Prostate Cancer Canada

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Early Detection Guidelines
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PSA

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Prostate Cancer Awareness Day at BC Legislative Assembly
VICTORIA, May 4, 2012- On Monday, May 7, Prostate Cancer Canada (PCC) will host their first Legislative Assembly Day to promote education and awareness of prostate cancer in British Columbia.

Media Advisory - Prostate Cancer Canada celebrates local Halifax hero
HALIFAX, April 25, 2012 /CNW/ - Please join Prostate Cancer Canada and members of the Halifax business community as we celebrate a local hero who has made an extraordinary contribution in the fight against prostate cancer through courage, inspiration and dedication.

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Early Detection Guidelines

Prostate Cancer Canada advises men and their doctors take the time to discuss the merits of prostate specific antigen (PSA) blood testing followed by a digital rectal examination (DRE) for early detection of prostate cancer. We also strongly recommend that men consider the following schedule for prostate cancer monitoring using PSA blood testing:

AGE 40

Establish a baseline PSA value. While the threat of prostate cancer is minimal at this age, it also precedes the onset of benign prostatic hyperplasia (BPH), the natural enlargement of the prostate that commonly occurs with age. The onset of BPH often results in rising PSA over time, and can be confused with the onset of prostate cancer. Your doctor can observe whether your PSA levels have risen, and if so, how quickly.

Unless your resulting baseline PSA score is of concern to your doctor, the PSA need only be repeated every 5 years until age 50. Men at higher risk of prostate cancer (eg. men whose father and/or brother developed prostate cancer and/or those of African or Caribbean descent) should begin annual PSA and DRE monitoring at age 40.

AGE 50

All men should begin annual or semiannual PSA monitoring if they have not yet done so. A minimal increase in PSA levels against your baseline score often (in consultation with your physician) requires no further action until your next annual test. A significant increase should prompt a discussion with your doctor or urologist about follow up PSA blood tests.

The PSA blood test not only helps to diagnose prostate cancer, but helps monitor for recurrence of prostate cancer after treatment. It allows a patient and his doctor to monitor if cancer is suspected, if lifestyle changes have had an impact or if cancer has regressed or spread.

Combining the results of PSA blood testing with DRE increases both the diagnostic power and the accuracy of these early detection methods.

1. PSA DISCUSSION

Like most cancer diagnostic tools, the PSA blood test comes with its pros and cons; however, men deserve the right to make their own informed decisions regarding the state of their health – even if that decision is to forego or delay treatment. Informed decisions are impossible, however, without regular PSA blood tests and digital rectal examinations (DRE) to assess the likelihood of cancer.

The PSA blood test is neither a test for prostate cancer nor an indicator of the type of prostate cancer. PSA levels in the blood increase when the size of the prostate or the number of prostate cells increases.

The usefulness of the test has been debated in medical and political circles for some time. Therefore, when deciding whether to take the test, men should consider the pros and cons and take into account age, risk factors and general health.

Pros

Research has shown that a rapid rise in PSA levels over months or years is a very strong sign of aggressive prostate cancer.
By the time a man develops advanced prostate cancer, his PSA is almost always very high.
Widespread testing results in early diagnosis – at the stage when the chances of a cure are good, and there are more options for treatment (ex. surgery, external radiation, Brachytherapy etc.).
The test may not be foolproof but it is the best early detection tool we currently have.

Cons

Sometime increased PSA blood levels are present when clinically insignificant prostate cancers exist – tumors that are smaller than 0.5cc in volume. These tumors may never become life threatening. A high PSA level can also signify non-cancerous conditions. Biopsying these men and treating their cancers may in some cases cause more harm than good.
Normal PSA levels are arbitrary. Sometimes PSA levels may be below normal levels even when cancer is present.

2. WHAT DO THE NUMBERS MEAN?

The PSA blood test checks the blood for minute quantities of an enzyme called prostate-specific antigen or PSA. A higher than normal amount of PSA in the blood is a possible indicator of prostate cancer, although other conditions of the prostate, such as benign prostatic hyperplasia and prostatitis, also elevate PSA levels.

Here are the general guidelines for PSA values:

PSA level in nanograms per millilitre	Usual description for average man
0 to 4 ng/ml	Within the normal range
4 to 10 ng/ml	Elevated
10 to 20 ng/ml	Moderately elevated
Greater than 20 ng/ml	Highly elevated

Remember, high PSA readings do not mean that you have prostate cancer. Many factors can contribute to an abnormally high level of PSA in the blood, and the general guidelines presented above are usually adjusted for some of these factors.

AGE
Aging increases the amount of PSA in the blood, so normal PSA levels are adjusted for age. Any PSA level of under 4 nanograms per millilitre (ng/ml) used to be considered insignificant. With more knowledge about the effects of aging on PSA levels, however, doctors would probably consider a reading of above 2.5 significant for a 45-year-old man and call for further testing.

RACE
A man's race affects his risk of developing prostate cancer and the amount of prostate-specific antigen that is within the normal range. Today, doctors may consider both a man's age and his race when determining whether his PSA blood test result is unusual. The following table shows age- and race-adjusted cut-off values for PSA -- or in other words, the PSA levels at the top end of the normal range for men of particular ages and races.

3. RELIABILITY OF THE PSA BLOOD TEST
So many factors can affect the level of prostate-specific antigen in the blood that one might ask whether the PSA blood test is useful in the diagnosis of prostate cancer. The answer is a resounding yes. The PSA blood test, especially when combined with a digital rectal examination (DRE), is a good indicator of the possibility of prostate cancer. The PSA blood test does not predict either the presence or absence of prostate cancer, but it does alert men and their physicians to the possibility of the presence of an early-stage cancer in the prostate.

