Screening for Prostate Cancer

Urologists Remain Divided Over PSA Blood Test

Dr. Catalona
Dr. William Catalona

ABCNEWS.com June 15 — Cancer specialists remain deeply divided over the effectiveness of the PSA blood test as a diagnostic tool for prostate cancer. Opponents of the PSA test (a blood test that measures levels of a protein called prostate-specific antigen) say it’s costly, often inaccurate and emotionally trying for the patient. Furthermore, they say, prostate tumors are slow-growing and most men die with prostate cancer, not of it. Dr. William Catalona, one of the nation’s leading urologists, disagrees: “Foregoing a test that can make a life-or-death difference just doesn’t make any sense to me, especially when we are making dramatic strides in narrowing the margin of error.” A professor of urology at Washington University’s School of Medicine in St. Louis, Catalona runs the largest prostate cancer screening program in the country. He treated New York Yankees manager Joe Torre for prostate cancer last year. Dr. Catalona joined a live chat on ABCNEWS.com to discuss the controversial PSA test and the latest treatment options for prostate cancer. Below is a transcript of the chat.

Moderator at 11:59am ET
Welcome to our chat with Dr. William Catalona, professor of urology at Washington University’s School of Medicine in St. Louis. Thanks for joining us.

Dr. William Catalona at 11:59am ET
Thank you very much. I'm glad to be here.

Moderator at 12:00pm ET
Dr. Catalona, when should men start getting regular check-ups for prostate cancer?

Dr. William Catalona at 12:01pm ET
I would say that for most men it would be age 50. Checkups should include a PSA blood test and a digital prostate examination. However, there are two "high risk" groups. These are men with a strong family history of prostate cancer, and black men. These men are more likely to develop prostate cancer at an earlier age and, therefore, should start screening at age 40.

Moderator at 12:02pm ET
Can younger men develop prostate cancer?

Dr. William Catalona at 12:02pm ET
Yes. Men can develop prostate cancer in their late 30s, and fairly commonly now, we are seeing men diagnosed with prostate cancer in their 40s.

Moderator at 12:02pm ET
Heath asks: What are the warning signs of prostate cancer?

Dr. William Catalona at 12:03pm ET
In general, there are no early warning signs of very early prostate cancer. The only way it can be detected in its early stages is to actually look for it, through the PSA test and the prostate examination. In more advanced prostate cancer, there can be symptoms of difficulty of urination, such as slowing of the urinary stream, urinary frequency, and having to get up at night to urinate.

Moderator at 12:04pm ET
Opponents of the PSA test point to the fact that false positive readings can run as high as 75%. Furthermore, they say it's costly and emotionally trying for the patient. Are these valid reasons to avoid the test?

Dr. William Catalona at 12:05pm ET
All of those reasons are true, but none of them are valid reasons for avoiding the test. Actually, the PSA test is the most accurate cancer screening test in medicine today. It's more accurate than pap smears or mammography, for example.

Moderator at 12:05pm ET
What is an abnormal PSA level?

Dr. William Catalona at 12:06pm ET
Very commonly, the number four is used as an abnormal PSA level. However, we have been using a level of 2.5 since 1995. And we have reported in JAMA that 22% of men whose PSA is between 2.5 and four have prostate cancer when they are biopsied. So there is not an absolute cut off that everyone agrees on. Certainly, any PSA level above 2.5, or steadily rising PSA level, is reason for concern.

Moderator at 12:07pm ET
Jeff writes: I am 25 and was recently diagnosed with prostatitis. I had been having pain on and off for about 3 months before I was finally diagnosed by a urologist. Should I be particularly concerned with the potential for prostate cancer, considering the problem I've had at such a young age?

Dr. William Catalona at 12:08pm ET
No. As far as we are aware, there is no direct link between prostatitis and risk for prostate cancer. However, both of these conditions can raise the PSA level, so prostatitis is one of the reasons for "false positive" PSA blood tests.

jeffs from netdoor.com at 12:09pm ET
I am 30. In my last checkup, my M.D. said that my prostate was "slightly enlarged." This was the first time my prostate was ever checked and the M.D. attributed this to increased levels of testosterone with age. I have no other symptomology other than a very slightly decreased urine stream, which usually is only like that when I first get up in the morning. I have no family history for prostate cancer.
Should this be a concern for an otherwise healthy 30-year-old? Is there anything I can do to improve prostate health (e.g. saw palmetto)?

