Repeat Prostate-specific Antigen Research Articles

Normalised repeat serum prostate-specific antigen: associations with age and magnetic resonance imaging results.

To assess the value of a repeat prostate-specific antigen measurement (PSA2) before magnetic resonance imaging (MRI) in men with a raised PSA (PSA1) <10 µg/L. Medical records of men aged < 75 years referred in 2021 for PSA1 3.0-9.9 µg/L (< 70 years) or 5.0-9.9 µg/L (70-74 years) were reviewed. PSA2 was sampled before MRI within 60 days from PSA1. Odds ratios (ORs) were calculated with logistic regression. Chi-square and trend-test were used for categorical variables. A total of 341 men were included. Median time between PSA1 and PSA2 was 28 days (interquartile range 20-35 days). PSA normalised in 16% (95% confidence interval [CI]: 13-21). Younger men were more likely to have a normal PSA2 (OR: 0.95 per year older, 95% CI: 0.92-0.99). Among men aged < 70 years, those with PSA1 < 5 µg/L were more likely to have normalised PSA2 than those with PSA1 ≥ 5 µg/L (21% vs. 10%, p = 0.01). A greater proportion of men with normalised PSA2 had a Prostate Imaging Data and Reporting System MRI score of 1-3 than men with non-normalised PSA2 (93% vs. 77%, p = 0.01). A clinically significant proportion of men with a moderately raised PSA value have a normal PSA2. Younger men and men with lower PSA1 were more likely to have a normal PSA2. Few men with normalised PSA2 had suspicious MRI findings. Routine repeat PSA-testing may be motivated in men with a moderately raised PSA value to save MRI resources, particularly in younger men.

Abstract 38: External Quality Assessment for Prostate Specific Antigen Test Accuracy: A Needs Assessment of Nigerian Tertiary Hospitals

Abstract Purpose: Prostate cancer is a major cause of death in African men, and the accuracy of prostate specific antigen (PSA) test results is important to ensure patients have access to accurate early diagnosis and treatment. External Quality Assessment (EQA) is an established framework to improve the quality of PSA results. We aimed to determine the need for implementing an EQA program for PSA in Nigeria. Methods: We used mixed-method design to collect data from 6 tertiary hospitals across the six regions in Nigeria. We conducted an online survey using a structured questionnaire developed from the International Standard Organization (ISO) 15189 checklist for accreditation of diagnostic laboratories. Responses were analyzed to obtain descriptive categorical data that was analyzed on Microsoft Excel. Using an in-depth interview guide, 12 respondents (6 Urologists and 6 Chemical Pathologists) from sampled hospitals were interviewed virtually. Responses were recorded and transcribed and relevant themes were identified and generated from the transcribed data. Results: Five of six laboratories sampled (83%) reported conducting repeat PSA testing. No sampled lab (0%) was enrolled in an EQA program for PSA. Eleven of the twelve respondents confirmed occasional disparities between PSA results and patient’s clinical status. They gave the impact of an erroneous PSA result on patient care as: extra unnecessary cost to the patient due to repeat testing; delay in decision making and initiating appropriate treatment; unnecessary invasive procedures. Training of lab staff, adoption of standard operating procedures and quality measures for EQA were considered opportunities to encourage PSA EQA practice while lack of funds for EQA programs, weak logistics for distribution of EQA samples and results, poor staff motivation and commitment were mentioned as barriers to effective practice uptake. Conclusion: There is a clear need for the implementation of an EQA program for PSA in Nigeria. This will reduce the incidence of incongruous PSA results, thus promoting better clinician approach to disease treatment and better patient outcomes especially in resource-constrained environments. Citation Format: Ifeyinwa Nnakenyi, Tonia Onyeka, Ngozi Idemili-Aronu1, Justus Onu, Echezona Ezeanolue. External Quality Assessment for Prostate Specific Antigen Test Accuracy: A Needs Assessment of Nigerian Tertiary Hospitals [abstract]. In: Proceedings of the 11th Annual Symposium on Global Cancer Research; Closing the Research-to-Implementation Gap; 2023 Apr 4-6. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(6_Suppl):Abstract nr 38.

Relationship Between Baseline Prostate-specific Antigen on Cancer Detection and Prostate Cancer Death: Long-term Follow-up from the European Randomized Study of Screening for Prostate Cancer

