ijhcqa10.1108/ijhcqaInternational Journal of Health Care Quality Assurance0952-6862Emerald Group Publishing Limited10.1108/ijhcqa.2011.06224eaa.004e-non-articleSecondary articleNews and viewscat-HSCHealth & social carecat-HMANHealthcare managementcat-HPLHeathcare policy & lawcat-HSQHealth service qualitycat-HSDHealth service deliveryUnited States of America - Prostate guideline causes many needless biopsies14062011245© Emerald Group Publishing Limited2011Prostate cancer guidelines, Healthcare research, Disease diagnosis and management.peer-reviewednoacademic-contentyesrightslinkexcludedUnited States of America - Prostate guideline causes many needless biopsies

Article Type: News and views From:International Journal of Health Care Quality Assurance, Volume 24, Issue 5

Keywords: Prostate cancer guidelines, Healthcare research,Disease diagnosis and management

Current guidelines for the early detection of prostate cancer recommend abiopsy for men whose PSA rises rapidly, no matter what the initial level. But anew study says that the practice does not help patients find aggressive cancersand results in many unnecessary biopsies.

PSA, or prostate-specific antigen, rises with age, and what is considerednormal varies. In general, a level under 4 nanograms per milliliter isconsidered safe. But even with a normal reading, an increase of 0.35 nanogramsper year is widely believed to be high enough to require a biopsy.

Researchers examined the records of 5,519 men with a base-line PSA under 3.They followed them for seven years with yearly tests and a biopsy if the levelrose above 4.

They also analysed PSA velocity – the rate of change in readings fromyear to year. But after adjusting for age, base-line PSA and other factors, theyfound little evidence that ordering a biopsy for men whose velocity was greaterthan 0.35 helped find prostate cancer. And it was particularly useless inuncovering the most aggressive types of cancer, the ones most important totreat.

The researchers, writing in the March 16 issue of The Journal of theNational Cancer Institute, concluded that using PSA velocity for prostatecancer detection is ineffective, that it leads to unnecessary biopsies and thatreferences to it should be removed from professional guidelines and policystatements.

Andrew J. Vickers, the lead author, drew an analogy: a basketball player’sheight, he said, is important to his ability to play, and it correlates veryclosely with his shoe size. But once you know his height, his shoe size isirrelevant to judging his value as a player.

Similarly, it is easy to demonstrate a statistical relationship between sharprises in PSA and cancer, but the correlation reveals no more information than isalready available with a PSA reading, a digital examination and a familyhistory. It is irrelevant in deciding whether a biopsy is needed.

Not all experts agree. Dr Anthony V. D’Amico, a professor of radiationoncology at Harvard, said that the methodology of Dr Vickers’s study wassound, but that the data gathered was almost certainly flawed.

The problem, Dr D’Amico said, is that many factors that have nothing todo with prostate cancer can cause a rapid increase in prostate-specific antigen.Sexual activity, riding on a bicycle or on horseback, a recent colonoscopy, abladder or prostate infection, even variations in the ways laboratories performthe test can radically affect the readings.

“It may well be that the high velocity in your case is not important,”he said. “But before you reach that conclusion, I would get a repeat PSA.”If there is still a spike after eliminating those other possible causes, hecontinued, a biopsy should be the next step.

Dr Vickers, a researcher at Memorial Sloan-Kettering Cancer Center in NewYork, agreed that prostate cancer was only one of many reasons for a high PSA.“A doctor sees a high PSA and says, ‘could this be cancer or someother reason?’” he said. “Well, the thought was that PSAvelocity could help you think this through” – that measuring the rateof change would be decisive.

But in practice, Dr Vickers said, it does not work. If he had strictlyapplied the guidelines to the men in his study, he said, one in every sevenwould have required a biopsy. This would mean millions of American men wouldneed biopsies, he said, with almost none revealing a cancer.

Dr Vickers and his colleagues acknowledged that there might be better methodsof calculating PSA velocity that could lead to more accurate predictions, andthat some effect might have been found if the patients had been followed formore than seven years.

But at this point, he is firmly against biopsies on the basis of velocityalone. “If your PSA is in the normal range, you shouldn’t get abiopsy,” he said. “Changes or spikes in PSA are not something toworry about if your PSA is still normal.”

For more information: www.nytimes.com