PSA Screening Flashcards
(27 cards)
Why do we repeat PSA in a few months, after first elevated PSA?
Because 25 - 40% decrease on repeat. Half life of PSA is 2-3 days.
DO NOT USE ANTIBIOTICS TO DRIVE IT DOWN, in an asymptomatic person.
What is now considered an elevated PSA?
age adjusted PSA
40 - 2.5
50 - 3.5
60 - 4.5
70 - 6.5
When should prostate cancer screening be started?
between 45-50 years old - SDM!
When should you start earlier screening?
40-45 years old - if black ancestry (2x risk), germline mutation (BRCA1/BRCA2), strong family hx of prostate CA (one immediate family member or two male relatives with prostate CA < 60 yo, died of prostate CA, metastatic prostate CA, family hx of hereditary cancers (Lynch, breast + ovarian)
What do large RCT show about prostate cancer screening?
prostate cancer screening reduces prostate cancer mortality and metastatic prostate CA at 16-22 years
Of note, by combing PLCO and ERSPC - 30% decrease with PSA screening by years 11-13
Again SDM
What is recommended screening interval for men between the ages of 50-69?
2-4 years
can be prolonged even more if PSA < 1
But how can this be more personalized?
depend on patient preference, age, PSA, prostate cancer risk, life expectancy, and general health
What about patients between the ages of 70-80 years old?
Consider discontinuing if PSA < 3 if patient > 75 yo
Need to assess life expectancy - if > 10 years consider screening every 2-4 years
USE AN ONLINE CALCULATOR TO DETERMINE LIFE EXPECTANCY
Risk of over diagnosis increases with age
How to improve SDM with prostate cancer screening?
SHARE
Seek patient participation
Help patient explore and compare options
Assess patient’s values
Reach a decision together
Evaluate the patient’s decision
What about DRE?
It can be used in conjunction to identify clinically significant prostate CA - in particular PSA >/= 2, and patients undergoing biopsy (helped improve PPV)
But it has poor PPV as a solo screening tx
How about PSA velocity?
not really relevant
How to decide on prostate bx?
Use online nomograms / risk calculators!
SDM - especially if low risk to hold off on biopsy
What do you need to tell a patient prior to biopsy regarding prostate CA?
That we are looking to identify clinically significant prostate CA. There is a portion that will be considered low risk - and be considered for active surveillance.
What is recommendation on MRI?
It CAN be ordered for patients prior to biopsy, but it is not considered a standard recommendation. Aids in identifying clinically significant prostate CA.
Review PIRADS and chance of clinically significant prostate CA
3 - 10%
4 - 40%
5 - 70%
for any cancer - just double (except last one is 85%)
What is recommendation of target lesions and prostate bx?
It is recommended to biopsy target lesions, and MAY perform a systematic template biopsy
SDM
What percent of people with a negative prostate MRI still have clinically significant prostate cancer?
10%
What is recommendation on serum or urine adjunctive tests?
Can use to further risk stratify those that are on the fence (from data point)
free PSA - the lower it is = greater chance of finding prostate CA on biopsy
Blood - 4K, isoPSA, PHI
Post-DRE urine - PCA3, SelectMDX
Urine - ExoDX
Tissue - ConfirmDX
What is recommendation for patient with a PSA > 50
May omit prostate bx where the bx poses a significant risk (anticoagulation, significant comorbidity, frailty) or immediate treatment is to be considered
Does not mean you don’t biopsy later
almost 99% chance of CSPC
What is use of elevated PSA level in repeat biopsy after negative bx?
Not to be used in isolation. Use other metrics that we have available (biomarkers, MRI, etc)
Use risk calculators that incorporate prior negative bx
What should you do about focal HGPIN?
Don’t do immediate re-biopsy, start using adjunct testing or MRI
What about multifocal HGPIN?
Closer follow up - use adjunctive testing or MRI
SDM!
What about ASAP or AIP?
Need to perform additional testing (additional adjunctive tests +/- MRI) with REPEAT BIOPSY (timing is SDM)
Almost 50% will find cancer on repeat biopsy (10-20% are GG2+)
What are some identifiable factors for patients that may lend to CSPC despite negative biopsy and negative MRI
PSAD > 0.15, PHI > 0.44, PSA velocity 0.3 / yr