BackgroundThe European Association of Urology guidelines recommend a risk-based strategy for prostate cancer screening based on the first prostate-specific antigen (PSA) level and age. ObjectiveTo analyze the impact of the first PSA level on prostate cancer (PCa) detection and PCa-specific mortality (PCSM) in a population-based screening trial (repeat screening every 2–4 yr). Design, setting, and participantsWe evaluated 25589 men aged 55–59 yr, 16898 men aged 60–64 yr, and 12936 men aged 65–69 yr who attended at least one screening visit in the European Randomized Study of Screening for Prostate Cancer (ERSPC) trial (screening arm: repeat PSA testing every 2–4 yr and biopsy in cases with elevated PSA; control arm: no active screening offered) during 16-yr follow-up (FU). Outcome measurements and statistical analysisWe assessed the actuarial probability for any PCa and for clinically significant (cs)PCa (Gleason ≥7). Cox proportional-hazards regression was performed to assess whether the association between baseline PSA and PCSM was comparable for all age groups. A Lorenz curve was computed to assess the association between baseline PSA and PCSM for men aged 60–61 yr. Results and limitationsThe overall actuarial probability at 16 yr ranged from 12% to 16% for any PCa and from 3.7% to 5.7% for csPCa across the age groups. The actuarial probability of csPCa at 16 yr ranged from 1.2–1.5% for men with PSA <1.0 ng/ml to 13.3–13.8% for men with PSA ≥3.0 ng/ml. The association between baseline PSA and PCSM differed marginally among the three age groups. A Lorenz curve for men aged 60–61 yr showed that 92% of lethal PCa cases occurred among those with PSA above the median (1.21 ng/ml). In addition, for men initially screened at age 60–61 yr with baseline PSA <2 ng/ml, further continuation of screening is unlikely to be beneficial after the age of 68–70 yr if PSA is still <2 ng/ml. No case of PCSM emerged in the subsequent 8 yr (up to age 76–78 yr). A limitation is that these results may not be generalizable to an opportunistic screening setting or to contemporary clinical practice. ConclusionsIn all age groups, baseline PSA can guide decisions on the repeat screening interval. Baseline PSA of <1.0 ng/ml for men aged 55–69 yr is a strong indicator to delay or stop further screening. Patient summaryIn prostate cancer screening, the patient’s baseline PSA (prostate-specific antigen) level can be used to guide decisions on when to repeat screening. The PSA test when used according to current knowledge is valuable in helping to reduce the burden of prostate cancer.

Prostate-specific antigen kinetics contributes to decision making for biopsy referral: the predictive implication for PSA retest in patients with elevated PSA levels.

It is common to repeat prostate-specific antigen (PSA) measurements for men with PSA elevation before prostate biopsy. In this scenario, they may have considerable psychological distress in fear of the presence of cancer until retests. We assessed possible clinical factors causing transient PSA rise and explored the parameters predictive of subsequent PSA change. As interfering conditions, the history of ejaculation, bicycling, and any types of infections were assessed using the questionnaire. The pattern of PSA change was compared in association with the various clinical factors. Predictive significance of PSA kinetics such as coefficient of variation (CV) and PSA velocity (PSAV) for PSA values at retest was evaluated. The rate of reversion to the normal range was 38.3% at retest. The rate of 12.8% of men showed a large increase by ≥20%, whereas 38.2% of men showed a large decline by ≥20% from the baseline. Men with younger age (≤60 years), small prostate (<20cc), and prior history of ejaculation or infections showed significantly larger PSA decrease than their counterparts. Those with large CV or PSAV before the baseline more frequently showed PSA decrease below the age-specific cutoff or decline by ≥10% from the baseline at retest. These parameters associated with PSA kinetics had independent predictive values for relevant PSA change at retest. Ejaculation and any types of infections should be avoided before PSA tests. Men with large PSA fluctuation before the baseline are likely to show a significant PSA decrease at retest. This predictive information may help both physicians to determine whether to proceed to an immediate biopsy and patients to reduce their psychological burden.

