Resolving a Controversy: The Value of PSA Screening

As time moves on, we are seeing continual developments in the diagnosis and treatment of prostate cancer, with several recent developments of particular interest.

Yet unanswered questions persist, and some of the most controversial concern screening for the disease. How much does screening for the level of prostate-specific antigen (PSA) in a man’s blood — which may indicate the presence of prostate cancer — help men overall, and how should we balance screening programs with our concern about the unnecessary diagnosis and treatment of slow-growing cases of the disease?

The medical and scientific communities are working to resolve these questions. Some suggest changing screening eligibility requirements or raising the PSA level — or the rate of change in levels over time — that are considered high enough to warrant testing for prostate cancer. Are there specific factors upon which to selectively screen certain individuals? Another hope is that the discovery of various biomarkers may lead to a more definitive test for prostate cancer — or better yet, help us determine more clearly which prostate cancers are indolent and which are aggressive. Until that happens, we grapple with the issue of whether PSA screening is a worthwhile alternative.

Similar questions spill over into the treatment arena when prostate cancer is caught early. If a man is told to “watch and wait,” is knowing about his disease worth the stress that knowledge can cause? For those who choose treatment for this stage of disease, are outcomes good enough to warrant the common side effects that can result, including urinary incontinence and erectile dysfunction?

In more advanced cases, when treatment is more definitively necessary, we often turn to strategies that have been with us for decades. The first radical prostatectomy, in fact, was conducted more than 100 years ago, and the importance of chemotherapy in advanced — especially high-burden – disease has persisted for half a century. Yet progress is regularly being made in these areas, and newer techniques are being added to our toolbox.

In the surgical realm, there’s a growing trend toward the less invasive: robotassisted laparoscopic prostatectomy is growing in popularity, and experimental strategies include a newer form of laparoscopy known as LESS and a urethral prostatectomy called NOTES. Radiation techniques are also evolving, with a focus on higher doses that are given in shorter courses and cause less damage to surrounding tissue. And since 2010, six new medical treatments for prostate cancer have been approved, including hormonal treatments Zytiga (abiraterone) and Xtandi (enzalutamide), immunotherapy Provenge (sipuleucel-T) and the chemotherapies Taxotere (docetaxel) and Jevtana (cabazitaxel). Just in the last year, there has been evidence that earlier use of chemotherapy may be better for certain patients than waiting until hormonal therapies are no longer effective.

While we certainly can’t answer all the questions about how best to screen, diagnose and treat prostate cancer, we have endeavored to fill this special issue of CURE with a wide array of information about state-of-the-art screening and care for all phases of the disease, as well as a look at what’s on the horizon. We hope this information will help you ask the most relevant questions and make informed decisions as you determine how to live with, and fight, prostate cancer.

DEBU TRIPATHY, MDEditor-in-ChiefProfessor of MedicineChair, Department of Breast Medical OncologyThe University of Texas MD Anderson Cancer Center