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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

The PSA Test

Graeme Gatherer 25.11.03

prostate cancer background facts
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
patient mr a n
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
mr a n continued
Mr A.N continued
  • ? BPH
  • Do PSA, U+Es, r/v with results
  • ? Consider alpha blocker
  • Do International Prostate Symptom Score
mr a n continued5
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
detecting prostate cancers
Detecting Prostate Cancers
  • Prostate specific antigen(PSA) test
  • Digital rectal examination
  • Transrectal ultrasound guided prostate biopsy
the psa test7
The PSA Test
  • Currently the best method of identifying localised cancer
  • Also found in men without prostate cancer
  • Rises with age
test limitations
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

test limitations9
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
test limitations10
Test Limitations
  • All men should know they are having a PSA Test and be informed of the implications
  • Opportunistic testing is not recommended
psa test practicalities
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)

referral guidance
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

digital rectal examination
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
transrectal ultrasound guided prostate biopsy
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
treatments for prostate cancer
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

treatment options
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
monitoring treatment
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
population screening
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
population screening19
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
  • 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