PD65-07 LIFESTYLE MODIFICATIONS AND THEIR EFFECT ON SERUM PROSTATE SPECIFIC ANTIGEN LEVELS

You have accessJournal of UrologyProstate Cancer: Detection & Screening VII (PD65)1 Sep 2021PD65-07 LIFESTYLE MODIFICATIONS AND THEIR EFFECT ON SERUM PROSTATE SPECIFIC ANTIGEN LEVELS Alexandre R. Zlotta, Jimmy Misurka, Katherine Lajkosz, Andrea Mari, Serena Marzario, Cynthia Kuk, Sophie O’Halloran, Alex Zisman, Annette Erlich, Michael Nesbitt, Dhiral Kot, Rob Hamilton, Girish Kulkarni, Nathan Perlis, Anto Finelli, Sigrid Carlsson, and Neil Fleshner Alexandre R. ZlottaAlexandre R. Zlotta More articles by this author , Jimmy MisurkaJimmy Misurka More articles by this author , Katherine LajkoszKatherine Lajkosz More articles by this author , Andrea MariAndrea Mari More articles by this author , Serena MarzarioSerena Marzario More articles by this author , Cynthia KukCynthia Kuk More articles by this author , Sophie O’HalloranSophie O’Halloran More articles by this author , Alex ZismanAlex Zisman More articles by this author , Annette ErlichAnnette Erlich More articles by this author , Michael NesbittMichael Nesbitt More articles by this author , Dhiral KotDhiral Kot More articles by this author , Rob HamiltonRob Hamilton More articles by this author , Girish KulkarniGirish Kulkarni More articles by this author , Nathan PerlisNathan Perlis More articles by this author , Anto FinelliAnto Finelli More articles by this author , Sigrid CarlssonSigrid Carlsson More articles by this author , and Neil FleshnerNeil Fleshner More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002109.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Guidelines recommend to repeat serum Prostate Specific Antigen (PSA) measurement to confirm an elevated value before proceeding with further testing. The effect of diet and lifestyle on repeat PSA levels to minimize false positives has rarely been examined. We aimed here to explore the effects of dietary and lifestyle changes on serum PSA values in men with intermediate PSA levels and normal digital rectal examination (DRE). METHODS: We used a case-control design including 204 men with PSA levels between 2-10ng/ml. 82 men who followed lifestyle changes (intervention group) were matched with 122 men (control group), who did not undergo any lifestyle modifications (avoiding spicy foods, alcohol, caffeine consumption and biking) before repeat PSA. PSA changes between baseline and repeat measurement were compared between the intervention group and controls using the Mann-Whitney U test. Multivariable logistic regression models were used to assess differences in PSA changes below different pre-determined thresholds. Linear mixed models implemented for changes in PSA as a continuous covariate helped visualize the predicted change in PSA from baseline. RESULTS: Age (61.0 vs 60.3 years), prostate volume (52.3 vs 49.0 cc) and PSA levels at baseline (5.83 vs 5.75 ng/ml) in the control and intervention arm, respectively, were not different. Compared to controls, at a median 2.81 months interval (IQR: 1.69-4.61), men in the intervention arm had a significantly lower total PSA on repeat PSA testing (4.14 vs 5.32ng/ml, p<0.001). Lifestyle changes resulted in PSA levels dropping below 4ng/ml in 40% of men with initial PSA 4-10 ng/ml in the intervention group vs 22% in controls (p=0.02). In the 2-4ng/ml range, 45% of men in the intervention group vs 14% in controls had their repeat PSA <2ng/ml (p=0.02). Intervention was an independent predictor of repeat PSA dropping <3ng/ml for men with baseline PSA of 3-10ng/ml (OR 5.39, 95% CI 1.96, 14.8, p=0.001). Limitations include the retrospective design of the study, absence of use of metrics to measure adherence to recommendations and lack of cycling information. CONCLUSIONS: In men with intermediate PSA levels and negative DRE, dietary and lifestyle modifications decrease serum PSA values more, and in a larger proportion than simply repeating the test. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1154-e1154 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexandre R. Zlotta More articles by this author Jimmy Misurka More articles by this author Katherine Lajkosz More articles by this author Andrea Mari More articles by this author Serena Marzario More articles by this author Cynthia Kuk More articles by this author Sophie O’Halloran More articles by this author Alex Zisman More articles by this author Annette Erlich More articles by this author Michael Nesbitt More articles by this author Dhiral Kot More articles by this author Rob Hamilton More articles by this author Girish Kulkarni More articles by this author Nathan Perlis More articles by this author Anto Finelli More articles by this author Sigrid Carlsson More articles by this author Neil Fleshner More articles by this author Expand All Advertisement Loading ...

A genetic risk assessment for prostate cancer influences patients' risk perception and use of repeat PSA testing: a cross-sectional study in Danish general practice.

BackgroundProstate cancer (PC) is the most common cancer among men in the western world. Genetic lifetime risk assessment could alleviate controversies about prostate specific antigen (PSA) testing for early diagnosis.AimTo determine how men interpret information about their lifetime risk for PC and how this can affect their choice of having a repeated PSA test.Design & settingA genetic test was offered for assessment of individual PC lifetime risk in general practices in Denmark, with the purpose of promoting appropriate use of PSA testing.MethodParticipants had a genetic lifetime risk assessment for PC diagnosis (either high or normal risk). A month after receiving the result, participants answered a questionnaire about their perceived risk of getting or dying from PC compared with other men, as well as their intentions for repeated PSA testing.ResultsNearly half (44.7%) of 555 participants who received the genetic risk assessment were not aware they had a genetic test. Nevertheless, compared with men with a normal genetic risk, those with high genetic risk reported higher perceived risk for PC (mean difference of 0.74 [95% confidence interval {CI} = 0.56 to 0.96] on a 5-point scale), higher perceived risk of dying from PC (mean difference of 0.48 [95% CI = 0.29 to 0.66] on a 5-point scale), and increased intention for repeated PSA testing (mean difference of 0.48 [95% CI = 0.30 to 0.65] on a 4-point scale).ConclusionDespite low awareness and/or understanding of the test result, a high genetic risk for PC made participants more aware of their risk, and it increased their intention and probability for repeated PSA testing.

Prospective evaluation of a new patient decision aid to enhance prostate cancer screening decision-making.

