Posted 2/28/2009 7:11 AM (GMT -6)
Clinical practice guidelines: every man should have an annual psa and dre starting at age 40 and lowered to age 35 for men at risk via family history (including mother, sisters with breast cancers) and African-American men.
A psa of 2.0 and over at any age should be investigated. A first step in investigating elevated:
psa 2.0 and above should be a fPsa (free) percentage test. (fpsa=unbound antigen test)
fPsa over 25% is associated with lower risk of PCa
fPsa test of under 15% is associated with higher risk of PCa
A benign cause of elevated psa and a low fPsa-% could be prostatitis (4-6 weeks of Cipro or similar antibiotic can be used )
BPH (normal aging enlargement of gland) does not cause a low fPsa-% It may cause an elevated psa level and as men age *this could be the reason they see psa rise over longer time spans. (bph with urinary flow restrictions can be treated with-avodart or proscar drugs)
Sampling for psa tests normally done at least 3 months apart and by using same lab that uses same proceedure are necessary to establish psa velocity (psav) and psa doubling time (psadt). The validty of such is increased if such testing involves at least 18 month span of time. But, progressive and serial increase in psa values should raise flags or concern that PCa is present and therefore greater degree of vigilance is mandatory.
PSAV that exceeds .75 ng/ml/yr is associated with a higher probability of PCa
PSADT of less than 12 years is associated with a high probability of PCA
(*PSADT- in less than 6 months or within 1 yr.-considered to be red flag-investigate such)
Psa's that bounce up and down are more indicative of benign processes than malignant.
Psa's that show continued rise over time, particularly 3 consecutive rises, 3 months apart are suspicious for PCa regardless of the level of psa. *recommending vigilance
Gland volume in cc mulitpled by .066 yeilds the amount of psa produced by a normal, non-malignant gland (cc volume can be measured by your doc), any amount of psa in excess of this should be considered by a malignant process, until proven otherwise. *E.G. prostate gland found to be 40cc you can calculate the normal psa level 40 x .066=normal psa level, anything higher than that number could be malignant PCa.
If these guidelines were used by all men it would eliminate advanced presentations of PCa, annual screening in this manner would present an opportunity to detect localized PCa in over 95% of men, such stats offer outstanding chance for curative approach to the disease.
The extremes in indolent vs. aggressive PCa's (kittens vs. tigers):
Kittens (generally) have low psa values (under 10) and long doubling times and low velocity. *Patients found 'indolent' versions of PCa (like defined by John Hopkins-Brady Urology) can be canidates for w.w.-watchful waiting (monitoring etc.) Patients whom chose such need to monitor their status vigilantly and be aware that "if" manifestations of disease progression become evident, then reevaluate their situation and consider local forms of treatment, before the window of opportunity for success could be come lost.
Tigers (generally) have high psa's (over 10) or very low psa's assocaite with very aggressive, high Gleason scores like: (4,3), (4,4), (4,5), (5,4), (5,5) cancers. These are dangerous because they could escape investigation for long periods of time since the psa's appear to be normal. High Gleason scores often have reverted to such a primitive state that they no longer secrete psa into the blood. * Thus the need for screenings with dre, possible blood marker tests and other tests like PAP, Pyrilinks etc. Perhaps the newer PCA3 urine detection method, also perhaps using the fpsa test and patient mentioning any potential symptoms to his doctor.
Some of this I paraphrased or with the * added my own comments to Dr. Strum's
*This should be considered generalized guidelines and information, since there are some unique rarer forms of PCa, these guidelines might not be fully applicable every variant (rare) type, thus maybe exceptions to some degree.
Post Edited (zufus) : 2/28/2009 5:48:39 AM (GMT-7)