treatment, which we know saves lives. It also would also identify some men with cancers that are clinically insignificant and may incur treatments that are life altering. To this end, what is most important is not being tested, but rather what happens after an abnormal test is detected. I feel that our approach must be tempered in this regard.
There are many tests currently available to help elucidate which men with an elevated PSA are at risk for clinically significant prostate cancer. These tests can be utilized to reduce the number of unnecessary prostate biopsies being performed. This will lower the risk of complications related to prostate biopsy, the worse of which are severe infection, bleeding and longer-term risk of erectile functional changes.
In light of this, I recommend using these tests to determine each individual’s risk of prostate cancer. 4K score (Opko Labs), Michigan Prostate Score (University of Michigan Labs), SelectMDx (MDxHealth), Prostate Health Index and Apifiny (Armune Biosciences) are but a few of the tests that have been validated for this indication. If a man’s risk is found to be elevated, each man will undergo an MRI of the prostate gland prior to any biopsy being performed. With this advanced imaging, we are looking for abnormalities in the prostate gland suggestive of cancer. At Rush, specific MRI sequences are performed to give a clear and detailed picture of the gland. If an abnormality is detected, then targeted biopsies are taken of the abnormal areas.
This approach eliminates the guesswork and reduces the chances of a falsely negative prostate biopsy, yet enhances the likelihood of detecting clinically significant cancers. It is smart screening.
Leslie Deane, MBBS, is a urologist with Rush University Medical Center.