87 Background: We previously developed screening nomograms to predict 15-year risk of all-cause mortality, prostate cancer diagnosis, and prostate cancer mortality, and incorporated them into a graphical patient decision aid (PtDA). Our objective was to prospectively recruit primary care patients interested in shared-decision making regarding prostate specific antigen (PSA) screening and assess the impact of individualized counseling using our new PtDA. Methods: 50 patients from one internal medicine practice were enrolled in a single-arm sequential trial design, with face-to-face clinician counseling and questionnaires. Eligibility criteria included men age 50-69 years old and life expectancy &gt; 10 years. Patients were excluded for a personal history of prostate cancer or PSA screening within the prior year. Participants completed baseline questionnaires regarding prior PSA testing, demographic information, health literacy, and the Control Preferences Scale (CPS). They then received standardized counseling (based on large trial and epidemiologic data) regarding PSA screening, followed by individualized counseling using our new PtDA. Participants then made a screening decision, and completed a post decision questionnaire including a Decisional Conflict Scale. Results: The median age was 60 (IQR 54; 65). 41 (82%) had a prior PSA test, while 9 (18%) had not. 42 (84%) of participants received some education beyond high school, 41 (82%) demonstrated high health literacy, and 45 (90%) desired to have an active role in decision-making based on the CPS. After undergoing counseling, 34 (68%) participants chose to undergo initial or repeat PSA screening, 8 (16%) chose against future screening, and 8 (16%) remained uncertain. 45 (90%) participants found individualized counseling using the PtDA more useful than standardized counseling. Finally, patients reported reduced decisional conflict compared to historical controls (P &lt; 0.001). Conclusions: Our process of standardized counseling followed by individualized counseling using our new PtDA was effective in reducing decisional conflict. The majority of participants found the PtDA more useful for decision making than standardized counseling. Clinical trial information: NCT03387527.

Implications of false-positive results for future cancer screenings.

False-positive cancer screening results may affect a patient's willingness to obtain future screening. The authors conducted logistic regression analysis of 450,484 person-years of electronic medical records (2006-2015) in 92,405 individuals aged 50 to 75 years. Exposures were false-positive breast, prostate, or colorectal cancer screening test results (repeat breast imaging or negative breast biopsy ≤3 months after screening mammography, repeat prostate-specific antigen [PSA] test ≤3 months after PSA test result ≥4.0 ng/mL or negative prostate biopsy ≤3 months after any PSA result, or negative colonoscopy [without biopsy/polypectomy] ≤6 months after a positive fecal occult blood test). Outcomes were up-to-date status with breast or colorectal cancer screening. Covariates included prior screening history, clinical information (eg, family history, obesity, and smoking status), comorbidity, and demographics. Women were more likely to be up to date with breast cancer screening if they previously had false-positive mammography findings (adjusted odds ratio [AOR], 1.43 [95% confidence interval, 1.34-1.51] without breast biopsy and AOR, 2.02 [95% confidence interval, 1.56-2.62] with breast biopsy; both P<.001). The same women were more likely to be up to date with colorectal cancer screening (AOR range, 1.25-1.47 depending on breast biopsy; both P<.001). Men who previously had false-positive PSA testing were more likely to be up to date with colorectal cancer screening (AOR, 1.22 [P = .039] without prostate imaging/biopsy and AOR, 1.60 [P = .028] with imaging/biopsy). Results were stronger for individuals with more false-positive results (all P≤.005). However, women with previous false-positive colorectal cancer fecal occult blood test screening results were found to be less likely to be up to date with breast cancer screening (AOR, 0.73; P<.001). Patients who previously had a false-positive breast or prostate cancer screening test were more likely to engage in future screening. Cancer 2018;124:2390-8. © 2018 American Cancer Society.

Refined Analysis of Prostate-specific Antigen Kinetics to Predict Prostate Cancer Active Surveillance Outcomes

BackgroundFor men on active surveillance for prostate cancer, utility of prostate-specific antigen (PSA) kinetics (PSAk) in predicting pathologic reclassification remains controversial. ObjectiveTo develop prediction methods for utilizing serial PSA and evaluate frequency of collection. Design, setting, and participantsData were collected from men enrolled in the multicenter Canary Prostate Active Surveillance Study, for whom PSA data were measured and biopsies performed on prespecified schedules. We developed a PSAk parameter based on a linear mixed-effect model (LMEM) that accounted for serial PSA levels. Outcome measurements and statistical analysisThe association of diagnostic PSA and/or PSAk with time to reclassification (increase in cancer grade and/or volume) was evaluated using multivariable Cox proportional hazards models. Results and limitationsA total of 851 men met the study criteria; 255 (30%) had a reclassification event within 5 yr. Median follow-up was 3.7 yr. After adjusting for prostate size, time since diagnosis, biopsy parameters, and diagnostic PSA, PSAk was a significant predictor of reclassification (hazard ratio for each 0.10 increase in PSAk=1.6 [95% confidence interval 1.2–2.1, p<0.001]). The PSAk model improved stratification of risk prediction for the top and bottom deciles of risk over a model without PSAk. Model performance was essentially identical using PSA data measured every 6 mo to those measured every 3 mo. The major limitation is the reliability of reclassification as an end point, although it drives most treatment decisions. ConclusionsPSAk calculated using an LMEM statistically significantly predicts biopsy reclassification. Models that use repeat PSA measurements outperform a model incorporating only diagnostic PSA. Model performance is similar using PSA assessed every 3 or 6 mo. If validated, these results should inform optimal incorporation of PSA trends into active surveillance protocols and risk calculators. Patient summaryIn this report, we looked at whether repeat prostate-specific antigen (PSA) measurements, or PSA kinetics, improve prediction of biopsy outcomes in men using active surveillance to manage localized prostate cancer. We found that in a large multicenter active surveillance cohort, PSA kinetics improves the prediction of surveillance biopsy outcome.

