Is the Prostate Test Still Worth It?

   July 15, 2009   

03/23/2009

By Lawrence A. Armour, contributor
March 23, 2009: 10:37 AM ET

Despite new doubts, a noted prostate surgeon explains why he thinks it’s still a potential life-saver.
Dr. David B. Samadi, chief of Robotics and Minimally Invasive Surgery at New York City's Mount Sinai Hospital
(Fortune) — Should men age 50 and older have an annual PSA test for prostate cancer? One of the hottest topics in medicine ratcheted up a few degrees last week when the New England Journal of Medicine released results of two large studies. They presented a mixed picture.

The first, a National Cancer Institute study that followed 76,700 men in the U.S. for seven to ten years, found thatwhile prostate cancer screenings led to an increase in diagnoses of cancer, they didn’t have an impact on the actual mortality rate.

The second trial, which followed 182,000 European men from seven countries for about 10 years, went the other way, reporting that the screened population had a 20% drop in death from prostate cancer.

Despite the apparent conflict, the New York Times reported the news in a front-page story headlined “Studies Show Prostate Test Saves Few Lives; Screenings Can Lead to Risky and Unneeded Treatments.” Other news accounts passed similar judgments.

Does that mean testing is no longer advisable? The Prostate Cancer Foundation, which pays for research aimed at developing lab tests for the early diagnosis, wasn’t convinced. Citing the “conflicting results” in the findings, it said: “The PSA test, with its limitations, remains an important tool in the diagnosis and treatment of prostate cancer.”

Others were more emphatic. “It’s not so much whether you’re going to do a PSA screening or not,” says Dr. David B. Samadi, chief of Robotics and Minimally Invasive Surgery at New York City’s Mount Sinai Hospital. “It’s what you do with the information. As a scientist and a doctor, you need to look at every patient on an individual basis. You can’t be dogmatic and treat this like a car wash where every car gets the same soap and water. You don’t biopsy every man with an elevated PSA and automatically send him for radiation or surgery.”

“It’s also politically dangerous,” he added. “If the insurance companies and government rely on these studies and conclude that PSA testing is not a cost-effective way of screening for prostate cancer, five years from now we’re going to be in big trouble.”

Background: Approximately 220,000 U.S. men will be diagnosed with prostate cancer this year, making it the second most common cancer (after skin cancer). Close to 30,000 U.S. men will die of it, making it the second most lethal (after lung cancer).

Unlike most other forms of cancer, the early stages of prostate cancer rarely produce symptoms. As a result, prostate cancer often isn’t detected until it has spread to other organs. If detected early, however, chances of treating and curing prostate cancer are high. For the last two decades, the first line of defense has been the PSA test, a simple, relatively inexpensive blood test that measures a prostate-specific antigen produced by the gland. Since cancer cells produce more PSA than normal cells, the level of PSA circulating in the blood is an indication of the probability of cancer.

Opinions vary, but age 50 is the point at which most urologists believe annual testing should begin. It drops to 45 for African Americans and men who have a history of prostate cancer in their family. Since the PSA test was introduced, deaths from prostate cancer have gone down. For many years, PSA readings over 4 were considered problematic. That has since dropped to 2.5, but an elevated PSA is just one piece of the puzzle.

FORTUNE talked with Dr. Samadi about the latest thinking on the PSA and other issues of prostate health. Excerpts:

How do you interpret PSA results?

An elevated prostate can reflect anything from an infection to the normal enlargement of the prostate that comes with age. You have to look at the patient as a whole. Are there any symptoms of prostatitis? Have any members of his family had prostate cancer? Did you feel a nodule when you did a digital rectal exam? What about the patient’s age? A 65-year-old patient with a PSA of 4 should not necessarily be treated the same way as a 52 year old or a 45 year old with the same PSA.

What about year-to-year changes in the PSA?

