PSA Screening Updates – Use of Nomograms.


Feeding on a fish in Venice, Florida; BJ Gabrielsen photo.


As you may have heard, in 2011, the U.S. Preventative Services Task Force (USPSTF) issued a controversial recommendation to no longer recommend prostate-specific antigen  (PSA) screening for healthy men under the age of 75.  The USPSTF’s recommendations often guide physicians in their decisions as well as impact what tests Medicare and private insurers will pay for. This recommendation evoked considerable response from the medical community.

The Johns Hopkins Hospital is consistently rated as the nation’s #1 urology department according to the annual survey published in U.S. News and World Report.  They published a response in the Jan. 3rd, 2012 issue of their Health Alerts entitled “Should You Have a PSA  Screening Test? Johns Hopkins Responds to Recent USPSTF Recommendations.” I encourage you to read the linked article. They concluded that targeted PSA screening focused on men with greater risk and active surveillance for those not requiring immediate treatment could shift the benefit / risk ratio toward greater benefit. Screening should not be discontinued but focused on reducing harm.

It is agreed that it would be desirable to limit the number of unnecessary prostate biopsies and their resulting side effects. To this end, the Johns Hopkins Health Alerts (December 22, 2011) discussed the use of nomograms to address problems with using specific PSA values to ascertain the need for a biopsy. A nomogram considers multiple weighted factors to calculate risk of having biopsy-detectable prostate cancer. These factors include race, age, PSA level, family history, digital rectal exams (DRE) and results of previous biopsies and whether one has previously taken finasteride (Proscar).

Another important factor which could be used to identify candidates for biopsies is PSA density (PSAD). In a recent article published Dec. 12, 2011 in Medical News Today (a recommended source of prostate cancer information), Dr. Martin Sanda of Harvard Medical School wrote that PSA screening could be improved to identify only aggressive cancer requiring treatment by adjusting various factors like prostate size (volume, density, PSAD), obesity and family history. In my own case in 1995, my PSA values at the time of cancer detection averaged around 4 ng/ml.  I had undergone a routine biopsy in 1994 which revealed no cancer but concluded that my prostate gland itself was not enlarged. I therefore reasoned that my smaller prostate gland seemed to be producing a more significant amount of PSA (4.0) than it might under normal conditions. Following up with a second biopsy in October, 1995, the presence of cancer was revealed. Therefore I was using the concept of “PSA density” (PSAD) without knowing about it medically.  In his article, Dr. Sanda also recommended nomograms to predict aggressive cancers and identify candidates for biopsies. The use of two specific urine genetic biomarkers, TMPRSS2:ERG and PCA3, (see Sept.21, 2011 post) was also mentioned in the article entitled “PSA Testing Combined with Other Relevant Patient Data Can Reduce Unnecessary Prostate Biopsies.” The article was also cited in the January 10th, 2012 issue of the ZeroHour Newsletter (from Zero-The Project to End Prostate Cancer).

Lastly, WebMD is an illustrated internet resource that covers many medical issues. One can however choose those areas of specific interest such as prostate cancer. On Jan. 24th, 2012, the WebMD-Cancer published an illustrated introductory primer dealing with prostate cancer. WebMD-prostate cancer should be added to the list of medical resources.



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