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Counterpoint: The Case for Immediate Active Treatment

Stacy Loeb and William J. Catalona

Active monitoring strategies recently have received attention as possible treatment options for men with low-risk prostate cancer who have a life expectancy of more than 10 years. However, no current criteria sufficiently predict outcomes for individuals with clinically localized disease and an otherwise long life expectancy who undergo either immediate or delayed treatment, or no treatment. This article describes the available evidence regarding treatment outcomes in men with low-risk prostate cancer and presents the case for immediate active treatment.

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Point: Impact of Prostate-Specific Antigen Velocity on Management Decisions and Recommendations

Stacy Loeb and H. Ballentine Carter

Prostate-specific antigen (PSA) velocity predicts the presence of prostate cancer on biopsy and a greater risk of prostate cancer death after radical treatment. A new variation on PSA velocity called the risk count was recently shown to provide incremental reclassification for intermediate to high-grade disease on biopsy beyond PSA and age. These markers therefore have the potential to reduce overdiagnosis and overtreatment of indolent prostate cancer, and several professional guidelines support the use of PSA kinetics along with other predictors as part of the diagnostic algorithm. Among men already diagnosed with prostate cancer, PSA kinetics may also be helpful in predicting prognosis after definitive therapy.

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Prostate Cancer Screening and Determining the Appropriate Prostate-Specific Antigen Cutoff Values

William J. Catalona and Stacy Loeb

Prostate-specific antigen (PSA) in combination with digital rectal examination forms the basis for current prostate cancer (CaP) screening programs. Although PSA screening was recently shown to reduce CaP-specific mortality in the European randomized trial, its limitations include the risk for unnecessary prostate biopsy and the diagnosis and treatment of some CaP that might never have caused suffering or death. A potential way to minimize these pitfalls is through the use of derivatives of PSA, particularly PSA kinetics, to increase the specificity for clinically relevant CaP. CaP is the second-leading cause of cancer death in men in the United States and many other westernized countries; accordingly, judicious screening of healthy men allows for diagnosis sufficiently early that all options (i.e., treatment or surveillance) are still available in most cases.