psa testing importance of multiple markers ian thompson md department of urology university of texas...

PSA TestingImportance of Multiple Markers

Ian Thompson MDDepartment of Urology

University of Texas HSCSan Antonio, TX

PSA (ng/mL)

Ris

k

0 1 2 3 4

0.0

0.1

0.2

0.3

0.4

0.5

Risk of Prostate Cancer

0 1 2 3 4

0.0

0.1

0.2

0.3

0.4

0.5

Risk of High-Grade Disease

Thompson IM et al. N Engl J Med 2004;350:2239-46

Population Screening with PSATrue Outcomes

4.0+

PSA 4+ 7.6%Positive biopsy 25%High grade 19%

Screen 10,000 Men

PSA 4+ 760Cancer 190High grade 36

PSA <4 9240Cancer 1386 High grade 208

Normal PSA 92.4% Positive biopsy 15%High grade 15%

<4.0

PSASEER, PCAW, Prostate Cancer Prevention Trial Data

Pause for a moment

You read in a throwaway magazine about the benefits of a bASA daily.

You worry about GI upset.You ask your own PCP, should I

take a bASA?How do they assess your risk?

10-year risk of coronary artery disease

So why do we use just PSA?

DRE

Age

Race/ethnicity

Family history

Prior negative biopsy

PSA velocity

Let’s just take some examplesPoint in play: Dichotomy of DRE as a solitary measure of risk

55 yo WM, -FHx, DRE+, no prior bx, PSA 0.3 – recommendation?

– Biopsy, right?

68 yo AAM, +FHx, DRE-, no prior bx, PSA 2.4 – recommendation?

– No biopsy, right?

This example (DRE dichotomy)

55 yo WM, -FHx, DRE+, no prior bx, PSA 0.368 yo AAM, +FHx, DRE-, no prior bx, PSA 2.4

What are these men’s risk of disease?1st man – Cancer=13% High grade

cancer=1%2nd man – Cancer=31%. High grade – 11%.

Doesn’t make any sense, correct?

The Next Step

• Adding Body Mass Index

• Adding Population ‘Norms’

• Adding pro-PSA