Advice On How To Use Prostate Screening

Dr. Martin Solomon, a Harvard Med School professor who serves as medical director of Brigham and Women's Primary Care of Brookline, Mass., talks about how men should go about deciding when to undergo PSA screening for prostate cancer.

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And joining us now to talk about what this study means is Dr. Martin Solomon. He's the associate professor of Internal Medicine at Harvard Medical School and medical director of Brigham and Women's Primary Care of Brookline. He joins us now from Boston.

Dr. Solomon, welcome to the program.

Dr. MARTIN SOLOMON (Associate Professor of Internal Medicine, Harvard Medical School; Director, Brigham and Women's Primary Care): Thank you, Michele. Good afternoon.

NORRIS: Do you find these studies helpful in advising your patients? A man, say, comes in, he's in his 50s and 60s and he wonders what these numbers mean to him. How does he decide whether or not to get this PSA test?

Dr. SOLOMON: Well, unfortunately, I think these studies only addressed a small part of the question, which is: What is the significance of an isolated, elevated PSA? And if PSAs are used for screening only on that basis, looking at an absolute high number, then you're going to have a very low outcome and a low yield. What most primary care clinicians do is to follow the PSA over time. And if the PSA is rising, that's a much better indication of whether or not there's a problem. So I encourage people to have the PSA, but I don't take action based on one PSA reading, regardless of the level.

NORRIS: And you say if it's rising. Let's say it's above four.

Dr. SOLOMON: It really doesn't matter what the absolute number is. There are lots of people out there with PSAs of eight, nine, 14 that have benign disease. What's really important is whether this is a changing phenomenon. And that's the advantage that a primary care physician has, where we can examine a patient, check the prostate. If the prostate feels reasonable, then simply monitor the PSA over time. And you may repeat it in three months or six months.

And if it remains flat, just continue to monitor. If it rises rapidly, and there are pretty strict criteria for what that means, then that might be a reason to consider a biopsy.

NORRIS: Now, this study also raises questions about the course of treatment. If cancer is found, there are questions about how the patient should proceed, whether - the question is about whether cancers are more aggressive than others. Which are dangerous? Which are the toothless lions that Dick Knox just described? Are there tests that you can do to determine whether or not the cancer is aggressive or not?

Dr. SOLOMON: Well, a lot can be told based on the appearance of the cells when the pathologist reviews them. We use something called a Gleason score, which assesses the rapidity of turnover of the cells, something about the structure of them. And there's a fairly good correlation between the Gleason score and how aggressive a tumor is.

So if a 55-year-old man comes in, has an abnormal PSA that's rising, and a biopsy's done and it shows prostate cancer with a very low Gleason score, then doctor - I think it's Rable's(ph) suggestion of expectant watching and observation is reasonable. But if they have a PSA of eight or nine or even seven, you might take a much more aggressive approach because we know those patients will do worse.

NORRIS: Well, we just heard Dr. Barry in that previous story say that this is a debate or a controversy that refuses to die. Dr. Solomon, this all seems very confusing.

Dr. SOLOMON: It is confusing. And I think it's important that patients understand that there is confusion around it. And that's why you can't just rush somebody off to a biopsy with an elevated PSA. You really have to talk about what it means. My experience, most patients do a lot of research on this. They often get multiple opinions before they make a decision.

NORRIS: And just quickly, we only have just a couple of seconds: When they ultimately make that decision, best to look to their doctors or to go that step further and do that extra research?

Dr. SOLOMON: Well, hopefully, the doctor will provide them with materials that they can read and do their own research, can do research online, talk to other physicians. But ultimately, they should try to make the decision with their primary care physician.

NORRIS: Dr. Solomon, thank you very much.

Dr. SOLOMON: Thank you.

NORRIS: That's Dr. Martin Solomon. He's associate professor of Internal Medicine at Harvard Medical School.

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