PSA is the most important biomarker in a common malignancy. I will continue to test men starting at age 35 if there is a family history of prostate or breast cancer. Depending on the vitality of the individual, I will continue with PSA testing for the duration of the man’s health.
I have been involved in prostate cancer diagnosis and management as a subspecialty of medical oncology since 1983. With the advent of PSA testing, the world of prostate cancer changed dramatically for the better. Routine use of PSA testing in Québec province showed a drastic reduction in advanced presentations in prostate cancer (Prostate 59:311-318, 2004). Anyone who manages prostate cancer patients would confirm the clinical value of PSA testing. In patients undergoing PSA screening, or in those undergoing interval PSA testing, advanced presentations of disease are rare. In men diagnosed with prostate cancer based on PSA screening, the decision to perform invasive treatment—and the skill of the physician performing such treatment—is the crux of the matter, not the value of the PSA as a lab test.
We physicians often toss the baby out with the bathwater. Specific criteria for those men best treated after active, objective surveillance have been published in multiple articles by Laurence Klotz, MD, president of the Canadian Urological Association. Other issues involving the skill of physicians performing any form of local therapy have been covered in the literature, but there have been no efforts to quantify the skill of such physicians. We rate consumer products like kitchen appliances, restaurants, and software but not the skill of urologists who do radical prostatectomy or cryosurgery.
When I first started my medical oncology practice in prostate cancer, the majority of my patients who had a radical prostatectomy were grossly incontinent. I identified a very small group of urologists scattered around the country who reported virtually no incontinence related to radical prostatectomy in their patients. I referred my patients to those urologists. As a result, I was not popular among my local community of oncology colleagues, but I was popular with my patients.
Individualization of patient care is an important but missing element in modern medicine. Academia tends toward polarization with statistical analysis. I will not pigeonhole patients and their care based on the findings of studies that average out the pluses and minuses of a test.