Still, there is considerable controversy over the value of the PSA blood test. Some studies report that no prostate cancer was found in 70 to 80 per cent of the men who had a biopsy because of an elevated PSA level. The medical community calls a higher than normal PSA level with no evidence of prostate cancer a “false positive”. Also, some researchers estimate that 20 per cent of prostate cancers would be missed if doctors relied only on PSA blood test results. In other words, one out of every five men tested would have prostate cancer and a normal PSA level. A PSA level in the normal range with the presence of prostate cancer is called a “false negative”.

There is also a misconception that the PSA blood test is not accurate. When the PSA blood test is conducted in accordance with the instructions provided, accurate assay results should be obtained.

The PSA value is not diagnostic for prostate cancer. It should be used in conjunction with clinical evaluation, digital rectal examination, and other laboratory tests or imaging techniques. If the PSA value is inconsistent with clinical evidence, additional testing is suggested to confirm the result. Confirmation of prostate cancer can only be determined by prostatic biopsy.

4. REFINEMENTS
Physicians have made refinements to the PSA blood test and to the analysis of PSA blood test results to improve its reliability as an indicator of prostate cancer, Doctors now consider the speed at which PSA levels rise, how quickly PSA levels double in amount (PSA doubling time), the sort of prostate-specific antigen in the blood (free versus total PSA), and the amount of PSA in relation to the size of a man's prostate (PSA density).

PSA doubling time: PSA doubling time relates PSA levels to time. It measures the time it takes for your PSA value to double. Sometimes, PSA doubling time is helpful in pre-biopsy guesses about whether a man has cancer and whether this cancer is likely to be aggressive or to have spread.

Percentage of Free to Total PSA (%fPSA): This measurement is a ratio comparing the amount of free PSA to the total amount of PSA in the blood. Free PSA travels alone in the blood; it is not bound to any other blood proteins.

This unbound or free PSA comes from BPH, not prostate cancer. So the higher a man's percentage of free PSA, the less likely it is that prostate cancer is to blame. Testing for free PSA (called %fPSA in some medical reports) is useful for men whose PSA level falls between 4 and 10-the grey area in which BPH could be the culprit. Readings of greater than 25 per cent free PSA (25 %fPSA) indicate that much of the elevated PSA is caused by BPH. A reading of under 10% suggests that prostate cancer is causing this elevation and, furthermore, that this cancer is probably large and in need of immediate treatment.

PSA density (PSAD): This measurement compares the size of a man's prostate, which is determined by a transrectal ultrasound (TRUS), with his PSA level. In simple terms, the doctor divides the PSA value by the size (or mass) of the prostate. If, for example, your PSA level is 4 and the size of your prostate in grams is 32, you would divide 4 by 32 to get a PSA density of 0.125. Usually, a PSA density under 0.07 is considered fairly safe, one between 0.07 and 0.15 could be attributable to either BPH or prostate cancer, and one above 0.15 indicates an increased likelihood that cancer is present. Prostate volume measurements, and thus PSA densities, are subject to TRUS operator/interpreter variability.

5. OTHER CONDITIONS OF THE PROSTATE
Benign prostatic hyperplasia (BPH) and prostatitis can also increase the amount of PSA found in a man's blood. BPH, a non-cancerous enlargement of the prostate, can elevate PSA levels because a larger prostate manufactures more prostate-specific antigen. Also, any prostate condition can weaken the tissues in the prostate gland, allowing more PSA to leak into the blood. Usually, PSA levels caused by BPH do not go as high as those caused by prostate cancer, nor do the levels tend to rise as quickly. However, most likely, if you have a higher than normal PSA level or one that is steadily rising, your doctor will discuss the value of having a prostate biopsy to determine whether cancer or some other condition is to blame.

Prostatitis, an inflammation of the prostate, can also affect PSA levels. Because this inflammation can break down tissues in the prostate gland, it can enable quite a bit of prostate-specific antigen to escape fairly quickly into the blood. An acutely inflamed or infected prostate can increase a man's PSA level to 100 nanograms per millilitre (ng/ml) or higher. After treatment for prostatitis, it can take up to six months for PSA levels to return to normal.

6. ASSESSING PROSTATE CANCER RISK

Prostate Cancer Assessment Tools (PCATs) are based on nomograms published in the Journal of Urology to ensure highly accurate assessments. Nomograms are paper-based decision-making statistical tools that are comprised of information from thousands of real-life observations from documented prostate cancer cases.

The tools assist patients and physicians in decision making by providing calculated predictions of the outcomes of various stages of prostate cancer.

The nomograms behind the 12 PCATs have an average accuracy rate of 80 per cent, and are of significant benefit to patients in that they eliminate bias and subjectivity that is inherent in the perspective of individual clinicians and caregivers.

To create this program for Canadian men, Prostate Cancer Canada partnered with a team of highly recognized researchers led by Dr. Pierre Karakiewicz, MD, urologist and director of the Cancer Prognostics and Health Outcomes Unit at the University of Montreal Health Centre.

Information published on the Prostate Cancer Canada website is provided for informational and educational purposes only. Information provided on this website, including information derived from the Prostate Cancer Assessment Tools (PCATs) and the prostate cancer nomograms, is not designed or intended to constitute medical advice or to be used for diagnosis. The PCATs are intended to provide information on your condition and to help inform your consultations with medical professionals. The information obtained from this website should not be a substitute for medical advice from a qualified medical professional.

Prostate Cancer Canada and the Centre Hospitalier de l'Université de Montréal assume no responsibility or liability for any consequence resulting directly or indirectly for any action or inaction you take based on or made in reliance on the information, services, or material on or linked to this site.

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