Dr. William Catalona at 12:11pm ET
The most common cause for prostatic enlargement is called benign prostatic hyperplasia, or BPH. Eighty percent of all men develop BPH, usually after the age of 50. BPH is the other condition besides cancer and prostatitis that can cause PSA levels to be elevated. Therefore, BPH is another common reason for "false positive" PSA blood tests.
Prostate cancer, in its more advanced stages, can also cause the prostate to become enlarged. So prostatic enlargement needs to be followed carefully by a urologist.
Saw palmetto is very commonly used by the general public for prostate health, and many people swear by it. However, there is little scientific evidence that proves its value. I think it does help some patients, but more study will be required.
Other useful measures would be a low-fat diet — especially avoiding red meat fat — vitamin E (200 units per day), selenium (200 micrograms a day), vitamin C (500 mg per day), possibly lycopene (5 mg per day). All of these are available over-the-counter without prescription.

Tyrone from att.com at 12:15pm ET
Can you discuss the "free" PSA test and what it can tell a doctor?

Dr. William Catalona at 12:18pm ET
The "free" PSA test is useful in men who have total PSA values of 2.5 to 10. In these men it is difficult to determine whether these mildly elevated PSA levels are due to prostate cancer or benign causes. The free PSA test allows a more accurate prediction of whether cancer is present or not.
If the free PSA is greater than 25%, then there is only a one chance in 12 that cancer is present. In contrast, if the free PSA is less than 10%, then there is nearly a 60% chance that cancer is present. The free PSA also indicates how aggressive a cancer may be — the higher the free PSA, the less aggressive, and conversely, the lower the PSA, the more aggressive.

D. Starr at 12:18pm ET
How important is it to get a second opinion before deciding any course of therapy or surgery once the diagnosis has been made?

Dr. William Catalona at 12:19pm ET
My feeling is that the patient should have complete confidence that he has all of the necessary information. If he can gain that level of confidence from one physician, then that's fine, but most patients prefer to get multiple opinions. And any knowledge is going to be useful in arriving at the best decision for that patient.

Audra from uncc.edu at 12:20pm ET
My dad was recently diagnosed (six weeks ago) and has my family worried that if he does not decide and act soon on a procedure, things will worsen quickly. What kind of time frame do you recommend to a patient, from diagnosis to treatment? How soon should he act on this?

Dr. William Catalona at 12:21pm ET
In general, prostate cancer is a slowly progressive cancer, so treatment is not an emergency. However, as is the case with all cancers, the sooner it's treated, the better the outcome. I usually recommend that the patients be treated within six to eight weeks of the time the diagnosis is made, unless there are some special circumstances that would preclude this.

Moderator at 12:21pm ET
What are the current treatment options for prostate cancer? Which one, in your opinion, is best?

Dr. William Catalona at 12:24pm ET
There are two potentially curative treatment options for prostate cancer — surgery and radiation therapy. In my opinion, if the patient is otherwise healthy, and the tumor is localized to the prostate, surgery offers the best chance for completely eliminating the cancer. In patients who either are unable to have surgery because of other health problems, or those who just do not want to have surgery, radiation therapy is also effective in many cases.
Of the two types of radiation therapy, radioactive seed implants and external beam, I believe that external beam is the more effective option. External beam is less convenient because it requires five treatments a week for seven and a half weeks, but I believe the added inconvenience is worth it.

Moderator at 12:25pm ET
Buckda writes: What do you think about CAB (Combined Androgen Blockade)? I was told this is a very effective treatment option instead of surgery."

Dr. William Catalona at 12:26pm ET
I would say androgen blockade is a very effective treatment, but it is never curative. It is usually used in patients with advanced-stage prostate cancer. Current evidence suggests that there is no additional benefit for combined androgen blockade over traditional blockade of testicular androgens only.

Jill from yr.com at 12:26pm ET
What is your opinion of using a LHRH analog for treatment?

Dr. William Catalona at 12:28pm ET
An LHRH analog is an injection that blocks the production of male hormones by the testicles. This is a very effective treatment, but again, is not a curative treatment. The use of LHRH injections is now considered standard hormonal therapy for the majority of patients with advance prostate cancer.

Moderator at 12:28pm ET
Dr. Catalona, thanks for your time today. What resources do you recommend for more information on the PSA screening test and treatment options?

Dr. William Catalona at 12:29pm ET
The resources I would recommend on both of these would be the American Cancer Society's public relations office (or online at www.cancer.org), and the American Urological Association's public relations office (or online at www.auanet.org). They both have guidelines and pamphlets that are accurate and very understandable.

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