THE "NEW" PROSTATE CANCER INFOLINK

A highly influential group of senior urologists have come together to propose a new model as a methodology for screening men for risk of prostate cancer.

The new model proposed by Crawford et al. (available as a free full text article in the journal Urology) seems to have considerable similarity to a model previously recommended by the prostate cancer specialty group at Memorial Sloan-Kettering Cancer Center (MSKCC) … and one of the authors listed is James Eastham from MSKCC.

Basically, Crawford et al. propose a model that is based on the following key presumptions and criteria:

• Primary care physicians have become confused by messages about PSA testing, specifically including things like PSA velocity, age-specific PSA, percent free PSA, PSA density, and PSA cutoffs of 1, 1.5, 2.5, and 4 ng/ml.
• Most primary care physicians don’t have the time or the knowledge to hold a detailed discussion of the pros and cons of PSA testing with individual patients at a routine office visit, but primary care physicians order about 90 percent of all initial PSA tests for risk of prostate cancer.
• PSA testing for risk of prostate cancer is appropriate for any man with a 10-year life expectancy.
• Detailed PSA data on > 500,000 men from a respected reference laboratory show that, among men aged between 45 and 70 years of age, about 70 percent have a PSA level of < 1.5 ng/ml.
• Men with a PSA level of < 1.5 ng/ml are at a very low risk for development of prostate cancer (and high-risk prostate cancer in particular) within the next 4 to 5 years
• A key goal should be “to avoid [unnecessary] PSA tests in men who would have little to no gain by focusing on age and health.”

So the new model being proposed by Crawford et al. goes like this:

• Men with a 10-year life expectancy making a normal “healthy patient” office visit to a primary care physician should get a PSA test as part of a normal panel of blood tests (if they haven’t had a PSA test in the preceding 5 years; see below).
• Men with a PSA level of < 1.5 ng/ml and no sign of risk for prostate cancer on a rectal exam (if a digital rectal exam has been administered) should be advised that their PSA level is normal and that they won’t need another PSA test for 5 years.
• Men with a PSA level of ≥ 1.5 ng/ml and/or any sign of risk for prostate cancer on a rectal exam (if a digital rectal exam has been administered) should then have an informed discussion about the meaning of such a PSA level and/or finding from the rectal exam and be referred to a urologist for additional testing if they wish to have such a referral or if the primary care physician considers this to be essential.
• Men who are referred to a urologist would be evaluated for all potential causes of the elevated PSA level, including benign prostatic hyperplasia (BPH), prostatitis, and prostate cancer.
• If there appears to be a risk for prostate cancer, then other tests can also be administered, including tests such as the Prostate Health Index or phi test, the 4KScore test, the PCA3 test, and/or the SelectMDX test, to identify men whose risk for clinically significant prostate cancer  seems to be real.
• If the risk appears to be low after re-evaluation by the urologist and the appropriate use of such a test or tests, the patient would be referred back to his primary care physician with a recommendation for a repeat PSA test in 1 year.
• If the risk appears to be high after such a test or test, the urologist and the patient should consider a TRUS biopsy.

Now let us be clear that this is a model that would be considered to be highly appropriate today by a wide range of urologists and many members of the patient advocacy community too. The question is going to be whether it is a model that is thought to be suitable by members of the primary care community and its organizational representatives (the American Academy of Family Physicians, the American Society for Internal Medicine, etc.) and the representatives of the epidemiology community (e.g., the U.S. Preventive Services Task Force).

We see two potential problems:

• There are no data from any prospective studies that we are aware of that actually demonstrate the value of such a screening model.
• There is no specific recommendation about when such testing should be initiated.
• There is no mention of active surveillance as a potential first-line management strategy for patients found to have low-risk prostate cancer after a prostate biopsy.

This does not mean that the model is a bad idea. It simply means that how useful it is is untested, and will be highly dependent on how well primary care physicians comply with such a model and how well urologists conform to it.

While The “New” Prostate Cancer InfoLink considers this to be a model worthy of extensive discussion — to involve the primary care community and the patient advocacy community as well as the urology community — we would feel that there are some additional, very clear objectives that need to be built into the model, starting with these two:

• A second key goal should be optimize the early diagnosis of clinically significant prostate cancer — especially among men who are known to  be at higher than average risk of this disorder.
• A third key goal should be to minimize risk for unnecessary over-treatment of men initially diagnosed with low-risk, non-lethal forms of prostate cancer that are unlikely to metastasize.

Filed under: Diagnosis, Risk | Tagged: Diagnosis, risk, screening |