Intended for healthcare professionals

Rapid response to:

Press Press

The PSA storm

BMJ 2002; 324 doi: (Published 16 February 2002) Cite this as: BMJ 2002;324:431

Rapid Response:

The PSA Storm

This letter concerns The PSA Storm and the letter to the San
Francisco Chronicle criticizing the use of PSA.

The PSA controversy will continue with us until sufficient data paves
a clear way for us on the relationship of PSA and the relative merits of
the modalities used to treat...whatever it is we are treating.

Irrespective, other matters are worth commenting upon in the letter.
In the opera, The Phanthom advises his love that "Hearing is
believing...the truth isn't what you want to see, in the dark it is easy
to pretend, that the truth is what it ought to up your mind, let
your fantasies unwind, in this darkness which you know you cannot fight.
Close your eyes start a journey through a strange new world, leave all
thoughts of the world you knew before." This is not so easy as it may

Today, it seems, no one has clean hands when it comes to taking a
position on the value of the use of PSA. Agendas are everywhere. The
paradigm, 'elevated PSA, do something', has a rational appeal to our
simplistic thinking that is so often correct. Although benign factors may
be the cause of an elevated PSA, missing a malignancy seems genuinely more
serious. Yet, in the realm of knowing, strong as it is in some
disciplines, we still falter when it comes to the biological sciences.
The early finding of an elevated PSA and the curative removal of the
prostate do not necessarily coincide. Nothing is more disheartening than
to remove a prostate in a young person with seemingly minimal and
localized disease only to have he PSA re-present itself later. What it
demonstrates is not that a lobby has been busy or successful in getting
doctors to use the test in anticipation of offering some modality, but
rather that we are still searching. Doing nothing about the situation is
not doing enough.

Yet, knowledgeable and committed scientists contend that any cancer
at presentation is de facto systemic disease. Here, one hears the call
for work on the causative end. Against this fatalistic philosophy are the
abundance of cases with no evidence of recurrent PSA or prostate cancer
for many years post radical prostatectomy.

The fact that the value of breast mammography is being challenged
presently in no way supports demeaning the use of PSA and its possible
association with early curable prostate cancer. Breast mammography is a
radiological study; PSA is a biochemical test. There are certainly
difference spatially in the function of a cell and the calcification of
cells. One cannot see noncalcified malignant breast cells by mammography.
And that is not what we are trying to see with PSA; we are assuming a
change in cellular behavior at the breaking point. At least this seems to
be the case.

I have had no experience with the 'dominance of the pro-screening
lobby' and my colleagues seem earnest in their contention that a rising
PSA in the face of a biopsy proven malignancy cannot mean spring is around
the corner; these seeds should be considered bad.

What the authors mean that the 'PSA test was unreliable, that it
often picked up innocuous tumours, and that picking up such tumours harmed
men by causing anxiety and by subjecting them to unnecessary cancer
treatments with serious side effects,' defies comprehension. What is
unreliable about an elevated PSA and what do they mean by innocuous

A brief window of opportunity is here in which to take a position.
It may not last; governments falter in their promises of health care. It
is unrealistic to expect the British to be interested in assessing the
screening value of PSA; the cost to the Crown would be staggering and as
someone once wrote, England is only a little larger than two times Lake
Victoria. In the same vain, America's promise is beginning to falter,
explaining the sudden rash of new modalities in the treatment of either
benign or malignant prostate disease. The window is to let things alone
and see what works best in the end.

Reflecting, it is worthwhile to muse on Hunter's advice to
Jenner who asked on whether to vaccinate; "Why think," responded Hunter,
"Try the experiment." The world knows the end of that. Rather than
berating one another we should respect differing stances and await the
ultimate assessment. The truth has a way of floating to the top.

Competing interests: No competing interests

16 February 2002
Anthony W. Orlandella MD
Assistant Clinical Professor of Urology UCI
None other
34052 La Plaza Suite 102 Dana Point CA 92629