Top doc gives ProState (Cancer) State of the Union

Questions value of PSA velocity; boosts Free PSA and MRIs.

By Howard Wolinsky

(Editor's notes: 1, The Active Surveillor. My motto is “Saving prostates daily.” But the real deal is to make sure you are aware of your choices, such as Active Surveillance. Still a whopping 40% of us choose surgery or radiation over AS. I share news and views to help you be an informed patient. The content is free but, if you can, dig deep and get a “paid subscription” and donate to keep the broadband on.

2) Dr. Scott Eggener put me on Active Surveillance in 2010. He is one of the great urologic oncologists. He saved me from unnecessary surgery, which in those days was still causing an epidemic of side effects. I work with him on research projects as a patient-researcher and on a campaign (his career goal) to rename Gleason 6 as a non-cancer. Folks, Dr. Eggenger’s got our backs—and prostates.)

By Howard Wolinsky

Scott Eggener, MD, Vice Chair of the Section of Urology, and Director of the High Risk and Advanced Prostate Cancer Clinic at the University of Chicago, warned his fellow urologists that not all patients need PSA (prostate-specific) screening.

“We’ve got a bit of an epidemic of sick older men getting PSA [tests],” he told the Large Urology Group Practice Association (LUGPA) recent annual meeting in Chicago.

He urged attendees to familiarize themselves with current screening guidelines.

(Check out my blog: “Should Older Prostate Cancer Patients Jump Off the Active Surveillance Train?” and calling for new guidelines. to screen older men.)

Targeted Urology Magazine in its article by Ben Saylor: “Eggener Urges Pragmatic Approach to Prostate Cancer Innovations” filled in readers on Eggener’s LUGPA talk in its March 14 edition.

Repeat, repeat, repeat

Eggener stressed the importance of repeating a PSA test when a patient has an elevated PSA level. “I’m not sure of any situation with screening treatment or posttreatment where you change the plan based on one new change in PSA. Always repeat it,” he stressed.

Not so fast with PSA velocity

Obtaining a baseline PSA leve, Eggener said, “is gold. PSA velocity, on the other hand, is not very helpful.”

(Targeted Urology: Dr. Scott Eggener, This doctor should be drawn and quoted. And he was.)

Some prominent doctors still may stress PSA velocity. Get informed by Mayo Clinic about about PSA velocity in PSA Tests.

Mayo agrees with Eggener: “PSA velocity is the change in PSA levels over time. A rapid rise in PSA may indicate the presence of cancer or an aggressive form of cancer. However, recent studies have cast doubt on the value of PSA velocity in predicting a finding of prostate cancer from biopsy.”

Eggener added: “There are a lot of tests out there that absolutely, positively outperform traditional PSA. The good news is some of them are easily accessible and cheap.”

The tests, he explained, do well at identifying men with PSA grade group 2 or higher. But he said he rarely orders them.

Free(all) PSAs?

“I tend to use PSA free, PSA, PSA density [tests], things like that. There are absolutely times I order these, but it’s certainly not a reflexive [automatic test triggered by outcomes from another] test. But there is absolute value in these tests. I do think it’s also important for us to remember all the cheap, free things that are at our disposal to make smart decisions with screening,” Eggener said.

“I think [the] free PSA [test]—if we could monetize it, commercialize it, sell it—is better than [the] total PSA [test] if you look at the raw data. If someone asked me, ‘Would I rather know my total PSA or my free PSA [level]?’ I’d rather know my free PSA [level], so every single person I screen, I get a free PSA [level] on.”

Learn from Mayo’s PSA Tests about the fine points of these tests:

• Percentage of free PSA. PSA circulates in the blood in two forms — either attached to certain blood proteins or unattached (free). If you have a high PSA level but a low percentage of free PSA, it may be more likely that you have prostate cancer.

• PSA density. Prostate cancers can produce more PSA per volume of tissue than benign prostate conditions can. PSA density measurements adjust PSA values for prostate volume. Measuring PSA density generally requires an MRI or transrectal ultrasound. For more on PSAD, see Dr. Michael Leapman’s Active Surveillor blog, “Yale urologic oncologist Michael Leapman covers PSA density...”

(Dr. Scott Eggener, UChicago)

The great MRI takeover

Eggener gave a shout out to MRI imaging.

When I had my first MRI test in 2011 as Eggener’s patient in the early days of prostate MRI scanning, there were kinks. Discover my personal hell with MRI testing—at the University of Chicago-at the hands of Torquemada the Tech:

However, Eggener said in Targeted Urology: “MRI has taken over. MRI is a win. There is value, but they’re good, sometimes great, and rarely perfect,” Eggener said.

PSMA-PET a winner

He added that prostate-specific membrane antigen (PSMA)-PET imaging. PSMA-PET, he said, is a “clear winner” vs MRI.

“It would be wonderful if PSMA-PET was cheaper, easier, quicker. I’d love to order it [for] all my patients, from surveillance on up. I don’t, because at least at our place, I’m told it’s a $7,000 test, and I try to be at least cost conscious with it. I hope there’s a time where we order it more regularly,” Eggener said.

