How many prostate biopsies are cancerous?

For example, among men with greater than 25% free PSA, only 8% are found to have cancer at prostate biopsy. In contrast, more than half of men with less than 10% free PSA are found to have cancer at biopsy.

emedicine.medscape.com - Prostate Cancer Diagnosis and Staging - Medscape Reference

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Digital rectal examination (DRE) and prostate-specific antigen (PSA) measurement are the two components necessary for a modern screening program. The indications for screening are controversial. Advocates of screening believe that early detection is crucial to finding organ-confined disease and to reducing the likelihood of mortality. When symptoms develop or when DRE results become positive, most cases have already advanced beyond organ-confined disease. Those who do not advocate screening note that screening can detect cancers that are not biologically significant (ie, in patients who will die with prostate cancer rather than from it), and subject patients to the risks of unnecessary intervention. The American Cancer Society (ACS) recommends that asymptomatic men with at least a 10-year life expectancy should be given an opportunity to make an informed decision with their health care provider after receiving information on the uncertainties, risks, and benefits of screening PSA evaluation. The recommended age at which men should receive this information varies by prostate cancer risk, as follows [1] :

Age 50 for those at average risk of developing prostate cancer

Age 45 for those at high risk, including African Americans and men with a first-degree relative (father, brother, son) diagnosed with prostate cancer before age 65 Age 40 for those at higher risk (more than one first-degree relative diagnosed with prostate cancer at an early age) Men who decide to be screened should be tested with a PSA test. A DRE may also be done as a part of screening. If screening does not detect cancer, the time between subsequent screenings depends on the PSA results, as follows [1] :

< 2.5 ng/ml – Retesting may be done every 2 years

≥2.5 ng/ml – Retesting should be done annually

The National Comprehensive Cancer Network (NCCN) notes the importance of identifying aggressive prostate cancer while avoiding the detection of indolent disease. For men 45-75 years old, the NCCN recommends a discussion of screening risks and benefits, followed by a baseline PSA and consideration of a DRE, especially in men with an elevated PSA level. [3] The NCCN recommends basing repeat testing intervals on PSA and DRE findings, as follows:

PSA < 1 ng/mL, DRE normal (if done) – 2-4 years

PSA 1-3 ng/mL, DR normal (if done) – 1-2 years

For patients with PSA levels above 3 ng/mL or very suspicious DRE results, the NCCN recommends repeat PSA, DRE, and workup for benign disease. Considerations regarding transrectal ultrasound (TRUS)–guided biopsy should take into account the correlation between PSA levels and the likelihood of finding prostate cancer on biopsy, which is as follows:

PSA ≤4 ng/mL – 15%

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PSA 4-10 ng/mL – 30-35%

PSA >10 ng/mL - >67%

American Urological Association (AUA) recommend against routine screening for the following groups [2] :

Any man with a life expectancy less than 10-15 years

Men under age 40 years

Men between ages 40 to 54 years at average risk

Men over age 70 years

For men 55 to 69 years of age, the AUA advises that the decision to undergo PSA screening involves weighing the benefits and risks. The guidelines strongly recommend the following [2] : A routine screening interval of 2 years or more in those men who have participated in shared decision-making and decided on screening. In 2018, the US Preventive Services Task Force (USPSTF) revised its controversial 2012 recommendation against prostate cancer screening. Currently, the USPSTF advises that in men aged 55 to 69 years, the decision of whether or not to undergo screening should be individualized. This is a grade C recommendation, meaning that there is at least moderate certainty that the net benefit is small. For men aged 70 years and older, the USPSTF recommends against PSA-based screening for prostate cancer. [4] The USPSTF concluded that currently available data are insufficient to support a separate, specific recommendation on PSA-based screening for prostate cancer in African-American men or in men with a family history of prostate cancer. While acknowledging the higher risk of prostate cancer in those groups, the USPSTF also notes the significantly higher risk of major infections after prostate biopsy in black men than white men, and the potential for harm in men with relatives whose prostate cancer was overdiagnosed. The USPSTF suggests that men with a positive family history who are most likely to benefit from screening are those with a first-degree relative who had advanced prostate cancer at diagnosis, who developed metastatic prostate cancer, or who died of prostate cancer. [4] Current guidelines from the European Society for Medical Oncology (ESMO) recommend against population-based PSA screening for prostate cancer, on the grounds that it reduces prostate cancer mortality at the expense of overdiagnosis and overtreatment. The ESMO also recommends against testing for prostate cancer in asymptomatic men over the age of 70 years. [5]

Contrasting study data

Data from a Canadian study showed that from 1989-1996, the mortality rate was lower in a PSA-screened cohort than in a control group. Research from Tyrol, Austria, also indicated that screening can aid in reducing disease-specific mortality. These beneficial effects are likely due to the fact that treatment, rather than observation, may enhance disease-specific survival. This was indicated in a Scandinavian study, which reported that radical prostatectomy was associated with significantly reduced disease-specific mortality, compared with watchful waiting. (No difference in overall survival was noted.) [12] However, a US study, the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, compared patients who received annual screening (the study offered PSA tests for 6 years and DREs for 4 years) with patients who did not undergo yearly testing and found no screening-related improvement in mortality. [13] Conversely, the European Randomized Study of Screening for Prostate Cancer (ERSPC) did show a decreased mortality in the trial's PSA-screened group; however, this multicenter study was flawed. [14]

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Similar to the American study, a randomized trial comparing Swedish men allocated to screening every third year with those who received no screening showed no difference in prostate cancer–specific survival. [15] The issue remains unresolved. US data have shown a decrease of 1% per year since 1990 in the prostate-cancer mortality rate, which coincides with the advent of PSA screening. Other theories have been proposed to account for the decrease; these include changing treatment practices and artifacts in mortality rates secondary to the changing incidence of prostate cancer.

Discontinuation of screening

In a 2010 study, Tang et al concluded that in the 75- to 80-year age group, discontinuation of PSA screening may be safe in African-American men with an initial PSA measurement of less than 6.0 ng/mL and in Caucasian men with an initial PSA measurement of less than 3.0 ng/mL. The investigators found that men in these groups are unlikely to develop high-risk prostate cancer or to die from prostate cancer. [16] The NCCN advises that, although very few men over the age of 75 benefit from PSA testing, a clinically significant number may develop aggressive cancers that pose significant risk if they are not detected before they produce symptoms. For that reason, testing may be considered in select patients who are very healthy and have little or no comorbidity, but clinicians may consider raising the threshold for biopsy to a PSA level of > 4 ng/mL. [3] As noted above, the USPSTF and ESMO recommend against PSA-based screening for prostate cancer for men aged 70 years and older. [5, 4]

emedicine.medscape.com - Prostate Cancer Diagnosis and Staging - Medscape Reference

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