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PURPOSE: To describe practice patterns and beliefs of primary care physicians and urologists regarding early detection and treatment of prostate cancer. SUBJECTS AND METHODS: National probability samples of primary care physicians (n = 444) and urologists (n = 394) completed mail survey instruments in 1995. Physicians were asked about their use of prostate-specific antigen (PSA) testing for men of different ages and their beliefs about the value of radical prostatectomy, external-beam radiation therapy, and watchful waiting for men with differing life expectancies. RESULTS: Most primary care physicians report doing PSA tests during routine examination of men older than 50 years of age. The majority say they continue to do them on patients over 80 years and to refer men with abnormal values for biopsy. In contrast, only a minority of urologists would recommend PSA tests or biopsy for abnormal values for men over 75 years of age. More than 80% of primary care physicians and urologists doubt the value of radical prostatectomy for men with [greater than] 10 years of life expectancy; more primary care physicians than urologists see probable survival benefit in radiation therapy for patients with life expectancy [greater than] 10 years (48% versus 36%) or [less than] 10 years (67% versus 53%). Thirteen percent of primary care physicians and only 3% of urologists consider watchful waiting to be as appropriate as aggressive therapy for men with [less than] 10 years of life expectancy. CONCLUSIONS: Primary care physicians are more aggressive about PSA testing and referral for biopsy than most urologists recommend. Both groups recommend PSA testing and believe that aggressive treatment is more beneficial than existing evidence indicates. Am J Med. 1998;104:526-532. [C] 1998 by Excerpta Medica, Inc.

Background: Most studies that have described the sensitivity and specificity of prostate-specific antigen (PSA) as a screening test have been conducted in urology practice settings or in media-based screening programs. The control patients from these settings may have a higher prevalence of urologic disorders that increase serum PSA levels than that of the general population in which screening efforts might take place, leading to biased estimates of sensitivity and specificity. Objective: To determine the sensitivity and specificity of serum PSA levels for the early detection of prostate cancer in a population-based setting. Patients and Methods: This population-based case-control study was conducted in Olmsted County, Minnesota, where the Rochester Epidemiology Project could identify all incident cases of prostate cancer through passive surveillance of medical care provided to local residents. Case patients were all 177 men (age range, 50-79 years) who were newly diagnosed as having prostate cancer from 1990 through 1992 and had a prediagnostic serum PSA determination (90% of all incident cases). Control patients were randomly selected from the Olmsted County population and had undergone a clinical examination to exclude prostate cancer. Results: The median (25th and 75th percentiles) of serum PSA levels was 9.4 ng/mL (5.4 and 18.6 ng/mL, respectively) for case patients and 1.2 ng/mL (0.7 and 2.1 ng/mL, respectively) for control patients (P

Prostate specific antigen (PSA) is the most valuable clinical tool available for the diagnosis and staging of prostate cancer. Serum PSA can detect twice as many prostate cancers as digital rectal examination can, and nearly two thirds of these detected tumors are organ-confined and potentially curable. While the diagnostic, routine digital rectal examination has no clinically significant effect on the serum PSA concentration, finasteride therapy causes a 50% lowering of the serum PSA value. The new concepts of PSA velocity, free versus complexed PSA, and age-specific reference ranges all appear to improve further the clinic utility of PSA as a detector of early, potentially curable prostate cancers in men who are most likely to benefit from therapeutic intervention. The serum PSA concentration, when combined with the local clinical stage and histologic grade based on the biopsy specimen, is an excellent predictor of pelvic lymph node status. The probability of pelvic lymph node involvement approaches zero for prostate cancer patients who have the following characteristics: local clinical Stage T1a-T2b disease, primary Gleason grade 1 or 2, and a serum PSA level of 17.1 ng/ml or less; local clinical Stage Tla-T2b disease, primary Gleason grade 3, and a serum PSA level of 8.0 ng/ml or less; local clinical Stage T1a-T2b disease, primary Gleason grade 4 or 5, and a serum PSA level of 4.2 ng/ml or less; local clinical Stage T2c disease, primary Gleason grade 1 or 2, and a serum PSA level of 4.1 ng/ml or less; local clinical Stage T2c disease, primary Gleason grade 3, and a serum PSA level of 2.0 ng/ ml or less; and local clinical Stage T2c disease, primary Gleason grade 4 or 5, and a serum PSA level of 1.0 ng/ ml or less. Staging bilateral pelvic lymph node dissection (open or laparoscopic) can be avoided in these select men. Serum PSA is also an excellent predictor of radionuclide bone scan findings. For patients with newly diagnosed, untreated prostate cancer, no skeletal symptoms, and a serum PSA concentration higher than 10 ng/ml, the probability of a positive bone scan approaches zero. For men who present with this clinical scenario, a staging radionuclide bone scan is not necessary. Using serum PSA to eliminate the staging bilateral pelvic lymph node dissection and radionuclide bone scan in select patients can result in significant economic savings to the health care system. Cancer 1995,75:1795-804.