Video: Prostate cancer prognosis

updated 7/8/2004 6:25:36 PM ET 2004-07-08T22:25:36

Prostate cancer is much more likely to kill if a man’s PSA level rises rapidly before the cancer is even diagnosed, according to a study that suggests a new and far more meaningful way of looking at PSA test results.

The finding could help patients and doctors make the often difficult decision of whether to undergo surgery or merely wait and watch.

The PSA test is widely used to diagnose prostate cancer by measuring levels of a substance called prostate-specific antigen in the blood. Up to now, doctors have focused largely on the PSA level itself, and not on how it changes over time.

Change over time is key
But researchers at Brigham and Women’s Hospital and elsewhere found that how fast PSA levels increased in the year before prostate cancer was diagnosed predicts which tumors are deadly nearly 10 times better than the PSA level itself.

“The study is pretty definitive,” said lead researcher Dr. Anthony D’Amico, a radiation oncologist at Brigham and professor of radiation oncology at Harvard Medical School. “It’s not the level of PSA that matters, it’s the change from year to year.”

The finding underscores the importance of getting regular PSA screenings, so that doctors can spot trends.

When doctors find prostate cancer, they often recommend “watchful waiting” over prostate-removal surgery, because the operation can cause impotence and incontinence and because some prostate tumors are so slow-growing that men die of something else before the cancer kills them.

But most men do not want to wait, so doctors are seeking better ways of predicting which tumors will be lethal.

PSA levels alone inconclusive
PSA levels alone are not always reliable. A recent study found the tests missed about 15 percent of prostate cancers in older men whose readings were supposedly normal — that is, at or below a count of 4.

The latest facts and figuresThe new study, reported in Thursday’s New England Journal of Medicine, followed 1,095 men, 65 years old on average, who had prostate cancer; they received PSA screenings at least once a year and underwent prostate surgery between 1989 and 2002.

Twenty-eight percent of the men whose level rose more than 2 points the year before diagnosis died of prostate cancer within seven years — despite having the gland and adjacent lymph nodes and seminal vesicles surgically removed.

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D’Amico said the findings make clear which patients need aggressive treatment, but not which ones can safely be monitored through repeated testing.

PSA is a protein that helps liquefy semen for ejaculation. An elevated PSA level can indicate benign prostate enlargement or prostate cancer. So when a man is found to have an elevated PSA level, doctors do a biopsy, withdrawing cells from the gland by needle for examination under the microscope for signs of cancer.

Guidelines call for annual PSA tests beginning at age 50 — or 45 for men with a family history of prostate cancer. D’Amico said a baseline PSA level should be determined at age 35 to spot changes.

Guidelines for deciding on surgery
Dr. Mark Jordan, professor and chief of urology at University of Medicine and Dentistry of New Jersey in Newark, said he believes the initial PSA level, and the percentage increase, are just as important as the rate of increase, or PSA velocity, but there are not enough guideposts for deciding on surgery.

“We’re not even sure if prostate cancer surgery prolongs life,” said Jordan.

Dr. Howard Parnes, chief of the National Cancer Institute’s prostate and urological cancer research group, said a high PSA velocity indicates substantial risk of relapse after surgery and death. But he said larger studies with longer follow-up are needed.

Parnes and D’Amico said the PSA velocity can be used now to identify which high-risk men could participate in studies of such treatments as radiation, hormones to suppress testosterone and cancer drugs that could be given in addition to surgery.

Prostate cancer is the No. 2 cancer killer among men, with an estimated 30,000 deaths and 230,000 new cases each year, according to the American Cancer Society. Despite that, only about 60 percent of American men over 50 have had a PSA screening.

Men have a one-in-six lifetime risk of getting prostate cancer. However, the death rate has fallen nearly 20 percent since the PSA test became widely used in the mid-1990s, a drop attributed to both earlier detection and better treatment.

Dr. William J. Catalona of Northwestern Memorial Hospital, who worked with D’Amico and helped develop the PSA test to determine risk of prostate cancer, said he thinks a biopsy should be done once the PSA level hits 2.5 or PSA velocity reaches 0.75 — as the National Comprehensive Cancer Network recently recommended.

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