psa pathways bph

PSA PathwaysBPH and Prostate Cancer

Christopher French MD FRCSC

Tuesday, January 19, 2010

PSA Utility

• A Screening Tool

• A Staging Tool

• A Post Treatment Marker


PSA Biology

• A surrogate for benign enlargement

• Spike rises and falls in inflammation/BPH

• A persistent rise above age adjusted limits ,not explained by a pattern of BPH, is associated with a 40% risk of cancer.

• High grade cancers (gleason 9 or 10) are typically not represented in the PSA level.


PSA Biology


Prostate Histology

Gleason 3+3Prostate Cancer

BPH


Recent Screening Studies

• PLCO

• Annual Screening vs Current Standard

• After 7-10 years the mortality rates were similar

• ERSPC

• Annual Screening vs unscreened control

• 20% reduction in prostate cancer mortality


Mortality Benefits of Screening

• Benefits of screening have to weighed against a potential 50% incidence of non life threatening cancers.


Prostate Cancer screening future

• Individualize the screening process

• Consider PSA patterns not single PSA

• Family history

• Educate on the safety of Active Surveillance

• Implement tools to complement PSA

• Chemoprevention


PSA Case 1

• 61 yo man with moderate obstructive symptoms and PSA 4.5 Benign feeling 55gm prostate. Healthy otherwise

Assumes a 15 year life expectancyBPH symptoms predominate visitScreening data suggest to rule out cancer


Management Priority• Clinical BPH

• Confirm with PSA pattern

• Biopsy?

• If Family History, or PSA pattern

• Alpha Blocker

• Symptom Control

• What about 5ARI?

• Failure of Alpha Blocker, chemoprevention?

OK, Repeat PSA is 2.3----BPH

What if it came back at 4.8 and 5.0?

Patient wants to see a urologist, who repeats PSA and it’s 5.0Biopsy shows BPH in 12 Cores, suggests alpha Blocker and a follow up with Uroflow and PSA in 1 year

Before he see’s the Urologist patient says that he is no better. Wants PSA checked sooner. Change Alpha blocker? Add 5ARI?

What if I said there is a tablet that can shrink your prostate by 30%, decrease your risk of BPH surgery and reduce your risk of prostate cancer by 25%. OK, at what cost Doc?


psa pathways bph

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