Gen Med 1A Morning Report

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Gen Med 1A Morning Report
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Questions

• What is the rate of prostate CA metastasis to the
  liver?
• If he has widespread evidence of metastasis on
  radiologic studies, could it be prostate given
  his current PSA level?

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Epidemiology

• Lifetime risk of prostate CA is 10, and 3 of
  dying from it.
• Autopsy studies show that men age 40-49 have a
  10 incidence, which increases with age to 80
  by age 80.
• In 2003, 185,891 US men were diagnosed with
  prostate CA, and 29,554 died from the disease.

U.S. Cancer Statistics Working Group. U.S. Cancer
Statistics Working Group. United States Cancer
Statistics 2003 Incidence and Mortality. Atlanta
(GA) Department of Health and Human Services,
Centers for Disease Control and Prevention, and
National Cancer Institute 2007.
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Metastatic Patterns In Adenomas
Cancer 20061061624-33.
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Metastatic Profile in Prostate CA
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Cancer 20061061624-33.
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PSA

• First described by Hara et.al in a series of
  papers between 1966 and 1971.
• PSA - Used in combination with DRE for diagnosis
  of prostate CA.
• Normal range is dependant on age.

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PSA and Disease Monitoring

• PSA, due to its sensitivity is often used to
  monitor for disease progression after local
  aggressive therapy.
• After local therapy a PSA will reach a nadir.
• Biochemical failure typically precedes symptoms
  by 5 to 7 years
• In 2005, ASTRO defined biochemical failure of RT
  is 2ng/mL above the nadir.

• CT and bone scans are low-yeild in biochemical
  disease progression and can be predicted based on
  absolute PSA value and PSA velocity.
• Thus, some groups recommend scans only in
  patients with PSA 10, or velocity 2ng per
  month.

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Normal PSA and Disease ProgressionCan it Happen?

• Due to its high negative predictive value, a
  negative PSA is typically equated with a disease
  free state.
• Disease progression in the absence of PSA
  elevations in rare and typically found in case
  reports.
• In one sereies, out of 4145 patients that were
  dxed with prostate CA, 46 (1.1)were identified
  and confirmed with disease progression having PSA
  
• Another study with 167 patients with disease
  progression, 8 had a PSA level Urol 20018374-379.).

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Normal PSA and Disease ProgressionCan it Happen?

• The typical patient with low PSA disease
  progression(Cancer 2007109198-204.)
• Gleason score 7
• Atypical histologic varients
• Locally advanced toumors
• Why the low PSA?
• Not produced by tumor (ability lost, change in
  cell population).
• High dose hook effect (J Urol 2001166213.).

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What Do You Follow Then?

• Some tumors secrete other markers
• CEA
• Neuron-specific enolase
• CA19-9, CA-125
• Alk phos
• DRE
• Scans

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For every 100 men over the age of 50 who have the
PSA test