It’s called PSA velocity, and I pay more attention to velocity than the actual number. If someone had a PSA of 0.5 two years ago, 1.1 last year and 2.5 this year, that’s a big move in velocity. All three numbers are within normal limits, but the year-to-year change is a very significant red flag. This patient should be under close surveillance by his urologist and would probably be a candidate for a prostate biopsy.

What’s the purpose of a biopsy?

You’re looking to see if any cancer is present, and if the answer is yes you want to see how aggressive it is and if it has spread outside of the prostate. These findings are given a numerical score, but once again the actual score does not necessarily dictate the treatment. The best course of treatment for a 73-year-old with low-risk prostate cancer might be to carefully follow him year by year, and chances are nothing will happen. On the other hand, if you have a 45 year old with the same score, you have a patient who has a clinically significant volume of cancer because he is young and has many years ahead of him. You put all this data together and discuss them with the patient. You don’t just treat numbers.

If you decide on treatment, your main options are watchful waiting, radiation or surgery?

Watchful waiting is a dangerous term. A better terminology is close surveillance, which means you need a compliant patient who will come in every three months for a PSA and a digital rectal exam. This is probably the best route for an older man who has a low-risk cancer. Radiation and seeds are usually done for older patients, and surgery is usually the best choice for younger patients who have many years ahead of them. There are benefits and risks to all types of treatment.

What are the risks of seed implants and radiation?

Radiation is a good route for many patients, but a lot depends on the skill of the radiation oncologist. With the implant, you’re basically shooting radioactive seeds into the prostate. If the seeds come too close to the urethra, they can cause severe irritation, and occasionally they completely miss the area where the cancer is. Radiation beam therapy, which typically involves 30-minutes of high-intensity radiation five days a week for eight weeks, can cause swelling and rectal and bladder bleeding. Sometimes urologists use a combination of seeds, external radiation and hormones, and that can cause everything from metabolic syndrome and cardiovascular problems to depression and other fallout.

Which is why, I suppose, you favor surgery.

Yes. For patients whose cancer is confined within the prostate and who have a life expectancy of greater than ten years, surgical removal of the entire prostate gland is still the gold standard. It is a complex operation that takes place in a densely packed part of the male anatomy, but it’s an operation that’s successfully done on a daily basis by skilled surgeons. The patients who are cured are spared the very severe pain that comes when prostate cancer metastasizes to the rectum, bladder and bone.

What are the benefits of your specialty, which is robotic-assisted surgery?

Unlike traditional open surgery, which starts with a six-to-eight-inch incision and is accompanied by heavy blood loss, a large amount of pain, and a long, uncomfortable recovery, robotic-assisted prostatectomy involves scaled-down surgical instruments that are inserted into the body through five small openings in the abdomen. Patients lose small amounts of blood and are up and walking a few hours after the procedure. They usually leave the hospital the next day and are often back at work in a month.

What about the risks of impotence and incontinence?

If the operation is done by an experienced surgeon who knows how to work around the critical nerves, it shouldn’t be a problem. Within six months of the operation, 97% of my patients have their normal urinary function back and 85% have regained their sexual function.

I’ve done more than 1,700 robotic prostatectomies, and you’d have a hard time convincing me that it’s necessary to cut someone open to remove a prostate. But the robotic procedure takes a while to learn and the robot doesn’t do the work by itself.

Do any foods or vitamins offer protection against prostate cancer?

A cancerous prostate has much less zinc than a normal prostate, which suggests that zinc supplements may be a way to keep prostate cancer from developing. Some tests suggest that selenium, vitamin D and vitamin E offer protection against prostate cancer. Most researchers feel a diet that’s low in animal fats and high in fruit, vegetables, omega-3 fatty acids, soybeans and soy-based foods is another good way to go.

FORTUNE contributor Lawrence A. Armour is collaborating with Dr. Samadi on a forthcoming book about prostate health and Dr. Samadi’s approach to surgery and other treatment.

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