Book Reviews

In men, the commonest cancer and a leading cause of death is prostate cancer. One of 8 Americans will develop prostate cancer. Up to 15% of all males in the USA will have an abnormal prostate specific antigen (PSA) (! 4 ng/ml). Having a serum marker for detection or prognosis is the holy grail of oncologists. Since 1970, PSA has been promulgated as a specific disease marker and increasingly as a screening tool. As a result, an epidemic of prostate cancers has occurred with an 85% increase in the last decade. Many asymptomatic men have been subjected to prostate biopsies and even radical surgery or radiation. The mortality has also decreased by 14% in the last decade. While some point to these changes as evidence for validation of this marker, others argue that the use of PSA has resulted in many insignificant prostate cancers being diagnosed and many men overtreated. These naysayers argue that no long-term randomized study has proven the worth of PSA. Major medical organizations differ greatly in their recommendations for the use of PSA as a screening tool. Those that use the PSA are continuing to define new parameters of the PSA assay including PSA density, velocity, free/bound ratio, etc. Unfortunately, the urological surgical community has embraced the use of PSA and as a result a randomized clinical trial is unlikely to be done soon. Michael Brawer has collected a series of authors who have written short chapters on many aspects of PSA including the history, chemistry, methods, and variations on PSA measurements (free, total velocity, density, complexes and age specific). Other contributors write about the utility of PSA for detection, repeating the biopsy, staging, and after surgery, radiation, hormonal and chemotherapy. Recommendations are plentiful, but few backup supporting data from controlled randomized trials are presented. There is an excellent chapter that details the various methods and the need to know about how the test has been standardized. The book represents a complete compendium of information about PSA, primarily from believers in its utility. Comparable data from the skeptics are barely mentioned. No information is presented on the cost effectiveness or utility of PSA testing. The impact on mortality is briefly mentioned. There are occasional statements that are contradictory. One author argues for the use of PSA when a randomized study shows no benefit for that indication. Hopefully, data for evidence-based decisions will be forthcoming. The one area that appears noncontroversial is the use of PSA as an indicator of relapse following treatment. Paul P. Carbone, Madison, Wisc. E.R. Barnea, E. Jauniaux, P.E. Schwartz (eds)