In 1987, the PSA test became available and was praised as a life-saving test making it possible to diagnose prostate cancer early enough to achieve a cure or permit treatment to prolong and improve the quality of life.
An article in the New York Times, printed in 2009, ignited a firestorm over the wisdom of performing the PSA test. While a Dutch study had found that the use of PSA screening resulted in 20 percent fewer deaths from prostate cancer, an American study concluded that treatment for all the prostate cancers discovered by PSA screening resulted in the same mortality rate as was experienced by patients, whose prostate cancer was left untreated and who were simply observed. Their conclusion was that PSA screening did not save more lives and that is what started the firestorm.
The American Urological Association devoted much of its 2009 annual meeting to the problem and produced a definitive publication on this topic, “PSA Best Practice Statement.” Since then, research on this subject has continued worldwide and “PIVOT” trials (Prostate cancer Intervention Versus Observation Trials) have been ongoing.
Recently the NY Times republished its 2009 article reigniting the controversy in the public eye. A new 16-member government panel not containing a single urologist or oncologist was quoted as reporting that considering the potential for serious complications resulting from treatment, there was no improvement in overall life expectancy.
This was contradicted in part by a report at the AUA annual meeting this year by Dr. Timothy Wilt of a “PIVOT” trial ongoing since 1994 showing that in men whose PSA was equal to or less than 10 or who had low-risk prostate cancer, surgical removal of the prostate did not reduce the mortality rate more than observation.
However, in men, aged 75 or less, whose life expectancy was at least 10 years and who had a PSA higher than 10, there was a definite benefit to surgical treatment amounting to a 7.2 percent benefit in absolute terms and a 64 percent reduction in mortality in relative terms.
For those, who did not have a 10-year life expectancy, either because of being older than 75 or due to other conditions or diseases, a PSA greater than 10 still did not warrant surgical removal of the prostate because there was no statistically significant reduction in mortality. So there remains a group of men with prostate cancer, whose PSA is over 10 and whose life expectancy is at least 10 years, who would definitely benefit by undergoing surgical removal of their cancerous prostates.
The obvious question of course is, “How is the doctor to find such a patient without doing periodic PSA screening?” The just as obvious answer is that PSA screening remains necessary to find these patients who would benefit from surgery and achieve a significant improvement in their life expectancies.
Have a Question? Call Dr. Okun at 718-241-6767