344 - Repeat prostate-specific antigen tests before prostate biopsy: A decreasing in PSA values is associated with a reduced risk of cancer and particularly high grade cancer

344 - Repeat prostate-specific antigen tests before prostate biopsy: A decreasing in PSA values is associated with a reduced risk of cancer and particularly high grade cancer

Abstract C88: Novel use of electronic health records (EHRs) to facilitate free community prostate screening events

Abstract Introduction Free screening events, while a valuable means to educate and provide cancer screening for individuals in socioeconomically disadvantaged communities, suffer from a number of limitations including: limited scope, poor patient follow up, and lack of long term tracking of individuals with high risk screening outcomes. The Center for Medicare and Medicaid Services advocates for electronic health records (EHRs) to flag opportunities for “reduction of disparities, research, or outreach.” EHRs represent a potentially powerful tool to assimilate and track individual screening outcomes. However, implementation of electronic health records a to facilitate free screening events such as for prostate cancer has not been reported. Among the barriers to EHR use for free screenings is the requirement to create billable encounters for each patient for whom personal health information is to be entered. Therefore, we reconfigured our EHR to create HIPAA compliant, non-billable encounters for the purposes of entering demographic information, tracking screening results, and generating follow-up letters to participants and their primary care physicians (PCPs) after a free community screening event in an at risk community. Materials &amp; Methods Between 2013 and 2015 our group hosted three annual free prostate cancer community-screening events in the city of New Haven, CT. To facilitate tabulation of demographic information and screening results we prevailed upon our EHR administrators to design workflows to allow for patient registration and patient data capture unique to our screening events that would not be associated with a billable encounter. Providers counseled patients on prostate specific antigen (PSA) testing, ordered testing if appropriate, and performed a digital rectal examination (DRE) for each encounter. Demographic information and DRE results were manually entered into the EHR by a registered nurse for all patients and PSA testing performed by our own hospital-based ancillary service with direct resulting of PSA tests into the EHR. Automatic electronic alerts were generated for all PSA results and were preconfigured to be routed to the MD directing the event and two nurse managers. Results In the most recent screening year, 93 men were screened of whom 27 (29%) were flagged for follow-up: 21 (23%) for abnormal screening results and six for benign urologic issues who requested follow-up with our physicians. Using demographic information entered at the time of registration, 26 of the 27 (96%) participants flagged for follow-up were successfully contacted and only one participant could not be reached for follow-up. Letters to PCPs were successfully transmitted for all participants who had provided PCP information during the intake process. Of 21 participants with abnormal screening, 3 were known to have a preexisting diagnosis of prostate cancer and were actively under the care of a urologist and/or oncologist, 3 had established relationships with urologists and indicated their intent to follow-up with their regular urologist, 9 underwent repeat PSA testing and were offered follow-up with one of our urologists at no cost, 3 were scheduled for MRI of the prostate for further stratification of risk, and 3 were scheduled for prostate biopsy with one of our physicians. All tracking of results, coordination of care, and external communication to participants and their PCPs was executed through the EHR Conclusion The electronic health record when reconfigured to serve as a platform for a community screening event, allows for a novel, secure and multidimensional tool to enhance screening, provide appropriate follow-up, and establish vital long-term relationships with participants. Citation Format: Charles Walker, Meghan Curran, Jay Patel, Beth A. Jones. Novel use of electronic health records (EHRs) to facilitate free community prostate screening events. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C88.

Psychological impact of serial prostate-specific antigen tests in Japanese men waiting for prostate biopsy.

It is common to repeat prostate-specific antigen (PSA) measurements for men with intermediate PSA elevation before prostate biopsy. In this scenario, men with persistently elevated PSA values may have considerable psychological distress. We attempted to determine whether elevated PSA values have psychological effects on these men in association with the timing of measurement, PSA kinetics, and biopsy results. In order to investigate the initial and late effects of PSA tests on psychological distress during serial measurements, two groups of men with screen-positive results (PSA≥3ng/ml) were studied-205 men whose first questionnaires regarding anxiety and depression were taken at initial screening (group A), and 103 men whose questionnaires were taken at repeated measurement for prior PSA elevation (group B). The level of distress was generally low. There were no significant differences in distress between the two groups, suggesting a constant psychological effect by elevated PSA values over a long period of time. The distress of men in group A increased significantly as PSA levels rose and decreased when they fell to normal range. On the other hand, the distress of men in group B did not change regardless of PSA kinetics, indicating that their psychological condition seemed susceptible to subtle PSA change only in the initial phase of measurements. Unexpectedly, men with benign results showed insignificant but higher distress after prostate biopsy. Although a small fraction of men have psychological distress caused by changes in PSA levels, the benefits, risks (psychological and physical), and limitations of PSA tests must be adequately explained to the patients before entering the screening program.

