Prostate Cancer Risk Can Be Predicted With a Single PSA Test

The highly acclaimed Institute of Medicine and now the U.S. Preventive Task Force have recommended against routine screening of asymptomatic men for prostate cancer. Now, a study presented by Christopher Weight, MD from the Mayo Clinic Department of Urology adds more information and confusion to the fire. Dr. Weight presented his data at a recent meeting of the American Urologic Association.

The Mayo Clinic followed men younger than 50 years old for 16.8 years.  They concluded that men at age 40 with a PSA value of less than 1ng/ml had a less than 1% chance of having prostate cancer at age 55. They had less than a 3% chance of having prostate cancer at age 60.  They concluded that men with a baseline PSA < 1% in their 40s appear to be able to safely avoid annual screening until age 55.  “Men with a baseline PSA greater than or equal to 1 have a substantial risk of subsequent biopsy and cancer diagnosis and should be followed annually.”

This is one of the first research studies to quantify the actual relationship of screening young asymptomatic individuals and the subsequent risk of developing the disease.  It is the type of research needed to help guide us to make safe and sane recommendations about the type of screening for prostate cancer and frequency of screening using blood tests, ultrasound and of course digital rectal examination to palpate the prostate. All the patients in the Mayo study received a PSA assessment, digital rectal exam and transurethral ultrasound of the prostate at study entry and biennially thereafter.

This study affirms the recommendation for performing a screening digital rectal exam on all men at age forty and subsequently. It begins to answer the question of who needs follow-up PSA testing and when.  However, more research is clearly needed.

The Veteran and the Oncologist

The 80 year old veteran was seated in the clinical exam room with his two sons who had brought him across the country for a visit with the Chief of the Leukemia and Lymphoma Section at a major Center of Excellence.  The veteran and the doctor had hit it off famously as soon as the patient walked into his office for the first time and noticed a picture of a military officer in an Australian army uniform hanging on the wall.

The veteran had come at the insistence of his sons to receive suggestions for treating a rapidly progressing lymphoma. He had been given a bleak prognosis by his local oncologist and his children felt a second opinion was worth the three hour plane flight and expense.

When the veteran walked into the office of the doctor and saw the picture of the Australian soldier hanging on the wall he said “I served with that outfit in the Philippines during WWII in the jungles. Who is that gentleman?”  “That’s my father,” the doctor answered.  For the next few minutes they swapped war stories.  These were not gruesome battle tales but stories of young men from different parts of the world relaxing and playing together to relieve the stress of battling a common and evil foe in an inhospitable climate far from home. The doctor and patient bonded with the doctor hearing many of the same limited number of war year stories these veterans shared with their families. He was now hearing it from a “Yanks” point of view. They swapped stories about the US and Australian unit working together and ambushing a British beer convoy on its way to bring the English troops their daily beer ration. The Aussies and Yanks buried month’s worth of beer in the jungle and then traded it back to the Brits in exchange for favors.   They shared stories about drinking scotch in the jungle and how the doctor’s favorite scotch was the same brand of scotch the veteran’s father had loved as well.

After two days of evaluation, the veteran was told he should be placed on an aggressive regimen of chemotherapy usually reserved for younger patients. Before his first administration of the drugs the doctor walked into the infusion center and leveled with the veteran. “We have not used this cocktail of four drugs on many individuals your age. I think you will do fine but I have to be honest with you that we don’t have much experience with these medications in older men and women.  Are you frightened by this?“ he asked.

The veteran calmly looked at his children and the doctor and said, “I haven’t really been afraid of anything since August 8th, 1945. “   So began the tale never shared before. On August 8th, 1945 , the soldier just six weeks shy of his 21st birthday , along with 99 of his fellow soldiers in the 11th Airborne Division, were training for a low altitude  jump mission for volunteers only . They were training in the remote jungles of the Philippines, jumping from slightly over 150 feet in preparation for a secret mission.  On that August morning they were assembled and were ordered to pack their parachutes and be ready for a mission briefing. Their commanding officer told them that they were leaving that evening to jump into Japan to map the beach landing sites for the Allied invasion of Japan to soon follow. They were to maintain complete radio silence until they had completed their reconnaissance and transmitted the information. If they survived that portion of the mission, they were to reassemble and began a secondary series of missions aimed at sabotage and local destruction of communications assets.  As they lined up to board their planes, the commander of Pacific operations thanked them for their service to their country and that he did not expect any of them to survive the mission.

The men flew in radio silence throughout the night of August 8th, 1945 and in the predawn hours of August 9th jumped into Japan.  The veteran said that as he left the plane his body was shaking in fear and for the first time in combat he voided into his pants on the way down. “I thought that I would be shot and killed by enemy fire before I hit the ground. I never expected to be alive to celebrate my 21st birthday. “The troops met no resistance and went about their primary mission quietly and expertly still maintaining complete radio silence. When they assembled at their rendezvous point, and broke radio silence to transmit the information they had been trained to obtain, they learned that the second atomic bomb had been dropped on Nagasaki that morning. A truce had been declared.  For these brave soldiers the war was over. Three weeks later they were in San Francisco awaiting discharge and a return home.

The chemotherapy went flawlessly. The soldier tolerated the first round well and returned home to complete the therapy locally under the direction of the Center of Excellence. Eight years later he remains disease free. He has never shared another war story with me, his proud son.