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A Provocative Analysis of PSA Screening

In 1987, Stanford University urologist Thomas Stamey published one of the early large case series that suggested that serum prostate-specific antigen (PSA) is sensitive, but not specific, for prostate cancer. Now, Stamey's team presents a provocative analysis that challenges PSA screening.

The researchers examined trends over time in data collected from 1983 to 2003 for 1317 consecutive patients who underwent radical prostatectomy for localized prostate cancer and who had preoperative PSA measurements. Rectal examination detected most cases in the earliest years, when patients' mean preoperative PSA level was 28 ng/mL (these were not screening PSAs); in contrast, most cases in later years were diagnosed as a result of PSA screening, and patients' mean preoperative PSA level was much lower (12 ng/mL). From 1983 to 1988, PSA level was highly correlated with several indicators of tumor aggressiveness (e.g., tumor volume, capsular penetration, Gleason grade). In contrast, from 1999 to 2003, serum PSA level was highly correlated with only one thing -- total weight of the excised prostate gland. By inference, PSA tests in the later years mainly reflected the amount of benign prostatic hyperplasia (BPH), and not tumor.

Comment: After reminding us that most older men harbor small prostate cancers, the authors question the value of using screening PSA levels in the range of 2 ng/mL to 10 ng/mL as the impetus for doing large numbers of routine biopsies. They argue that we're detecting mainly incidental prostate cancers whose "elevated" PSA levels result primarily from BPH, not cancer. Their article's title -- The PSA Era in the United States Is Over for Prostate Cancer -- likely will spark controversy, especially among urologists.

— Allan S. Brett, MD

Published in Journal Watch General Medicine October 29, 2004

Citation(s):

Stamey TA et al. The prostate specific antigen era in the United States is over for prostate cancer: What happened in the last 20 years? J Urol 2004 Oct; 172:1297-301.

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