Repeat Prostate-Specific Antigen Tests Before Prostate Biopsy Decisions.

Despite limited scientific support, a repeat prostate-specific antigen (PSA) test before prostate biopsy decisions is common. We analyzed biopsy outcomes in 1686 men from the STHLM3 study with PSA 3-10 ng/mL and two PSA tests taken within eight weeks and before prostate biopsy using percentages and multinomial logistic regression. We found that omitting prostate biopsy for men with PSA values decreasing to PSAs of 3 ng/mL or less would save 16.8% of biopsy procedures, while missing 5.4% of the cancers with Gleason scores (GSs) of 7 or higher. The proportion of cancers with GSs of 6 or lower was independent of the first PSA value, as well as of PSA change. Also, the risk of tumors with GSs of 7 or higher decreased with both decreasing and increasing PSA levels: It was 18.6% (95% confidence interval [CI] = 16.3% to 20.9%) for men with PSA changes of less than 20%, 12.1% (95% CI = 8.0% to 16.2%) for men with PSA levels increasing at least 20%, and 6.6% (95% CI = 3.8% to 9.3%) for men with PSA levels decreasing at least 20%.

Pathology and Quality of Life Outcomes Following Office-based Transperineal Prostate Biopsy

To report the incidence of prostate cancer diagnosis and quality of life outcomes following transperineal prostate biopsy. Forty-six consecutive patients underwent office-based transperineal prostate biopsy for an elevated prostate-specific antigen and a normal digital rectal examination without prior prostate biopsy. Prior to biopsy, a repeat prostate-specific antigen was obtained to ensure persistent elevation. Silodosin (8 mg daily) was initiated the day prior to biopsy and continued for 1 week. A total of 18-20 biopsy cores were obtained per patient. All patients responded to a visual analog scale ranging from 0 to 10 immediately following the completion of both the local anesthesia and the biopsy procedure. In addition, an International Prostate Symptom Score (IPSS), Rectal Function Assessment Score, International Index of Erectile Function, Center for Epidemiologic Studies Depression Scale, and postvoid residual were obtained at baseline and 30 days following biopsy, except IPSS which was also obtained at day 7. The mean patient age was 63.3 years with a mean prostate volume of 41.8 cm(3). The mean visual analog scale was 4.2 for the local anesthesia and 3.0 for the biopsy. Thirty-one patients (67.4%) were diagnosed with prostate cancer, with 18 having a Gleason score ≥ 7. Compared to baseline, no adverse changes in IPSS, Rectal Function Assessment Score, International Index of Erectile Function, Center for Epidemiologic Studies Depression Scale, or postvoid residual were detected at day 30. No patient required catheterization, developed sepsis, or required hospitalization. Office-based transperineal prostate biopsy was well tolerated with reasonable treatment-related discomfort, a high rate of prostate cancer diagnosis, and the absence of significant morbidity including sepsis.

Editorial Comment

Prostate specific antigen (PSA) levels are often evaluated in an attempt to detect early prostate cancer, however false positive PSA tests are common.1 A strategy to limit false positives, surrounding concerns that prostatitis may increase PSA, has been to defer biopsy decisions until after a course of antibiotics and repeat PSA measurement. This strategy has been evaluated in prior studies, including several small randomized trials, with differing conclusions regarding its benefit.2–4 The authors report a prospective, randomized trial investigating the impact of six weeks of fluoroquinolone antibiotics on PSA levels in asymptomatic men with an elevated PSA. This single-institution study randomized 150 of 1,151 eligible patients with a PSA between 4.0 and 20.0 ng/mL to 6 weeks of fluoroquinolone therapy (ciprofloxacin, but due to formulary changes a proportion received levofloxacin) or 6 weeks of observation. The primary endpoint was change in PSA 8 weeks after randomization. Rate of cancer diagnosis was a secondary outcome for patients who received a biopsy. A near significant difference in the change in PSA across groups was reported (−0.68 vs. 0.01 ng/mL for treatment and observation groups, respectively, p=0.052). 62% of treatment patients and 72% of observation patients underwent biopsy with no difference in cancer detection rate (63% vs. 52%, respectively, p=0.60). The authors conclude that asymptomatic patients with elevated PSA should not receive antibiotics prior to determining if a prostate biopsy is warranted. While the authors are commended for completing a prospective randomized trial to inform the debate on this urological practice, one limitation of this study is the lack of a pre-trial power calculation to plan enrollment. Despite this limitation, the post-intervention median PSA levels in both the treatment and observation groups were above most accepted biopsy thresholds (5.1 ng/mL and 5.0 ng/mL, respectively), indicating that even if the study had found a statistically significant difference, it may not have been clinically relevant. Also, as shown in this study, a decrease in PSA does not indicate an absence of prostate cancer. Given this trial and others on the topic have not provided convincing evidence of this practice, the authors are correct in concluding evidence does not support this management strategy. The risks and costs associated with unnecessary antibiotics are not trivial.5 When hospitalizations after transrectal prostate biopsy were assessed in the Michigan Urological Surgery Improvement Collaborative (MUSIC), 95% of hospital admissions were for infectious complications, and the majority of cultures identified fluoroquinolone resistant organisms.6 With rising antibiotic resistance7 and in an era increasingly focused on quality care and appropriate healthcare utilization, we do not recommend antibiotic therapy prior to making decisions about prostate biopsy in asymptomatic men with elevated PSA. This practice is also highlighted within the American Board of Internal Medicine and American Urological Association’s Choosing Wisely campaign as something that physicians and patients should question.8

