OCT 16, 2013 02:00 PM PDT

PSA Screening and Early Detection for Prostate Cancer 2013: Controversy and Opportunity

  • James H Semans MD Professor of Surgery, Division of Urologic Surgery, Director, Duke Prostate Center, Duke Cancer Institute, Duke University Medical Center
      Judd W. Moul is James H. Semans, MD Professor of Surgery, Division of Urologic Surgery, and Director of the Duke Prostate Center, Duke Cancer Institute at Duke University Medical Center. Prior to joining Duke, he was Professor of Surgery at the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Maryland and an attending Urologic Oncologist at the Walter Reed Army Medical Center (WRAMC) in Washington, DC. In addition, he was Director of the Center for Prostate Disease Research (CPDR); a Congress-mandated research program of the Department of Defense based at USUHS and WRAMC. In 2004, he completed a 26-year U.S. Army career, retiring as a full Colonel in the Medical Corps, and became Chief of the Division of Urologic Surgery at Duke. Serving as Chief from 2004 to 2011, he brought innovation and growth to the program. Most notably, he started the Duke Prostate Center, expanded the urology residency training program through a novel collaboration with the Department of Defense and was able to maintain Duke Urology as a top 10 program in the nation throughout his tenure. Dr Moul completed his Urologic Oncology Fellowship at Duke University and graduated Summa Cum Laude from Pennsylvania State University. He earned his medical degree from Jefferson Medical College, where he was elected to Phi Beta Kappa and Alpha Omega Alpha. Dr Moul currently serves on the editorial boards of Prostate Cancer, Prostate Cancer and Prostatic Diseases, BJU International, American Journal of Mens Health, Brazilian Journal of Urology, World Journal of Urology, and Oncology REALTIME. He has published over 500 medical and scientific manuscripts and book chapters and has lectured at national and international meetings. He has appeared on ABC, NBC, CNN, PBS, and other media as a prostate cancer authority. Honors and awards received have included the American Medical Associations Young Physicians Section Community Service Award for his national involvement in prostate cancer patient support groups, the Sir Henry Welcome Research Medal and Prize from the Association of Military Surgeons of the United States, the prestigious Gold Cystoscope Award by the American Urological Association, the Baron Dominique Jean Larrey Military Surgeon Award for Excellence, the Order of Military Medical Merit from the Surgeon General at the US Army, and the Castle Connolly National Physician of the Year award.


    While the Prostate Specific Antigen (PSA) blood test has been available since 1986 and FDA-approved for the early detection of prostate cancer since the early 1990s, 2012 marked a critical inflection point when the US Preventative Services Task Force (USPSTF) gave PSA a D-rating and generally discouraged its use. This D-rating was based on one randomized controlled trial (RCT) that showed no survival benefit to screening and another RCT that showed a survival benefit but at the cost of over-detection of non-life-threatening tumors. Despite the USPSTF, the PSA test remains widely used and many experts feel that the PSA test is still valuable when used in a more intelligent way. In using PSA more effectively, the American Urological Association (AUA) and the National Comprehensive Cancer Network (NCCN) suggest that all men have a baseline PSA test at age 40 to assess their future risk of prostate cancer. Using this baseline along with changes over time in the form of PSA Velocity (PSAV) or PSA Doubling Time (PSA-DT) can help doctors pick of prostate cancer in young men where finding cancers is more relevant. Further ways to use PSA smarter include age-adjusting PSA levels to increase detection of important cancers in young men while avoiding detection of non-life threatening cancers in older men. Taking into account other high risk features such as family history and race/ethnicity can fine tune early detection efforts. In addition to using total PSA, other PSA tools include the percent free PSA, complexed PSA, and the urine-based molecular marker, PCA-3 can further improve the accuracy of prostate cancer early detection efforts. Finally, if a prostate cancer is detected, better risk stratification can help doctors decide if a patient requires active treatment with surgery or radiation or active surveillance.

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