AUA has new guidelines for prostate cancer ~ Includes PSA tests at 40.

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Tony Crispino
Veteran Member

Date Joined Dec 2006
Total Posts : 8128
   Posted 4/28/2009 12:56 PM (GMT -6)   
Thanks to Kathy Meade again for the attached...
Testing at 40? It's about time.  The AUA (American Urologic Association) has begun it's meetings in Chicago.  Starting with new guidelines for prostate cancer screening.  The following points from the attached article include:
  • Serum PSA predicts the response of prostate cancer to local therapy.
  • Routine use of a bone scan is not required for staging asymptomatic men with clinically localized prostate cancer when their PSA level is ≤20.0 ng/mL.
  • CT or MRI scans may be considered for the staging of men with high-risk clinically localized prostate cancer when the PSA is >20.0 ng/mL or when locally advanced or when the Gleason score is ≥8.
  • Pelvic lymph node dissection for clinically localized prostate cancer may not be necessary if the PSA is <10.0 ng/mL and the Gleason score is ≤6.
  • Periodic PSA determinations should be offered to detect disease recurrence.
  • Serum PSA should decrease and remain at undetectable levels after radical prostatectomy.
  • Serum PSA should fall to a low level following radiation therapy, high intensity-focused ultrasound and cryotherapy and should not rise on successive occasions.
  • PSA nadir after androgen suppression therapy predicts mortality.
  • Bone scans are indicated for the detection of metastases following initial treatment for localized disease, but the PSA level that should prompt a bone scan is uncertain. Additional important prognostic information can be obtained by evaluation of PSA kinetics.
  • The kinetics of PSA rise after local therapy for prostate cancer can help distinguish between local and distant recurrence.
  • <Extract>There is emerging evidence from studies done in Sweden that a single PSA determination in your 40s helps determine your lifetime risk of developing prostate cancer. This is relatively new data and it will allow us to tailor our screenings strategies. It's clear from that data and from the Prostate Cancer Week Awareness campaign over the last two decades in the United States, and the two studies published in the NEJM — the PLCO and the European screening trial — that not everybody needs to be screened every year. So starting with a baseline PSA at 40 gives you some idea what your future risk is and how often you need to be screened.

    My own commentary:  Logic has been telling me that mortality and prostate cancer is more predictable than has been found.  If a man in his forties has high risk PCa, then what are his chances with the disease.  I have spentthe last two and a half years finding virtually no studies that include 40 year old men.  The recent releases of the screening contraversy continued that trend.  My thought is that if we are studying 55 and up and there is little mortality, then where do we get 28,000 men a year dying from this disease in this country?  My answer was that it's at least in part the younger group flying under the radar of studies.  The irony of the day is that the US report that questions screening, will now lead to more of it.  I am not surprised.



    Age 46 (44 when Dx)
    Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
    Geason 4+3=7, Stage pT3b, N0, Mx
    Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
    HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
    IMRT radiation for 38 Treatments ending August 3, '07
    Current PSA (January 13, 2009): <0.1
    My Journal is at Tony's Blog  

    mountain top high
    Regular Member

    Date Joined Mar 2009
    Total Posts : 22
       Posted 4/28/2009 7:00 PM (GMT -6)   

    Thanks for the update, Tony. Interesting stuff.

    I'm 43 and was asked by the James Cancer Center/Solove Research Institute if I would participate in a study to determine why so they're seeing so many men in their 40s coming in with PCa. It's not a drug testing study or anything "active" like that, but they are aggregating the data on younger guys so they can look for patterns.

    Mountain Top High, Age 43
    PSA 1.6 (2006), 1.9 (2007), 6.0 (6/2008), 3.9 (7/2008 after 30-day Cipro course)
    8/08 biopsy--high grade PIN
    11/08 biopsy--Dx (age 43), Gleason 7 (3+4), T1c
    Da Vinci RP 2/9/09 (Dr. Abaza, Head of Robotic Uro, James Cancer Center @ Ohio State)
    Path--PCa 9%, 39.5 grams, T2c, contained in capsule, margins & lymph nodes clear
    Catheter 1 week, no nighttime incontinence
    @ 6 wks: 4-5 pads/day, since 7 weeks out 1-2 pads/day with regular ab/core exercises
    Complete ED, pump twice daily, fighting with insurance for Viagra, ordered from alldaychemist, 4/23/09 started 100mg nightly 

    Regular Member

    Date Joined Jun 2008
    Total Posts : 91
       Posted 4/28/2009 10:47 PM (GMT -6)   
    Could you define, in "laymen's terms," what is meant by serum PSA and kinetics of PSA? Thanks...
    Husband and father of two (current ages 5 and 7).
    Age when diagnosed: 47 (currently 48)
    Pre-surgery PSA: 13.7
    Pre-surgery Gleason: 4+3=7
    CT Scan, Bone Scan, PET Scan: Clear
    Robotic Surgery on May 28, 2008, at Barnes Hospital in St. Louis.
    Right nerve bundle spared; left bundle removed.
    Gleason: 4+3=7
    Involved 10% of prostate; all quadrants involved
    Extraprostatic extension at left base and apex
    Extensive perineurual invasion present.
    Bladder neck, lymphvasular space, seminal vesicles, 17 examined lymph nodes, and all surgical margins FREE of tumor.
    Four-week post-surgical PSA = 0.1
    Seven-week post-surgical PSA = .01
    October 2008 PSA = 0.0
    January 2009 PSA = 0.0
    April 2009 PSA - 0.0
    Next PSA scheduled for July 2009.