MP21-03 HOW ACCURATE IS THE PSA TEST? A PREVALENCE STUDY OF DISTURBED PSA VALUES IN A TERTIARY REFERRAL HOSPITAL

You have accessJournal of UrologyProstate Cancer: Detection & Screening III1 Apr 2016MP21-03 HOW ACCURATE IS THE PSA TEST? A PREVALENCE STUDY OF DISTURBED PSA VALUES IN A TERTIARY REFERRAL HOSPITAL Cedric Poyet, Karim Saba, Noemie Lautenbach, Lanja Saleh, Martin Umbehr, Tullio Sulser, Michael Müntener, and Arnold von Eckardstein Cedric PoyetCedric Poyet More articles by this author , Karim SabaKarim Saba More articles by this author , Noemie LautenbachNoemie Lautenbach More articles by this author , Lanja SalehLanja Saleh More articles by this author , Martin UmbehrMartin Umbehr More articles by this author , Tullio SulserTullio Sulser More articles by this author , Michael MüntenerMichael Müntener More articles by this author , and Arnold von EckardsteinArnold von Eckardstein More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.637AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Prostate specific antigen (PSA) is of paramount importance for the detection and monitoring of patients with prostate cancer. We and others have reported artifical altered PSA levels due to the presence of heterophilic antibodies (hA). Unrecognized artifical high PSA levels due to hA can lead to severe overtreatment of patients. The prevalence of altered PSA levels due to hA interference or other factors is unknown. METHODS Recoveries of all PSA samples taken consecutively in our hospital from February to May 2014 using a 3rd generation electrochemoluminescence assay (ECLIA) from Roche diagnostics were determined by diluting the patient samples with a standard serum of known PSA concentration. Samples with recoveries <80% or >130% of the expected values were retested and PSA was determined again after adding a blocking reagent for hAs (Scantibodies Laboratory, Santee, CA). RESULTS A total of 1500 serum probes were consecutively analyzed. Four out of 1500 probes (0.27%) showed reproducibly disturbed recoveries. Two samples showed falsely-elevated PSA values (Sample 1: 62.5-fold falsely-elevated; Sample 2: 1.6-fold falsely-elevated). The other two samples showed falsely-low PSA values (Sample 3: 8263-fold falsely-decreased; Sample 4: 31-fold falsely-decreased) (Table 1). After pretreatment of the patient sera with a blocking reagent for hAs, 3 out of 4 samples showed normal recoveries. Sample 3 could not be reanalyzed because of lack of original sample material and patients death. CONCLUSIONS We conclude that about 0.3% of PSA tests by the 3rd generation Roche are disturbed. Although a very rare event this interference puts a relevant amount of patients worldwide at risk of over- or underdiagnostics. Manufacturers and clinical laboratories should know the rates and kinds of interference for their PSA test used. In case of clinically implausible high or low PSA levels, clinicians should rule out sampling errors and repeat PSA tests by including determinations of recoveries, and, if pathological, absorbing hA in the serum of the patients. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e245 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Cedric Poyet More articles by this author Karim Saba More articles by this author Noemie Lautenbach More articles by this author Lanja Saleh More articles by this author Martin Umbehr More articles by this author Tullio Sulser More articles by this author Michael Müntener More articles by this author Arnold von Eckardstein More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

97 Repeat prostate-specific antigen (PSA) tests before biopsy decisions: Results from the STHLM3 diagnostic trial

97 Repeat prostate-specific antigen (PSA) tests before biopsy decisions: Results from the STHLM3 diagnostic trial

Association of changing prostate-specific antigen (PSA) levels on repeat testing with lower risk for Gleason Score (GS) ≥ 7 prostate cancer.

