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The PSA Test

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

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  1. The PSA Test Graeme Gatherer 25.11.03

  2. 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

  3. 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

  4. Mr A.N continued • ? BPH • Do PSA, U+Es, r/v with results • ? Consider alpha blocker • Do International Prostate Symptom Score

  5. 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

  6. Detecting Prostate Cancers • Prostate specific antigen(PSA) test • Digital rectal examination • Transrectal ultrasound guided prostate biopsy

  7. The PSA Test • Currently the best method of identifying localised cancer • Also found in men without prostate cancer • Rises with age

  8. 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

  9. 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

  10. Test Limitations • All men should know they are having a PSA Test and be informed of the implications • Opportunistic testing is not recommended

  11. 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)

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. Conclusions • 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

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