PSA and Other Tumor Markers – Jon McDermed, Diagnostic Products Corp. Dr. McDermed presented a review of several tumor markers useful in prostate cancer diagnosis and future course predictability. PSA is still the primary tumor marker for PCa. The levels of PSA have been dropped as determinants of prostate cancer presence vs benign prostate conditions. He quoted from a paper by Thompson, et. al. in the NEJM 350, 2004 which showed the statistics of PCa distribution in several low ranges of PSA. For instance, of men with PSAs between 0.6 and 2.5 in his study cohort of 2,950 men, there were 10.1% with biopsy proven cancer. This level of PSA often is considered “OK” by many urologists who don’t go further in their diagnostic process. For PSAs between 1.1 and 2.0 in this same cohort, Thompson reported 17% biopsy proven cancers. The data further showed that for PSAs below 0.5, there were 6.6% cancers detected by biopsy. To summarize, PSA levels below 2.0 had, combined, 33.7% detectable prostate cancers! (ED Note: Too often men with detectable PSAs in this range are told they don’t have prostate cancer and to return again in 3 to 6 months for another PSA). He pointed out that the new level for considering a biopsy has been dropped to 2.5 from the previous level of 4.0. This means many more men are being subjected to biopsy procedures. Later papers to be reviewed will discuss the use of color Doppler ultrasound to refine the biopsy sampling process and reduce the mostly unguided character of many biopsies. Conventional black and white ultrasound procedures are the norm in these dx procedures and their relative accuracy in identifying tumor areas is poor. He discussed the use of other markers including: PAP, NSE, CGA, and CEA (respectively Phosphatic Acid Phosphatase, Neuron specific enolase, Chromogranin A, and Carcinoembryonic Antigen). The PAP marker is useful in predicting likelihood of post brachytherapy failure and has been written about by Dr. Michael Dattoli, an eminent practitioner of brachytherapy (and the other radiotherapy techniques) in Sarasota, Florida. Drs. Stephen Strum and Charles Myers, well known medical oncologists who specialize in prostate issues, also recommend these tests for men undergoing prostate cancer diagnosis. In community practice, these non-PSA markers are not utilized very extensively. As in PSA, the greatest value of these markers lies in having a base line established for some time against which changes can be measured. Dr. McDermed spent some time addressing the issue of PSA Velocity as a prime measurement. He cited literature that showed PSA doubling time is highly correlated with the relative aggressiveness of a prostate tumor. To achieve this measurement, he indicated that at least three measurements of PSA taken 6 months apart are needed. (Ed Note: A very recent publication by Dr. D’Amico, of Brigham and Women’s Hospital in Boston showed the great usefulness of PSAV in PCa). He reviewed the non-PSA indicators and discussed their usefulness. PAP, he reported, is a “more specific marker” than PSA but doesn’t have its sensitivity. It is mostly used to track changes in pts with bony metastases. He also suggested that it has utility in androgen independent PCa where PSA expression may be suppressed by the anti-androgen treatments. He showed a graph based on work by Dattoli and Han (separate publications) that showed some 21% post brachy failure for PAP levels <3 and 61% failure rate for PAP levels => 3. Han’s work related PAP levels to post radical failures. CGA (chromogranin A) is a neuroendocrine marker that may be useful in identifying presence of small cell variant of PCa. This variant is inherently androgen independent according to Dr. McDermed. CEA can be elevated in other tumors and also can indicate small cell variant of PCa with its inherently androgen independent character. It may also indicate the presence of a “secondary primary cancer” , e.g. colon. McDermed discussed “third generation PSA ultrasensitive” testing and how it is useful in early detection of doubling times in periods of low absolute levels of PSA that may be rising slowly. Standard PSA measurements usually report levels below 0.3 ng/ml as “undetectable”. Dr. McDermed’s company has the ultrasenstive PSA assay that will detect PSA changes in the range below 0.02 ng/ml. He also emphasized the importance of monitoring other body organs and blood during androgen deprivation therapy. Because hormonal blockade can and does induce osteoporosis he recommended that men use the Pyrilinks-D assay to monitor bone loss. Also, liver function tests should be run as part of complete CBC panels. Dr. McDermed’s take-away message to men battling recurrent PCa is to maintain close watch on one’s own blood chemistry as well as markers of bone density, bone resorbtion, liver function, etc. He indicated that “intermittent androgen deprivation” therapy is gaining more adherents because of the potential improvement in QOL and survival. Dr. Steven Strum- “Status and Strategy in the Successful Treatment of Prostate Cancer” Dr. Strum is the lead author of one of the best books on PCa, “A Primer on Prostate Cancer” in collaboration with Ms. Donna Pagliano. The book is written on a very understandable level for non-medically trained persons. In it, Strum discusses the need for maximal efforts in diagnosis in order to do the best staging job possible. He goes into detail about the issues of determining cancer volume, PSA velocity, use of other markers, etc. The writer has read many books on PCa and can unhesitatingly recommend this one to any man dealing with a prostate issue; be it BPH, Prostatitis, or prostate cancer. It is published by the Life Extension Foundation, in Hollywoood, Florida. Dr. Strum’s presentation at the Conference was essentially the highlights of the book. He referred to the availability of many predictive nomograms, Partin Tables, Narayan Tables, and neural nets to help patients look at probabilities for organ confined disease, extra-capsular extension, seminal vesicle involvement, etc. He used a six point program from which to develop this ideas: 1. Listen to the biology of the PCa 2. Establish a baseline of test results 3. Validate key or critical data inputs 4. Integrate all the info with nomograms, tables, etc. 5. Refine the workup based on 1 thru 4 6. Examine therapy options within the CONTEXT of the patient’s life. His slides and presentation data were all based on the content of the above referenced book which belongs alongside every man entering the prostate cancer wars. EDITOR’S NOTE: Earlier in our review of Dr. Charles Myers’ presentation we expressed some question about his statistic that at any given moment, 30 million men in America have some degree or another of prostate cancer. In a personal communication from Dr. Myers, he explained where that number comes from: for males under 10 years old, autopsies show no PCa. For males between 10 and 20, about 1% are positive and with each decade the numbers increase. Between the ages of 50 and 60 some 40-50% of men test positive for PCa, and for men over 80 “nearly everyone is positive”. Dr. Myers said that applying these numbers to the entire US male population produces the 30 million figure which he believes most likely is an under estimate! The reported number of prostate cancers diagnosed annually is approximately 240,000 with 30,000 deaths. One can only conclude, therefore, that of all the above mentioned autopsy-detected prostate cancers, just a small %age develop into “need-to-be-treated” cases. In fact, the commonly quoted prostate cancer risk factor for an American male is 1 in 6. And the risk of death from PCa is about 1 in 32. The terrible pain and agony associated with death from prostate cancer should make every man aware of the need to fight this disease vigorously. NPC Program Review, 2005 Remember we are NOT Doctors and have NO medical training. This site is like an Encylopedia - there are many pages, many links on many topics. Support our work with any size DONATION - see left side of any page - for how to donate. You can help raise awareness of CAM.