PSA TESTING AND PROSTATE CANCER
DEMOGRAPHICS
Prostate cancer is the most common cancer in males. 2000 new cases of prostate cancer are diagnosed in Western Australia every year. Prostate cancer is the third most common cause of cancer-related deaths in males (12%).
Risk factors
Increasing age, family history (2-11 times higher), smoking (2 times higher), ethnicity (African Americans 2 times higher, Asians lower), obesity, dietary excess (animal fat)
Digital rectal examination
The prostate feels very firm, irregular, asymmetrical or nodular.
DIAGNOSIS
The issue of PSA as a screening test is highly debated amongst urologists. When utilised appropriately, in combination with digital rectal examination (DRE), it is still the best and cheapest tool for the early detection of prostate cancer.
Half of patients with a PSA of 4-10 and abnormal DRE will have prostate cancer. If the PSA is elevated, with a normal DRE, the risk is 30%. Non-cancer causes of PSA include BPH, urinary tract infection, urinary retention, ejaculation, prostatitis and urological instrumentation. If these are suspected and treated, the PSA test should be repeated in 4 to 6 weeks.
PSA
Men interested in their prostate health should have the first PSA should be performed at the age of 40 years, especially if a patient’s father or brother have prostate cancer. Studies show that if the PSA is >0.6, there is a 3.5-fold increased risk of cancer over the next 25 years, with worse cancer survival rates if diagnosed. The same applies for a PSA of >0.7 in a man aged 50 years.
WHEN TO REFER
- When the PSA is higher than the 95th percentile
- When the PSA increases by more than 0.4 ng/ml/year
- When the DRE is suspicious, regardless of PSA level
If the PSA is higher than the median, the patient should be monitored with regular DRE and PSA.
Finasteride (Proscar or Duodart) is becoming a popular treatment for BPH. Finasteride reduces the PSA by 50% so it is important to remember that the threshold PSA level for an abnormal result is lower in these patients. Other factors that may lower PSA are previous TURP, prostate supplements, anti-inflammatories and obesity.
Prostate cancer is diagnosed on transrectal ultrasound guided biopsy of the prostate. This is performed under local anaesthetic or sedation, and 12-14 cores of tissue are taken from all the zones in the prostate. There is a small risk of missing anterior tumours, and some patients with negative biopsies and persistently rising PSA tests may undergo an extensive transperineal biopsy using a grid or prostatic MRI.
MANAGEMENT
Once a diagnosis of prostate cancer is made, the urologist will assess the patient’s life expectancy, co-morbidities, PSA, Gleason grade and biopsy cancer stage.
Patient factors
The benefits of active treatment are greatest in a young, fit patient with prostate cancer. If the patient is >75 years of age and/or has multiple co-morbidities that reduce his life expectancy to less than 10 years, then expectant management may be appropriate.
Disease factors
Studies show that 30% of prostate cancers are potentially incurable using a PSA cut-off of 4.0. With lower thresholds for biopsy, we are detecting a higher proportion of minimal risk disease. In Western Australia, UroPath have provided a online nomogram (http://www.uropath.com.au/pre-operative-nomogram.html) to predict the likelihood of minimal risk disease for a patient and suitability for active surveillance.
The following table describes the parameters and treatment for different stages of cancer progression. The parameters are stereotypical and should only be used as a rough guide, as there are many exceptions.
| Risk | Diagnosis | Treatment Options |
|---|---|---|
| Minimal | PSA <10 Gleason 6 Stage T2 <3 positive cores <50% each positive core |
Active surveillance Low dose (seed or LDR) brachytherapy Robotic, laparoscopic or open radical prostatectomy with nerve-spare Watchful waiting |
| Intermediate | PSA <10 Gleason 6-10 Stage T2, N0, M0 |
Robotic, laparoscopic or open radical prostatectomy Image-modulated radiotherapy (IMRT), low dose (seed or LDR) or high dose (HDR) brachytherapy Watchful waiting |
| High | PSA >10 Gleason 7-10 Stage T2-4, N 0-1, M0 |
IMRT + neoadjuvant androgen deprivation therapy (ADT) +/- HDR boost Multi-modal therapy (surgery +/- radiotherapy) Watchful waiting |
| Metastatic | PSA >20 Gleason 7-10 Stage T2-4, N 0-1, M 1 |
Early ADT Delayed ADT Targeted radiotherapy for symptom control |
Whole Body Bone Scan
This is performed to exclude bony metastases, for patients with biopsy Gleason score >7, PSA >10 ng/ml and palpable disease (cT2/T3) prior to treatment. In general, a bone scan is recommended prior to curative treatment as a positive result is a contraindication to surgery or radiotherapy.
MRI
Urologists use multi-parametric prostate MRI scans to help with planning treatment for prostate cancer, or when there is clinical suspicion of cancer with persistently negative biopsies. There is a general consensus that MRI should not replace biopsy for the initial diagnosis of cancer.
Further information about treatment options can be found in the articles or links below. Please click here for information about radical prostatectomy (link to 3E Radical Prostatectomy).
REFERENCES
The references are for health care professionals. To access information for your patients, please click here to be directed to the Resources page.
PSA SCREENING
Esserman L, Shieh Y, Thompson I. Rethinking screening for breast cancer and prostate cancer. JAMA 2009;302(15):1685-92. http://jama.jamanetwork.com/article.aspx?articleid=184747
Lawrentschuk N, Klotz L. Active surveillance for low-risk prostate cancer: an update. Nat Rev Urol 2011;8:312-20.
http://www.nature.com/nrurol/journal/v8/n6/pdf/nrurol.2011.50.pdf
USANZ 2009 PSA Testing Policy http://www.usanz.org.au/uploads/29168/ufiles/USANZ_2009_PSA_Testing_Policy_Final1.pdf
USANZ Media Release – 23 September 2009
National Cancer Institute Fact Sheet regarding PSA Test (PDF file – PC NCI fact sheet.pdf)
The Early Detection of Prostate Cancer in General Practice: Supporting Patient Choice (PDF file – PSA How to Use.pdf)
BONE SCAN
Briganti A, Passoni N, Montorsi F, et al. When to perform a bone scan in patients with newly diagnosed prostate cancer: external validation of the current available guidelines and proposal of a novel risk stratification tool. Eur Urol 2010;57:551-8.
http://eu-acme.org/europeanurology/upload_articles/Briganti%20April%2010.pdf
PROSTATE MRI
Barentsz J, Richenberg J, Futterer J. ESUR prostate MR guidelines 2012 (PDF file – PC MRI.pdf)
ACTIVE SURVEILLANCE
Lawrentschuk N, Klotz L. Active surveillance for low-risk prostate cancer: an update. Nat Rev Urol 2011;8:312-20.
http://www.nature.com/nrurol/journal/v8/n6/pdf/nrurol.2011.50.pdf
PROSTATE CANCER
Prostate cancer
http://www.urologyhealth.org/urology/index.cfm?article=146 - UrologyHealth.org is the official Web site of the American Urological Association Foundation.
American Urological Association guideline for the management of clinically localised prostate cancer: 2007 update
Advanced prostate cancer fact sheet - UrologyHealth.org is the official Web site of the American Urological Association Foundation.
European Association of urology guidelines on prostate cancer - uroweb.org is the official Web site of the European Association of Urology
