Prostate cancer with low PSA

[Guest guest]

Hi All,

Please see the below.

I have no family history of prostate cancer and a low level

of PSA. I wonder how much of the below might apply to

me and other CRers having low PSA level.

New Engl J Med 2004;350:1802-1803

A.Beatty

Prostate Cancer with Low PSA Levels

to the editor:

et al. (May 27 issue)1

have provided a fascinating picture of the preva-

lence of prostate cancer in men with " normal "

prostate-specific antigen (PSA) levels in the Pros-

tate Cancer Prevention Trial. They found surprising-

ly high rates of prostate cancer in men with PSA

values of 4.0 ng per milliliter or less.Many authors

have pointed out that PSA screening is flawed be-

cause of its relatively poor sensitivity and specifici-

ty.2 One potential strategy to improve the sensitiv-

ity of PSA evaluations in the context of metastatic

disease includes " PSA velocity, " or PSA doubling

times.3 Since the Prostate Cancer Prevention Trial

has annual data on subjects with normal PSA deter-

minations,it would be of interest to know what the

PSA doubling time was for those in whom prostate

cancer eventually developed in this otherwise low-

risk group,as compared with the doubling time for

the members of the cohort,in whom prostate can-

cer did not develop.Doubling times may give some

useful insight into this population of men with

otherwise silent prostate cancer.

1. IA,er DK,Goodman PJ,et al. Prevalence of

prostate cancer among men with a prostate-specific antigen level of

=4.0 ng per milliliter.N Engl J Med 2004;350:2239-46.

2.Barry MJ.Prostate-specific –antigen testing for early diagnosis

of prostate cancer.N Engl J Med 2001;344:1373-7.

3.Patel A,Dorey F,lin J,deKernion JB.Recurrence patterns

after radical retropubic prostatectomy:clinical usefulness of pros-

tate specific antigen doubling times and log slope of prostate specif-

ic antigen.J Urol 1997;158:1441-5.

Alan I.Glaser

to the editor:

As noted by et al.,a low-

er PSA threshold for recommending biopsy would

allow more prostate cancers to be detected but

would also increase the number of unnecessary

biopsies.One method of improving the power of

the PSA test is to measure free PSA;the higher the

fraction of free PSA,the lower the risk of prostate

cancer.

The Mayo Clinic guidelines state that when the

total PSA level ranges from 2.0 to 3.9 ng per millili-

ter and free PSA makes up more than 18 percent of

the total,the risk of prostate cancer is less than 10

percent.When thetotalPSAlevel rangesfrom2.0to

3.9 ng per milliliter and free PSA makes up less

than 10 percent of the total,the risk of prostate

cancer is more than 30 percent.

I believe that a biopsy should be recommended

if the total PSA level is 2.0 ng per milliliter or higher

and the fraction of free PSA is less than 10 percent

of the total.

Bernardo Rocco, Deliu Victor Matei, Ottavio de Cobelli

to the editor:

et al. show that 15.2%

of men without clinical risk factors have pros-

tate cancer.However,clinically significant prostate

cancer has been defined as a tumor with a volume

greater than 0.5 cm 3 and a Gleason score greater

than or equal to 7.1

In the study by et al.,67 of 449 men

with biopsy-proven prostate cancer (14.9 percent)

had high-grade disease;however,a low tumor bur-

den on needle biopsy does not necessarily indicate

a low tumor volume or a low stage of cancer.2

Hautmann et al.analyzed 133 cystoprostatectomy

specimens from men with PSA levels below 4.0 ng

per milliliter;44 percent had prostate cancer and

12 percent had a tumor volume of 0.5 cm 3 or great-

er.3 Extrapolating these data,about 350 of the 2950

patients in the study of et al.could be

affected by clinically significant prostate cancer.

1.Stamey TA,Freiha FS,McNeal JE,Redwine EA,Whittemore AS,

Schmid HP.Localized prostate cancer:relationship of tumor vol-

ume to clinical significance for treatment of prostate cancer.Cancer

1993;71:Suppl:933-8.

2.Montironi R,Mazzucchelli R,Scattoni V,Bostwick DG.Patho-

logical finding in TRUS prostatic biopsy — diagnostic,,prognostic

and therapeutic importance.Eur Urol Suppl 2002;1:60-75.

3.Hautmann SH,Conrad S,Henke RP,et al.Detection rate of

histologically insignificant prostate cancer with systematic sex-

tant biopsies and fine needle aspiration cytology.J Urol 2000;163:

1734-8.

Milton W.Datta, Jules J.Berman, Rajiv Dhir

to the editor:

As members of the National Cancer

Institute 's ative Prostate Cancer Tissue Re-

source (CPCTR),we read with great interest the

findings of et al.Patients who have pros-

tate cancer with low serum PSA levels are not un-

usual.A review of the CPCTR database of 4022 pa-

tients with prostate cancer who were treated with

radical prostatectomy between 1987 and 2003 iden-

tified 506 patients with initial PSA levels of less than

4.0 ng per milliliter (12.6 percent),and 155 with val-

ues of less than 2.0 ng per milliliter (3.9 percent).

Our data indicate that patients whose initial PSA

values were less than 4.0 ng per milliliter were

younger and had lower Gleason scores,smaller tu-

mors,and lower tumor-recurrence rates (during an

average follow-up of 3.8 years)than other patients.

It should be noted,however,that roughly 30 per-

cent of patients with cancer who presented with se-

rum PSA levels of less than 2.0 ng per milliliter still

had high-grade disease (Gleason score,7 to 10).

These findings demonstrate that clinically anno-

tated tissue resources can be used to corroborate

and enhance clinical data sets.CPCTR tissues and

data are available to cancer researchers.Addition-

al information can be found on the Web at www.

prostatetissues.org.1

1.Melamed J,Datta MW,Becich MJ,et al.The ative Pros-

tate Cancer Tissue Resource:a specimen and data resource for can-

cer research.Clin Cancer Res 2004;10:4614-21.