The Association between PSA and Prostate Size

Right on the heels of the American Cancer Society’s recent controversial response to breast and
prostate cancer screenings guidelines, a new study from the Mayo Clinic has emerged analyzing
the correlation between prostate-specific antigen (PSA) levels and prostate size. The study
discovered that routine annual evaluation of prostate growth does not predict the development of
prostate cancer. The study also suggests that a rapidly rising PSA level would automatically
prompt a biopsy to determine the possibility of prostate cancer.

However, a change in prostate size should not determine the decision to biopsy the gland for
cancer. It’s the rising, or rapidly fluctuation PSA level, among other indicators, that should
prompt the decision to investigate the possibility of cancer further.

The study, based on data in the Olmsted County Study of Urinary Health Status among Men,
followed the prostate examinations of 616 men between the ages of 40 and 79, who did not have
prostate disease, every two years for 17 years. Out of the study group, 9.4% of the subjects
developed prostate cancer. Those who were diagnosed had a faster rise in PSA levels, at an
increase of 6% per year. Those who were not diagnosed with cancer only experienced an increase
of 3.3% per year. Interestingly, the increase in prostate size was similar between these two
groups, with a change of 2.2% per year.

What the study seems to demonstrate is that there is no relationship between the growth rate of
the prostate and the rise in PSA levels. However, the study indicated that a rising PSA level alone
prompted the need for a biopsy to determine the likelihood of cancer. Of course rising PSA levels
are a great concern, but the amount of fluctuation between the numbers is what should be
monitored when determining the need for a biopsy.

Many oncologists take into account not only three sets of recent PSA screenings, but also a digital
rectal exam (DRE) and Gleason scores (which classifies the stage and grade of prostate cancer).
The disease progresses differently in every patient. Therefore, these three numbers, factored in
with age and family history, are what give doctors a clearer picture of what kind, stage, level and
progression of prostate cancer they are dealing with.

Additionally, the study followed the subjects on their prostate exams every two years. It’s no
surprise that a PSA level should rise so high in 2 years, which is why doctors use a variation of
testing factors to determine a baseline for fluctuations, as well as recommending screenings
annually, sometimes bi-annually for patients with high risk factors.

This method appears to be upheld in another recent international study by the Fox Chase Cancer
Center in Philadelphia. The findings showed that patients that had undergone radiotherapy and
experienced a rapid PSA level rise within 18 months were more likely to die from the disease.
Early PSA failure predicted more than a 25% decline in five-year survival rate of the group
compared with failure after 18 months. In a separate analysis for this particular study group, the
time to PSA failure overrode Gleason score, tumor stage, age, and PSA doubling time as a
predictor of mortality. Even though the study group had been diagnosed with cancer and treated
with radiotherapy, the findings indicated that it is not advisable to wait until the PSA rises or
another clinical evidence manifests itself. Initiating treatment sooner without waiting for other
signs or symptoms of prostate cancer is the best course of action.
The take-away message for both of these studies is that 1) PSA levels and prostate growth rates
work independently of each other and 2) the length of time that PSA levels are not actively
monitored, and allowed to fluctuate and rise, can deeply impact mortality.