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The PSA Test

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2nd most common cause of cancer related deaths in men. In UK- 20,000 Dx ... Adjuvant therapy- impotence, loss of libido, breast swelling and hot flushes ... – PowerPoint PPT presentation

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Title: The PSA Test


1
The PSA Test
  • Graeme Gatherer 25.11.03

2
Prostate Cancerbackground 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, UEs, 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 mans 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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