AUA report and update no. 12: Friday, May 1, 2009

And still the stream of information continues, with  reports about frequency of PSA testing, nerve-sparing in men with Gleason 6 disease, and HIFU as a form of salvage therapy after first-line radiation:

Based on data from the PCLO trial, Crawford and colleagues have proposed that we could significantly reduce the frequency of testing of men for prostate cancer risk.  They studied data from 29,581 men in the screening arm of the PCLO trial who had an initial PSA < 4 ng/ml and at least one subsequent screening test. After five annual rounds of screening, 3,295 of these men (11 percent) had PSA values that had increased to > 4  ng/ml. When stratified by baseline PSA the percentages of men converting to a PSA level > 4  ng/ml were: 1.3 percent of men with an initial PSA < 1 ng/ml; 7 percent of men with an initial PSA of 1 – 1.99 ng/ml; 29.7 percent of men with initial PSA of 2 – 2.99 ng/m; 66.6 percent of men with an initial PSA of 3 – 4 ng/ml. Based on these results, the authors proposed a new testing strategy:

  • Every 5 years or more for men with a PSA < 1 ng/ml
  • Every 2 or more years for men with a PSA of 1 – 2 ng/ml.

The authors point out that this would reduce the number of PSA tests performed in these cohorts by 70 percent per year, leading to an overall reduction in PSA tests of about 50 percent per year, with a potential estimated cost savings of $1 billion per annum.

Roberts et al. conducted a retrospective analysis of data from a group of 73 patients with Gleason 6 disease in 4 or more cores of predominantly 12-core biopsies to develop criteria that would identify candidates with the greatest probability of organ-confined disease who can safely undergo nerve-sparing radical prostatectomy without compromise of oncologic efficacy. They showed that 79.5 percent of men had organ-confined (pT2) prostate cancer despite having multiple positive biopsy cores. Significant independent risk factors for extraprostatic extension (EPE) were ≥ 6 positive biopsy cores or a PSA density > 0.11 ng/ml/cm3. Of men with <6 positive biopsy cores and a PSAD >11ng/mL/cm3 (lowest risk group), 96.8 percent had organ-confined disease.

Mallick and colleagues evaluated the use of high intensity focused ultrasound (HIFU) as salvage therapy following radiation failure in 84 patients with a rising serum PSA but no evidence of metastasis. Median pre-HIFU PSA levels and Gleason scoress were 5.2 ng/ml and 7 respectively. The pre-HIFU stage was < T2a in 76 patients (90.5 percent) and T2b-T2c in 8 (9.5 percent). Median follow-up was 42 months. Sixty patients (71.4 percent) achieved a PSA nadir < 0.5 ng/ml at 3 months of follow-up. Biochemical recurrence-free survival at 48 months was achieved in 52.4 percent of patients. Men at lower risk experienced a better recurrence-free survival than intermediate or high risk patients. Post-operative complications included transient pelvic pain (19.0 percent), transient urinary retention (28.6 percent), and urinary incontinence (29.8 percent). There were no cases of rectal fistula. Post-operative impotence occurred in 44.3 percent of patients who were previously potent.

2 Responses

  1. Re: PCLO and PSA data analysis by Crawford and collegues — I don’t see any age or ethnic separation of the data, so if you get an initial PSA of 4.0 over 5 annual years of screening, and every 2+ years if initial PSA was 1-2 ng/ml. All the rest, its every year. I think we are missing “risk” factors here; however, I believe that this type of study is a good beginning.

  2. Dear George: Since I wasn’t in the room for Dr. Crawford’s presentation, I don’t know (yet) what other risk factors he may have referred to or assessed in this study. I am merely relating what I do know was said, but he has to have presented more detailed information.

    While this is a thought-provoking analysis, I am also always suspicious about data from such retrospective analyses because that’s what they are — retrospective.

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