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The PSA Test . Graeme Gatherer 25.11.03. Prostate Cancer:background facts. 2 nd most common cause of cancer related deaths in men In UK- 20,000 Dx annually, 9500 die Rare below 50. Median age 75 Increased risk with +ve FH, African, African/Carribean

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The psa test l.jpg

The PSA Test

Graeme Gatherer 25.11.03

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Prostate Cancer:background facts

  • 2nd most common cause of cancer related deaths in men

  • In UK- 20,000 Dx annually, 9500 die

  • Rare below 50. Median age 75

  • Increased risk with +ve FH, African, African/Carribean

  • Range of tumours- slow growing to very aggressive

  • Men are more likely to die with prostate cancer than of it

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Patient Mr A.N

  • 60yrs

  • Initial presentation- frequency,dysuria,fever

  • Urine- E.coli, Rx Cephalexin, fluids

  • 4 weeks later, c/o nocturia x 2, occas.hesitancy, occas.urgency, frequency, term.dribbling, no haematuria

  • “slight inconvenience”, otherwise well

  • pr ?mildly enlarged prostate

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Mr A.N continued

  • ? BPH

  • Do PSA, U+Es, r/v with results

  • ? Consider alpha blocker

  • Do International Prostate Symptom Score

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Mr A.N continued

  • PSA 9.5 (0-4)

  • D/W Colleague, suggested repeat in a month or so

  • Noticed in another patients notes that other GP had referred to urology a patient with a PSA of 5.

  • Prompted me to do some reading

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Detecting Prostate Cancers

  • Prostate specific antigen(PSA) test

  • Digital rectal examination

  • Transrectal ultrasound guided prostate biopsy

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The PSA Test

  • Currently the best method of identifying localised cancer

  • Also found in men without prostate cancer

  • Rises with age

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Test Limitations

  • Not diagnostic

  • Is tissue specific but not tumour specific-

    Thus- benign enlargement, prostatits, lower UTIs can cause elevated PSA

    About 2/3 of men with an elevated PSA do not have prostate cancer detectable at biopsy

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Test Limitations

  • Up to 20% of all men with clinically significant prostate cancer will have a normal PSA

  • Test will lead to the identification of cancers which would not have become clinically evident in the man’s lifetime

  • Test will not distinguish between aggressive tumours/non aggressive

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Test Limitations

  • All men should know they are having a PSA Test and be informed of the implications

  • Opportunistic testing is not recommended

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PSA Test Practicalities

  • Before having a PSA test men should NOT have:

  • an active urinary infection

  • ejaculated in the previous 48 hrs

  • exercised vigorously in the previous 48hrs

  • Had a prostate biopsy in the previous 6 weeks

  • if practical, do before digital rectal examination

    (if not- delay for 1 week after DRE)

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Referral guidance

  • Prostate Cancer Risk Management Programme, as interim guidance recommends the following cut-off values are used for the PSA test

    Age(years) PSA cut-off

    50-59 3 and above

    60-69 4 and above

    70 and over 5 and above

    Whereas a very high PSA is strongly suggestive of cancer it is less clear when mildly elevated

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Digital Rectal Examination

  • DRE is a useful diagnostic test for men with symptoms- it allows assessment of the prostate, although many early cancers will not be detected

  • DRE is not recommended as a screening test in asymptomatic men

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Transrectal ultrasound guided prostate biopsy

  • Uncomfortable/painful

  • Significant anxiety

  • 20% tumours get “missed”

  • Prolonged follow-up and anxiety for men with neg. Bx but pesistently high PSAs

  • Risks of infection/haematuria/haematospermia

  • 2/3 men undergoing TRUS are not found to have cancer

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Treatments for prostate cancer

  • The management of localised cancer is central to the controversy surrounding screening

  • Lack of evidence- ?reduction in mortality

    ?which treatment option

    Active treatments have significant S/Es

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Treatment Options

  • Active monitoring

  • Radical prostatectomy- complications include incontinence, impotence and operative mortality

  • Radiotherapy- diarrhoea/bowel problems, impotence, incontinence

  • Adjuvant therapy- impotence, loss of libido, breast swelling and hot flushes

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Monitoring Treatment

  • PSA levels are used to monitor disease activity in those with established cancer

  • Can give an early indication of the progression of a cancer

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Population Screening

  • Calls for a national screening programme

  • Randomised controlled trials are needed

  • Definitive information from USA/European trial will be available later this decade.

  • Benefits and harms must be assessed

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Population screening

  • Potentially harmful effects of prostate screening are particularly significant

  • Screening would lead to some men(with indolent disease) suffering from impotence, incontinence and death who would not have done so had screening not been introduced

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  • To date, no good evidence to say whether or not screening would reduce mortality

  • Men who ask about PSA test need balanced information to make an informed decision

  • Ref: Prostate Cancer Risk Management Programme