    Veteran Member

    Date Joined Feb 2008
    Total Posts : 1858
       Posted 4/29/2009 1:21 AM (GMT -6)   
    The meaning of "serum" here is simply the medical term for blood, i.e. the level of PSA in the blood. The term "kinetics of PSA" means the activity of the PSA, i.e. what was the level after treatment and if present is it static, falling or rising and the rate of such changes. For example if the PSA after surgery is undetectable but becomes detectable and begins to rise , say, two or more years later, then that is more indictative of local re-occurrence rather than distant metastases. The doubling time of blood PSA is indicative of the aggressiveness of the tumour ( these are all the "kinetics of PSA post treatment"
    1/05 PSA----2.9 3/06-----3.2 3/07-------4.1 5/07------3.9 All negative DREs
    Aged 59 when diagnosed
    Biopsy 6/07
    4 of 10 cores positive for Adenocarcinoma-------bummer!
    Core 1 <5%, core 2----50%, core 3----60%, core 4----50%
    Biopsy Pathologist's comment:
    Gleason 4+3=7 (80% grade 4) Stage T2c
    Neither extracapsular nor perineural invasion is identified
    CT scan and Bone scan show no evidence of metastases
    Da Vinci RP Aug 10th 2007
    Post-op pathology:
    Positive for perineural invasion and 1 small focal extension
    Negative at surgical margins, negative node and negative vesicle involvement
    Some 4+4=8 identified ........upgraded to Gleason 8
    PSA Oct 07 <0.1 undetectable
    PSA Jan 08 <0.1 undetectable
    PSA April 08 <0.001 undetectable (disregarded due to lab "misreporting")
    PSA August 08 <0.001 undetectable (disregarded due to lab "misreporting")
    Post-op pathology rechecked by new lab:
    Gleason downgraded to 4+3=7
    Focal extension comprised of grade 3 cells
    PSA September 08 <0.01 (new lab)
    PSA February 09 <0.01

    Elite Member

    Date Joined Oct 2008
    Total Posts : 25393
       Posted 4/29/2009 8:07 AM (GMT -6)   
    I agree fully with the testing at 40, al men of all races of all risk groups, and establish a good baseline, way in advance. If my GP told me to start at 40, I would have done so, I was told to wait to 50 since there was no PC in my family and that I was caucasion, so I did what I was told, and bingo, I ended up with a serious dose of PC anyway.
    Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5
    3rd Biopsy Sept 08: Positive 7 of 7 cores, 40-90%, Gleason 7, 4+3
    Open RP surgery 11/14/8, Right nerves spared, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
    Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
    First PSA Post Surgery   2/9 .05, 6 month on 5/9

    John T
    Veteran Member

    Date Joined Nov 2008
    Total Posts : 4269
       Posted 4/29/2009 11:44 AM (GMT -6)   
    This is sage advice and the guidelines are resonable. We could eliminate a lot of costs if doctors would stop giving bone and CT scans to low risk patients. My bone and CT scans were $12,700, insurance paid way less, but it is still a cost to the individual and the system.

    64 years old.

    I had an initial PSA test in 1999 of 4.4. PSA increased every 6 months reaching 40 in 5-08. PSA free ranged from 16% to 10%. Over this time period I had a total of 13 biopsies and an endorectal MRIS all negative and have seen doctors at Long Beach, UCLA, UCSF and UCI. DX has always been BPH and continue to get biopsies every year.

    In 10-08 I had a 25 core biopsy that showed 2 cores positive, gleason 6 at less than 5%. Surgery was recommended and I was in the process of interviewing surgeons when my wife's oncologist recommended I get a 2nd opinion from a prostate oncologist.

    I saw Dr Sholtz, in Marina Del Rey, and he said that the path reports indicated no tumor, but indolant cancer clusters that didn't need any treatment. He was concerned that my PSA history indicated that I had a large amount of PC somewhere that had yet to be uncovered and put me through several more tests.

    A color doppler targeted biopsy in 11-08 found a large tumor in the transition zone, gleason 6 and 7. Because of my high PSA Dr. suspected lymph node involvement, 30% chance, and sent me to Holland for a Combidex MRI, even though bone and CT scans were clear.

    Combidex MRI showed clear lymph nodes and a 2,5 cm tumor in the anterior. I was his 1st patient to come up clear on the Combidex which has a 96% accuracy,

    I've been on a no meat and dairy diet since 12-08 and PSA reduce to 30 while I awaited the Combidex MRI.

    The location of the tumor in the anterior apex next to the urethea makes a good surgical margin very unlikely. Currently on Casodex and Proscar for 8 weeks to shrink my 60 mm prostate. Treatment will be seeds followed by 5 weeks of IMRT while continuing on Casodex and Proscar. So far no side affects from the Casodex.

    As of April 10 and 7 weeks on Casodex and Proscar PSA has gone from 30 to 0.62 and protate from 60mm to 32mm. Very minor side affects. Doc says all this indicates tumor is not aggessive

    Awaiting schedule for seed impants


    Elite Member

    Date Joined Oct 2008
    Total Posts : 25393
       Posted 4/29/2009 12:07 PM (GMT -6)   
    I agree JohnT, the bone scans/CT should be reserved, in my opinion to PSA >10, or PSA with high velocity rates, and biopsied Gleasons of at least 7, possibly in the 4+3 configuration. This alone would save millions of dollars a year.
    Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5
    3rd Biopsy Sept 08: Positive 7 of 7 cores, 40-90%, Gleason 7, 4+3
    Open RP surgery 11/14/8, Right nerves spared, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
    Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
    First PSA Post Surgery   2/9 .05, 6 month on 5/9

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