284 Background: PSA levels are often verified before recommending a prostate biopsy because of the variability of PSA, We used data from the STHLM3 trial to assess the value of a second PSA test taken prior to biopsy. Methods: STHLM3 is a prospective and population-based prostate cancer diagnostic study performed in Stockholm, Sweden, 2013-2015. 1686 men in STHLM3 with a PSA value 3-10 ng/ml performed a second PSA test within 8 weeks of the first test and then underwent prostate biopsy. We compared proportions of cancer detected in men with stable PSA levels (2nd PSA within +/-10% of 1stPSA) to men whose PSA levels increased or decreased at least 10%, respectively. Results: Men with GS ≥ 7 cancer in the biopsy had more stable PSA than men with benign biopsies; the median change was 13.7% (inter-quartile range (IQR) 6.1-26.9) in men with benign biopsies, 13.0% (IQR 6.1-25.6) in men with GS ≤ 6 tumors and 8.2% (IQR 4.5-16.7) in men with GS ≥ 7 tumors. The average risk of having GS ≥ 7 cancer was 15.4% (95% CI 13.7 – 17.1) after the first test (i.e. the entire cohort), 21.6% (95% CI 18.6 – 24.6) in men with stable PSA levels compared with 13.5% (95% CI 10.2 – 16.7) and 9.0% (95% CI 6.6 – 11.4) if PSA levels increased or decreased at least 10%, respectively. There were no significant differences in risk of GS ≤ 6 tumor for men with stable PSA compared to men with increasing/decreasing PSA. Conclusions: As previously shown, the risk of prostate cancer decreases if a repeat PSA test shows decreasing levels. We show that this effect mainly affect GS ≥ 7 tumors, and that the risk of prostate cancer also decreases with increasing PSA values. Our findings need validation, but suggest that PSA is more stable in men with GS ≥ 7 cancer, whereas elevated but fluctuating PSA levels to a higher degree are caused by other processes (e.g. inflammation). Use of decision tools could aid incorporation of complex information such as repeat PSA values in diagnostics.

Inflammation of Prostate and Prostate-Specific Antigen

Noncancerous conditions (e.g., benign prostatic hyperplasia and prostatitis) can elevate serum prostate-specific antigen (PSA) levels, limiting the specificity of PSA screening for prostate cancer. In recent years, several studies have also demonstrated a relationship between chronic prostatitis/chronic pelvic pain syndrome and increased PSA levels. However, in asymptomatic patients, routine screening for this diagnosis is not performed before transrectal biopsy to rule out prostate cancer. These asymptomatic men with elevated PSA levels frequently show evidence of inflammation when their expressed prostatic secretions are examined, or on their prostate biopsy specimens. This raises the problem of appropriate evaluation in the presence of chronic prostatitis and elevated PSA levels not only in prostate cancer screening programs, but also in cancer-negative biopsy findings. Thus, there has been investigation into ways to decrease the confounding from inflammation, including repeat PSA measurements after a period of observation or a course of empiric antibiotics. This article reviews the evidence regarding elevations in PSA due to prostatitis and describes the controversy over the optimal approach to reduce its confounding impact on prostate cancer screening. Nowadays, it appears that in patients with prostatic inflammation and increased PSA, an antimicrobial regimen may provide more acceptable initial treatment than proceeding directly to prostate biopsy. Additional evidence is necessary in the form of a randomized clinical trial in which all patients undergo biopsy, regardless of the PSA response to antibiotic or placebo.

Impact of the 2012 United States Preventive Services Task Force statement on prostate-specific antigen screening: analysis of urologic and primary care practices.

To identify the effect of the 2012 United States Preventive Services Task Force (USPSTF) prostate-specific antigen (PSA) recommendation statement on primary care referral patterns and urologists' decision making. Men referred to our institution for newly elevated PSA level from June 2011 to June 2013 were identified. Patients with a prior history of prostate cancer or biopsy were excluded. Clinical and management parameters were compared between those presenting in the year before vs the year after the USPSTF statement. Factors predictive of receiving a prostate biopsy were identified using multivariate regression analysis. A total of 201 men were identified in the pre-USPSTF period and 212 men, thereafter. The groups were comparable in age, race, prostate cancer family history, PSA values, and digital rectal examination findings. At the initial evaluation, patients presenting after the statement were more likely to undergo PCA3 testing (27% vs 11%; P <.01) and repeat PSA testing (82% vs 72%; P = .02) and less likely to undergo immediate biopsy (16% vs 24%; P = .03). The proportion of patients ultimately receiving a biopsy was equivalent. The groups were similar in the percentage of positive biopsies, Gleason distribution, and D'Amico risk. African American race and family history were predictors for receiving a biopsy in the post-USPSTF group but not in the pre-USPSTF group. The 2012 USPSTF recommendation statement has not affected the number or clinical characteristics of patients referred to a tertiary center for elevated PSA level. After recommendation, urologists ordered significantly more PCA3 and repeat PSA tests and recommended fewer biopsies at the initial visit. The fraction of patients ultimately receiving a biopsy remained the same.