As men age, they often develop a non-cancerous increase in the size of
the prostate, known as benign prostatic hyperplasia. This also elevates
PSA, which leads to controversy as to whether or not to send the man for
a prostate biopsy. The latter is an invasive procedure, but it is the
method by which prostate cancer is diagnosed.
Over the last twenty years, much research took place to determine what
constitutes a normal PSA level. In the '80s and '90s, physicians used a
cutoff of a value of 4. However, doctors now know that there is really
no "normal" level of PSA. Instead, there are ranges and trends of PSA.
Generally, the current acceptable cutoff is 2.5, so any level above 2.5
is considered an abnormal PSA.
The normal level of PSA changes over a man's lifetime. As previously
stated, as a man ages, the prostate gland’s volume increases. Thus, the
actual cut off point of normal PSA level changes as a function of age.
For men in their 70s, one might accept a level of 2.5 because the
likelihood of that person's elevation of PSA being a consequence of
benign prostatic hyperplasia is much greater than his likelihood of
having prostate cancer. For younger men, it might be worrisome when
the PSA rises to 2.5.
PSA level trends
Physicians are also interested in how the PSA level changes over time.
For example, a PSA that rose gradually over many years, even if the
level itself were over 4, is much less concerning than a number that
jumped from 2 to 4 in one year. The rate change of PSA over time is
known as the PSA velocity. Also, PSA doubling time is the time it takes
for the PSA to go from some level to twice that level.
In a man with prostate cancer, the shorter the PSA doubling time is, the
greater the rate of growth of the disease. This is a prognosticator and
it suggests the need for medical intervention instead of observation.
PSA level to monitor the activity of prostate cancer
Treatment for early stage prostate cancer is usually local therapy,
namely surgery or radiation therapy. When the prostate is removed, PSA
levels normally drop to zero. When radiation is used, there may still be
some detectable PSA, but at very low levels.
After surgery or radiation, physicians generally check the PSA every
three months for a few years. When the PSA level remains stable over
time, the likelihood is strong that the person has been cured.
Thereafter, doctors can decrease the interval of checking the PSA.
Ongoing measurements of PSA are an important means to follow a person
with a history of prostate cancer. While there is controversy about
using PSA as a screening tool in the general population, there is none
about the value of PSA as a monitoring tool in someone who has been
treated for prostate cancer.
When the PSA level climbs over several sequential measurements, it is
considered to represent what is called a biochemical failure, PSA-detectable
disease, or PSA recurrence. How to manage a PSA recurrence varies from
one patient to the next. Certainly, there are men who have a rising PSA
after local therapy who will never have any problem with recurrent
cancer.
However, there are people who will develop a cancer recurrence,
characterized by a rapidly rising PSA before they have detectable cancer
on a scan. Aggressive treatments can make a difference in the lives of
these men.
Treatment for PSA recurrence
Currently available treatments include the use of hormonal or
androgen-deprivation therapy, to prevent the production or action of the
male hormone testosterone on prostate cancer cells. This can be achieved
via the surgical removal of the testicles, or, more commonly, through
the use of hormonal medications.
Unfortunately, hormonal treatments often fail after a period of time,
and rising PSA levels may be the first indication. If the PSA is
rising, it signifies what is called hormone-refractory prostate cancer.
Nonetheless, in this late stage of disease, further treatment is still
available.
Over the past year or two, more studies have proven the benefit of
chemotherapy in advanced prostate cancer. Not only does chemotherapy
prolong life in men with hormone-refractory prostate cancer, but it can
also improve their quality of life.
Conclusions
While debate remains about the best use of PSA testing in the population
at large, especially for screening, experts agree that PSA and its
relationship to prostate cancer has had a significant effect on making
treatment decisions for a disease that affects many men.
Carol L.
Kornmehl, M.D., FACRO
Dr.
Kornmehl is the medical director of radiation oncology at Passaic Beth
Israel Regional Medical Center, Passaic, NJ and author of the critically
acclaimed consumer health book, "The Best News About Radiation Therapy"
(M. evans, 2004). Her website is
www.RTSupportDoc.com
Contact Carol
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