PCa ScreeningNew Areas of Research

Francesco Montorsi

Milan

Ullmert D; BMC Med. 2008 Feb 15;6:6

• In 1974–1986 blood samples were obtained from a cohort of 21,277 men aged up to 50

• Through 1999, 498 men were diagnosed with prostate cancer, and of these 161 had locally advanced or metastatic prostate cancers

• Three controls, matched for age and date of venipuncture, were selected for each case. Conditional logistic regression was used to test associations between molecular markers and advanced cancer

The Malmö Preventive Project (mPP)

Ullmert D; BMC Med. 2008 Feb 15;6:6

Two-thirds of the advanced cancer cases occurred in men with the top 20% of PSA levels (0.9 ng/ml or higher)

The Malmö Preventive Project (mPP)

• Men who had PSA values at or below 1.2 ng/ml at age 60 had a 0.3% risk of prostate cancer death by age 85.

• The risk of dying of prostate cancer by age 85 increased to:

1.5% in men whose PSA value was 1.5 ng/mL at age 60 (67th percentile). 3.7% in men who had a PSA level of 2.1 ng/mL at age 60 (80th percentile). 8.9% in men who had a PSA level from 2.1 to 3.4 ng/mL at age 60 (90th percentile)15% in men who had a PSA level of 5.2 ng/mL at age 60 (95th percentile) 31% in men who had a PSA level of 15 ng/mL (at age 60 99th percentile). Lilja H et al AUA Meeting, Chicago, 2009

PSA at Age 60 Predicts Prostate cancer Mortality by 85

The Malmö Preventive Project (mPP)

• Sixty-year-old men with PSA at or below the population median can be advised that although they may harbor cancer, it is unlikely to become life threatening

• Those with PSA elevated above thresholds such as 3 or 4 ng/mL are at greatly increased risk of clinically diagnosed prostate cancer and prostate cancer-specific death

CONCLUSIONS BY DR LILJA

Lilja H et al AUA Meeting, Chicago, 2009

The Malmö Preventive Project (mPP)

Median PSA level:• men aged 40-49 was 0.7 ng/mL • men aged 50-59 was 0.9 ng/mL

Baseline PSA value (age <60 years old)

Prostate cancer rate

<0.7 ng/mL 0.4%

0.7-2.5 ng/mL 4.1%

2.6-4.0 ng/mL 18.9%

4.0-10.0 ng/mL 29.1%

>10.0 ng/mL 50.0%

Loeb S. et al. Urology 2006,67:316–320

Loeb S. et al. Urology 2006,67:316–320

Baseline PSA level was a significant predictor of CaP diagnosis

Baseline PSA in PCa patients 50-60 yo

Baseline PSA in PCa patients 50-60 yo

Loeb S. et al. Urology 2006,67:316–320

Tang P et al, J Urol 2010;183,946-951

An initial PSA cutoff of 1.5 ng/ml may be better than median PSA 0.7 ng/ml to determine the risk of PCa in men ≤50 years

old

Increased Risk of PCa in FU years in men with baseline PSA > or < 1.5

Tang P et al, J Urol 2010;183,946-951

Robool et al, J Urol 2009; 182:2112-22

• Examination of a greater number of data sets suggests that for men 50 to 70 years a PSA greater than 1.5 ng/ml is a marker for greater risk of PCa in the short to medium term (up to 8 years),

• These men are at 7.5-times greater risk for prostate cancer than those with PSA less than 1.5 ng/ml.

• For younger men with longer follow-up a lower PSA should be considered.

• In addition, the PSA threshold should be lower for men with a prostate volume less than 40 cc, black ethnicity or a family history of prostate cancer.

AUA Prostate Cancer Guidelines 2009

AUA Prostate Cancer Guidelines 2009

“It seems reasonable to obtain a baseline PSA testing at age 40 to assess the risk for further PCa detection”

NCCN Prostate Cancer Guidelines 2010

CONCLUSIONS

• Initial evidence is suggesting that men in their 40 - 50 years represent a population who needs to be investigated

• It would be interesting to study both men with and without a family history of PCa