1. Prostate cancer and fast-rising PSA
Posted Nov 2nd 2006 11:00AM by Kristina Collins

Thank you Kristina for this blog. This information is significant not just because of what it tells us but because of the author and institution it comes from.

As the lead author of the cited research puts it, "But the findings suggest men should consider getting a first PSA test around age 40, instead of the more usual 50, to use as comparison for future changes, contends Dr. H. Ballentine Carter of Johns Hopkins University, the study's lead author." The experts I follow have been convinced for some time that PSA testing at age 40 is a good idea, and even at age 35 for men at high risk. However, these doctors are considered by their peers to be either at the leading edge, to put it positively, or out of the main stream. Personally, I agree with both characterizations: I'm convinced that that main stream is a sluggish stream. A key concept is that getting tested early will help establish a baseline from which to check for tell-tale changes in the future, even though it is highly unlikely that the initial PSA test will suggest a problem.

It is valuable to have Dr. Carter and his team weigh in with this study, published in the prestigious Journal of the National Cancer Institute. The team represents leading doctors from Johns Hopkins' famed Brady Urological Institute, the citadel of prostate cancer surgery in the world, and Dr. Carter is one of the top leaders at the Institute. Their research is known to be meticulous, and their findings are highly regarded. This is the first I have seen that a prominent research team has suggested testing at age 40.

Quoting from the article again, "'The rate at which a man's PSA rises may be more important than any absolute level for identifying men who will develop life-threatening cancer while their disease is still curable,' he said. 'This is a test that doesn't just diagnose prostate cancer. It diagnoses prostate cancer that's going to actually cause harm.'"

This new study was stimulated by and builds on what look like breakthrough studies by the D'Amico team, at least in my survivor's eyes. The D'Amico results in two papers in prestigious journals demonstrated that an increase in PSA of more than 2.0 in the year prior to diagnosis suggests a challenging case even if the usual indicators (PSA level, Gleason Score, and stage) indicate a low risk case. (And a rise of two or lower in the year prior would be an additional favorable prognostic sign.) Dr. D'Amico is a highly regarded researcher, and it is encouraging to me as a survivor when I see that the earlier results are now bearing further fruit and doing so quickly. You get a sense that the researcher/clinician community is homing in rapidly on know-how that will be of great benefit to patients. I am also impressed by the way the Johns Hopkins researchers took information already in their extensive data base and harvested it to address issues suggested by the D'Amico work.

As the linked article put it: "How fast a man's PSA was rising a decade before his cancer was diagnosed - even before it reached that biopsy-triggering level of 4 - predicted his survival 25 years later, regardless of his ultimate cancer treatment, Carter concluded. Those with a higher PSA velocity - the level rose more than a count of 0.35 a year - had a 54 percent survival rate, while those whose PSA rose more slowly had a 92 percent survival rate. What does that mean for men today? That it's a good idea to order a biopsy for a man with a low but fast-rising PSA, Carter said. And men diagnosed with prostate cancer whose PSA is rising slowly may be ideal candidates for monitoring instead of surgery or other treatment, he added."

Note that the figure of 0.35 a year is less than half the figure of .75 per year that is often used as a benchmark for concern today.

We need to bear in mind a couple of points, one being that the data in the study indicate history not destiny for prostate cancer patients who are surviving in the middle of the current decade. The earliest patients whose data were used in the study by Dr. Carter and his colleagues had blood samples frozen beginning way back in 1958. It's likely that therapies for most of the men in this group who developed prostate cancer were applied before the last ten years, during which time substantial progress has been made. I'm convinced that men diagnosed today with a rise of greater than 0.35 per year will have a substantially better survival than 54% counted from the 25 year point from the decade before their diagnoses.

Dr. Carter was the lead author on another significant recent study, the Johns Hopkins study of what they called "deferred therapy." That study essentially said that deferring therapy for low-risk men who were older was a reasonable strategy provided there was adequate monitoring. They found that many men deferring therapy would not need to be given a curative therapy later, and also that those who did need it would have a high likelihood of preserving their chances for a cure. I imagine the current study adds the rise of 0.35 a year or less to the standards for judging who would be a good candidate for deferred therapy.

As a survivor, I like the synergy of the research: the D'Amico studies stimulate a new Johns Hopkins study that refines earlier Johns Hopkins conclusions and suggests expansion and refinement of the applicability of the D'Amico study. This is especially encouraging because it happens in a context where several other major institutions also have found "deferred therapy" under different names to be a reasonable option for low risk men (U. of Toronto, Memorial Sloan Kettering, Erasmus University, a major British institution, and others). Perhaps the key question is who is truly a low-risk patient, and research is clearly refining the answer to that question.

Jim (web site: http://www.mycancerplace.com/profile.php?id=147)

Posted at 9:09AM on Nov 19th 2006 by Jim Waldenfels