Prostate cancer news reports: Friday, September 18, 2009

In today’s news reports we have focused primarily on data showing that specific things do not seem to work well in prostate cancer risk assessment and diagnosis:

  • Neither PSA velocity nor the PSA/serum testosterone ratio are normally predictive for risk of prostate cancer in undiagnosed patients.
  • Post-surgical tumor volume is not predictive for risk of prostate cancer progression.
  • A new nomogram predicts risk of pathological upgrading post-surgery.

Vickers et al. have published yet another report showing that PSA velocity (PSAV) does not normally or reliably enhance prediction of biopsy outcome in a large, representative, population-based group of men. In their third study showing this lack of correlation, they used data from over 2,700 patients with a PSA < 3 ng/ml at initial screening and which subsequently rose to about  ≥ 3 ng/ml and who were evaluated and biopsied in the screening arm of the European Randomized Study of Screening for Prostate Cancer (ERSPC). According to their analysis, inclusion of PSAV led to very small enhancements in predictive accuracy only if the percentage of free  PSA (%fPSA) was also included, but even then it did not improve prediction of risk for high-grade disease. Furthermore, the enhancement depended on specific modeling of a nonlinear relationship between PSAV and cancer. There was no apparent benefit if data from men with with higher PSAV values were excluded, and higher PSAV values were actually associated with lower risk. The authors’ specific conclusion was that, “In men with PSA of about ≥ 3 ng/ml, we found little justification for formal calculation of PSAV or for use of PSAV cut points to determine biopsy. Informal assessment of PSAV will likely aid clinical judgment, such as a sudden rise in PSA suggesting prostatitis, which could be further evaluated before biopsy.”

Morote et al. have analyzed data to investigate whether the ratio of serum testosterone level (sT) to PSA level could be used as an improved  predictor of prostate cancer risk, compared to PSA level alone. Their analysis was based on data from 439 consecutive men with a normal digital rectal examination and a serum PSA level of 4.1-20 ng/ml who had a transrectal ultrasonography-guided biopsy using a 10-core scheme, with an additional 1-8 cores according to prostate volume and patient age. Their results do not support the use of the sT/PSA ratio for predicting the risk of prostate cancer and to increase the specificity of PSA. However, they did confirm, yet again, that the percentage of free PSA (%fPSA) has independent predictive value for risk of prostate cancer.

Based on data from > 850 men treated between 1998 and 2007, Porten et al. have shown that there is no evidence that post-surgical prostatic tumour volume is an independent predictor of prostate cancer outcome and that it should not be considered as a marker of tumor risk, behavior, or prognosis.

Finally, on a more positive note, Moussa et al. have developed yet another new nomogram — this time a nomogram that enables clinicians to predict the likelihood of upgrading after surgery in patients with low- and intermediate-grade prostate cancer in the recent era of extended prostate biopsy sampling. The nomogram is based on data from 1,017 patients who had a radical prostatectomy after biopsy showing Gleason scores of 3 + 3 = 6 and 3 + 4 = 7 between 2000 and 2007. The mean age of the patients was 60 years, and their mean PSA level was 6.62 ng/ml. Of the 1,017 patients, 336 (33.0 percent) were upgraded, 623 (61.3 percent) remained the same, and 58 (5.7 percent) were downgraded. The authors suggest that this nomogram might be useful to both the urologist and the patient with low- and intermediate-grade prostate cancer, most specifically when the possibility of a more aggressive Gleason score could change management decisions, and when management options other than surgery may need to be considered, because of the inability to identify the pathological Gleason score post-surgery if surgery is not being carried out.

One Response

  1. How little we seem to know ….

    And the Moussa et al. study says that they don’t get the right Gleason score in over a third of all TRUS biopsies — not a confidence builder. Seems like all concerned would want to know the Gleason score before treating or monitoring prostate cancer.

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