Prostate Specific Antigen

This state-of-the-art reference provides a comprehensive review of prostate specific antigen (PSA) and related prostate markers-examining velocity, density, and age-specific reference ranges for increased sensitivity in PSA tumor identification and selection of patient therapies.
Supplemented with helpful drawings, photographs, and tables that reinforce and clarify essential issues!
Considering PSA as a monitor for cancer, Prostate Specific Antigen explores

PSA levels during radiation, chemotherapy, and hormone therapy treatments

increased PSA levels in older men

the effect of acute urinary retention, acute bacterial prostatitis, and benign prostatic hyperplasia on PSA concentration levels

and more!
With contributions by over 30 internationally distinguished experts and containing nearly 2000 timely references, Prostate Specific Antigen is an essential tool for all urologists and urologic surgeons; medical, urologic, and radiation oncologists; pathologists; clinical chemists and biochemists; primary care physicians; and fellows, residents, and medical students in these disciplines.

The discovery of prostate-specific antigen (PSA), a serine protease, was one of the most important accomplishments in urologic oncology in the past 15 years. In a relatively short time and in an extraordinary way, this tumor marker affected virtually all medical and surgical aspects of prostate cancer, the most prevalent malignant neoplasm in men. Today, the PSA test is an essential tool for screening, early detection, staging, definition of outcome, selection of treatment, assessment of therapeutic effects, and determination of overall prognosis.

The strengths of Prostate Specific Antigen are in its coverage of the history of PSA, the various immunoassays for PSA, PSA density and velocity, PSA levels and age, and the biochemistry of PSA. Also useful are the discussions of early detection and the algorithms for diagnosis in men who are at risk for prostate cancer. The discussions of preclinical aspects are rather weak and poorly organized, however. Chapter 2, on basic science, has a well-written description of the biochemistry of PSA, its relation to other proteases of the kallikrein family, and the physiology and metabolism of PSA; it also includes an informative illustration that shows how the immunochemical properties of PSA affect immunoassays. Nevertheless, other important preclinical features of this marker are not mentioned.

Some aspects of the molecular regulation of PSA production are included in the chapter on hormonal treatment. This chapter discusses the changes in PSA that are associated with various endocrinologic treatments, including preoperative neoadjuvant treatment and intermittent androgen suppression, both of which are of unproved benefit. Interesting data on the changes in PSA observed with a variety of endocrine treatments and the correlations between PSA and established end points (such as palliative or symptomatic benefit, progression of disease, and survival) are described only briefly in this chapter.

In the chapter on chemotherapy, the authors adequately discuss PSA as a marker for drug development, but there is excessive emphasis on ``PSA responses'' in phase 2 trials, and there is no mention of the findings of recent prospective randomized trials. The description of the in vitro effects of drugs on PSA secretion is interesting, but the in vitro assay needs clinical validation. The excessive emphasis on the assessment of the therapeutic benefits of various hormonal and nonhormonal regimens on the basis of PSA results makes these chapters resemble a review of the treatment of prostate cancer.

This book covers most topics related to PSA in prostate cancer, but not important aspects of the natural history of the disease that have become apparent as a consequence of the routine use of PSA testing in patients with prostate cancer. Among these are stage migration and biochemical relapses, which in some respects are a manifestation of stage migration. Many patients seen in practice today present with biochemical relapses -- that is, rising serum PSA levels as the only manifestation of disease activity after primary treatment with surgery or radiation -- or with second relapses after androgen-deprivation treatment initiated at the time of an initial biochemical relapse. Such relapses are a challenge for clinicians, and consequently a review of what is known about the natural history of the disease and a balanced discussion of therapy would have been a welcome addition to this book.

Because of the profound influence of PSA testing on screening for prostate cancer and on the diagnosis and management of this disease, a book focused primarily on PSA will unavoidably be a compendium of information about prostate cancer. This is not the case with this well-written book. However, it is too specialized for physicians who seek guidance on how to use PSA values in the diagnosis and management of prostate cancer in their patients.

Mario A. Eisenberger, M.D.
Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.