Learn more about PSMA PET in my blog, “Inquiring minds want to know: Why isn't PSMA PET used in men with low-risk prostate cancer?”

Deciphering Decipher

Eggener gave kudos to Decipher “based on extensive validation [and] really good science. I do think it has value in certain clinical situations [such as deciding] between surveillance and treatment when you’re looking for something to tip the needle a little bit.”

Still, he said: “No matter what the Decipher [score] shows, you’re not going to change a darn thing in your counseling or your management for that patient,” he said.

Focusing on focal

Regarding focal therapy, Eggener said,“There are a lot of visceral opinions on focal therapy and a lot of blowback. I have absolute confidence there’s going to be a subset of patients [for whom] focal therapy is a very reasonable option.”

Rad views?

Eggener also touched on radiation therapy, including proton therapy and hypofractionation: “Proton therapy is exactly the same as regular radiation therapy for prostate cancer. It’s not any better, it’s not any safer, there are not fewer adverse effects.”

Regarding hypofractionation, he reminded the audience of its place in the clinical guidelines as a viable option. “If…your patients are getting 6 to 8 weeks of radiation therapy, there’s only 1 benefit of those 6 to 8 weeks…and it’s not to the patient,” he stressed.

Ouch.

“You have to be balanced in what to embrace vs what not. It is easy to be wowed by new things. I think it’s part of our operating system, and it’s also…easy to be hijacked by things that may not be so important for patients,” Eggener said.

What’s else is new?

—Did Dr. Eggener’s comments on the Decipher grab your attention? You ought to to attend ASPI’s monthly session: “Sorting out biomarkers: A Guide for patients on Active Surveillance.” PSAs, MRIs and biopsies each tell part of the story on prostate cancer. But increasingly, biomarkers are playing a role in making decisions on Active Surveillance vs. treatment for men with lower-risk prostate cancer. The program features Jonathan Tward, MD, PhD, an international authority on biomarkers.

The webinar will be held at noon to 1:30 p.m. Eastern on Saturday March 29, 2025. Register here: https://zoom.us/meeting/register/wsESZAXeR8Shp7FU60FHvg

Send your questions in advance to: contactus@aspatients.org

—The story of my personal PCa journey appears in the spring edition of Cancer Health Magazine. Give it a spin: Deciding Not to Treat My Cancer/Active surveillance spares men with low-risk prostate cancer, like me, from aggressive treatment and its side effects. Early reviews are good. Please give me some love and comment.

Check out your personal microbiome

By Howard Wolinsky

Researchers at University of California, San Diego are validating the gut microbiome--the community of germs in our gut that help keep us going— as a biomarker for prostate cancer aimed at men on Active Surveillance for low-risk prostate cancer.

Participants get a free diet assessment/score, a microbiome report, and $25 gift card,

Don’t wait. Sign up to see if you’re eligible.

Men aged 40-80 being screened for prostate cancer or on active surveillance (Grade Group 1 Prostate Cancer) are eligible. Subjects are not eligible for participation if they have taken antibiotics within the last 3 months or have undergone prostate cancer treatment.

The study is evaluating a test called PRIMUS (Prostate Cancer Risk Insight through Microbiome Understanding) that is being optimized and researched to assess its potential in predicting prostate cancer risk and progression.

On a personal note, I used microbiome information from a defunct Israeli companyto reverse my newly diagnosed type 2 diabetes. Read all about it: https://www.medpagetoday.com/special-reports/apatientsjourney/70477

ZERO loses DOD funding battle

By Howard Wolinsky

Last week, ZERO Prostate Cancer took the fight to Congress to try to maintain funds at the U.S. Department of Defense for prostate cancer research—especially for men with lethal cancers.

The war is over. We lost. But ZERO promises to stand up and fight another day.

A ZERO spokeswoman said: “Despite our best efforts and nearly 4,000 direct advocacy actions to lawmakers, Congress finalized funding legislation on Friday evening, averting a government shutdown. Due to this unprecedented situation, the Congressionally Directed Medical Research Programs (CDMRP), which houses the Prostate Cancer Research Program (PCRP), has suffered a 57% funding cut.

“This means that for the first time in history, the Department of Defense (DOD) will operate under a Continuing Resolution (CR) for a full fiscal year. ZERO and the PCRP are inextricably linked. In fact, ZERO was founded to advocate for the creation of the PCRP. The program’s groundbreaking research at the DOD has led to FDA-approved treatments and saved many lives. Cutting this vital funding is a gut-wrenching blow to the patients, families, and communities who depend on these lifesaving breakthroughs.”

“While we were unable to prevent this cut, our work is far from over. ZERO is actively pursuing multiple avenues to protect the PCRP and to ensure that robust funding is available for this critical program for years to come. The CR does not reverse NIH cuts. It cuts funding for NIH by approximately $280M due to reduced funding transferred from the 21st Century Cures Act.”

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