I receive it and always find it very interesting. Here is an article
from the winter issue of Quest that I found intriguing. Also, note the
last paragraph, "Furthermore, we recently reported that 10- year
progression-free survival following radical prostatectomy is
statistically significantly higher in men with a preoperative PSA level
of 2.6 to 4 than in men with higher PSA levels.". I'm assuming that the
2.5 cutoff period for biopsy will become the "new norm"?

Answers to Common Questions About PSA Testing

This information is an adapted version of a medical journal article
written by William J. Catalona, MD; Misop Han, MD; and Stacy Loeb, MD.

Should Screening for Prostate Cancer Begin Before 50 years old?

We, as well as the National Comprehensive Cancer Network, recommend a
baseline PSA test for all men at age 40 years to assess their risk for
prostate cancer.

A relevant study (Whittemore) reported that PSA levels in young
adulthood are useful predictors of prostate cancer detection many years
later.

In our PSA screening study, the baseline PSA level for men in their 40s
was a stronger independent predictor of prostate cancer risk than
ethnicity, family history, or digital prostate examination findings

The value of annual PSA testing for men in their 40s is that changes in
PSA level over time (PSA velocity) can be used to help guide a
recommendation for biopsy.
Another reason to begin screening men at a young age is evidence
suggesting an excellent outcome for treatment in this age group. In a
randomized clinical trial of radical prostatectomy versus watchful
waiting (Bill-Axelson), men younger than age 65 years had the largest
survival advantage with radical prostatectomy.

Furthermore, younger men are less likely to experience impotence and
incontinence after surgery.

Should a PSA Value Below 4.0 Trigger a Biopsy?

The 4.0 ng/mL PSA threshold for prostate biopsy misses a substantial
proportion of prostate cancer cases at PSA levels less than 4.

When PSA 4 is used for recommending biopsy, approximately one third of
tumors have already spread to the margins of the prostate gland or
beyond . Overall, prostate cancer was detected in 15.2% of men with
total PSA levels less than 4.

As a result, beginning in 1995, William J. Catalona, MD lowered the PSA
threshold for biopsy in his research studies and in his clinical
practice to
2.5 ng/mL for men of all ages. Many urologists now follow this
recommendation.

The use of a lower PSA threshold immediately increases the number of
prostate biopsies performed; however, many of these biopsies would
ultimately be performed for a higher PSA level anyway. The lower PSA
threshold merely allows them to be performed sooner.

In addition, the number of unnecessary biopsies in men without prostate
cancer can be reduced through the informed use of the PSA test and
other PSA factors such as PSA velocity, PSA density and percent
freePSA.

Prostate cancer screening should avoid detecting cancer so early that
diagnosis and treatment of "harmless cancer" cause unnecessary
medical complications.

We found that prostate cancer detected at a PSA level of 2.6 to 4.0 is
statistically significantly more likely to be organ-confined than
cancer detected at a PSA level of 4.1 to 10. And, it is not more likely
to meet criteria for "insignificant" disease.

In a recent update of our early studies, we found that when we used 2.5
as the threshold for biopsy, fewer than 10% of cancer cases were
"insignificant" at any time interval during the 12-year study
period.

Another study in Austria (Pelzer) validated our findings. Compared with
cancer detected in patients with PSA levels of 4 to 10, cancer detected
at lower PSA levels was statistically significantly more likely to
occur at earlier stages and in younger patients, that is, in optimal
candidates for treatment with good potential for cure.

Furthermore, we recently reported that 10- year progression-free
survival following radical prostatectomy is statistically significantly
higher in men with a preoperative PSA level of 2.6 to 4 than in men
with higher PSA levels.

http://www.drcatalona.com/quest/quest_Winter06_4.asp