Not all prostate cancer (PC) is systemic, any more than all breast cancer or other tumor types are systemic. If they were, we would never cure PC, breast cancer, or any other malignancy. Physicians claiming that every man with PC needs androgen deprivation therapy (ADT) as primary and sole therapy are blindly ignoring the growing numbers of men who present 8 to 15 years after radical prostatectomy (RP) or radiation therapy (RT) with a flat prostate specific antigen (PSA) graph. Emphasis on the use of routine PSA monitoring starting annually at the age of 40 with PSA velocity and doubling time determinations as a standard part of PSA reporting will increase the numbers of men diagnosed earlier, with a lower tumor burden, and cured with local modalities of treatment (Labrie et al, J. Clin. Endocrinol. Metab, 1995; Labrie et al. Urology, 1996). PSA testing with these enhancements should start earlier, at age 35, in men with a familial history of PC.
In addition, the use of routine free/total PSA levels should increase our ability to diagnose PC earlier since fractionation of PSA allows us to monitor the malignant-associated portion of PSA called complexed PSA. Evaluation of risk of PC using neural net technology as per the ProstaSure blood test also will enable an earlier diagnosis of PC (Babaian et al., Urology, 1998). As our standard and hopefully routine approach to monitoring PSA and other biological expressions of tumor cell activity increases, the percentage of men cured of PC should increase as well.
This is borne out in a recent report in which PC was detected in 22% (73/332) of men 50 years or older whose PSA reading was between 2.6 and 4. All cancers detected in this setting were clinically localized. This study indicates that PSA readings greater than 2.6 and less than 4.0 may represent a 22% risk of PC (Catalona et al., JAMA, 1997). The use of a free PSA test would help determine which of these men whose PSA readings were greater than 2.6 but less than 4.0 have a high probability of PC versus a low probability of PC. Such a test could reduce the number of unnecessary biopsies in the low-risk subset and focus a need for more comprehensive biopsying in the high-risk subset.
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