Rapid PSA progression has generally been defined as a doubling time of less than 3 years. Some researchers have found that a PSA velocity of more than 2.0 ng/mL per year corresponds to disease progression (N. Engl. J. Med. 2004;351:125–35).
The intervention criteria on a program of watchful waiting or “active surveillance” should include PSA doubling time or grade progression, Dr. Klotz advised. (See box.)
A 50-year-old man with good-risk prostate cancer could potentially face the psychological burden of living with prostate cancer for around 30 years, Dr. Klotz noted. But even patients who have been treated for prostate cancer still worry. At an office visit, the first thing that comes to the mind of a patient treated for prostate cancer is his PSA level.
To determine the validity of a watchful waiting approach, the START trial (Standard Treatment Against Restricted Treatment) will randomize 1,200–2,000 good-risk prostate cancer patients to active surveillance with selective delayed treatment or definitive therapy (radical prostatectomy, brachytherapy, or external beam radiation therapy).
Selective Use of PSA Testing
Instead of routinely testing PSA levels in all men, physicians could provide information on prostate cancer screening, suggested Timothy J. Wilt, M.D., an internist at the Minneapolis Veterans Affairs Center for Chronic Disease Outcomes Research.
This information could include the difference between prostate cancer and other prostate problems, descriptions of what PSA testing and digital rectal examinations can and cannot tell them, the consequences that may result from having a PSA test, and the risks and benefits of treatment options available for prostate cancer.
Physicians should target testing or treatment to men most likely to benefit from them but should also reassure those who are unlikely to benefit that not testing PSA or undergoing watchful waiting “is compassionate care that is likely to provide superior health outcomes,” Dr. Wilt recommended during another session at the symposium.
Criteria for Intervention
In patients with “good risk” prostate cancer (Gleason score of 6 or less, PSA level of 10.0 ng/mL or less, and clinically localized stage T1c-T2a), physicians may want to use either of the following strategies to determine when to intervene and begin appropriate treatment:
Rapid PSA Doubling Time
▸ Measure PSA level every 3 months for 2 years and then every 6 months thereafter.
▸ If the PSA doubling time is less than 3 years, it may be time to intervene.
Gleason Grade Progression on Repeat Biopsy
▸ Biopsy between 1 and 2 years, then every 3 years, stopping at age 80 years.
▸ Treat if there is progression to a predominant Gleason pattern 4 or worse.
Source: Dr. Klotz