Articles tagged with: phi

26
August
2013

A Personal Perspective on Testing for Prostate Cancer

A Personal Perspective on Testing for Prostate Cancer

This is the first in a series of posts by highly respected guest authors.

This week, Henry Woo, a Urologist from NSW, gives a balanced and concise view of the current controversies surrounding PSA testing.

“As an urologist who has subspecialized in just the area of prostate disease, I see men with prostate cancer every working day. Every single consulting session I will see a number of men with advanced prostate cancer who are enduring either the side effects of the palliative drug treatment for advanced prostate cancer or who are battling the complications associated with advanced prostate cancer.

In Australia, over 3,200 men die from prostate cancer each year. This is a greater number than the women who succumb to breast cancer each year. Irrespective of what the denominator is in terms of how many are diagnosed each year, as the second greatest cause of cancer specific deaths in men (after lung cancer), it is continues to astound me that anybody can sweep these facts under the carpet. But to give the denominator, number of men who are diagnosed with prostate cancer in Australia each year currently sits at just under 20,000.

It is well recognized that not all men diagnosed with prostate cancer will actually die from their cancer but will instead die from some other cause. The majority of cancers will follow an indolent slow growing course and will never cause harm. This said, these statistics include men who in spite of dying with prostate cancer (and not from it) have significantly suffered from the effects or treatment for advanced prostate cancer or were successfully treated for prostate cancer that otherwise have lead to a prostate cancer related death.

The overzealous desire to fight prostate cancer has had significant consequences. Many men who did not need treatment have been unnecessarily treated and of these, some have experienced complications associated with radical treatment. This has been a huge problem and with its recognition, attempts are being made to rectify this problem. Significant progress has been made in getting smarter about who needs treatment and also reducing the risks of complications associated with treatment.

Not all men diagnosed with prostate cancer need treatment. There has been a major shift towards treating early stage prostate cancer conservatively by what we call active surveillance and watchful waiting. Active surveillance differs from watchful waiting in that curative treatment has not been ruled out. Active surveillance is a program of monitoring that attempts to strike the right balance between avoiding the overtreatment of prostate cancer yet at the same time attempting to minimize of missing any window of opportunity to deal with the cancer should it subsequently prove itself to be more aggressive than originally anticipated. Protocols for active surveillance vary but contemporary monitoring includes monitoring PSA blood test levels and periodically carrying out MRI scans of the prostate or progress biopsies. If there is evidence that suggests that the cancer is more aggressive than originally thought or if the disease appears to have progressed, the option of treatment remains on the cards. Watchful waiting implies that curative treatment has been ruled out and monitoring is carried out until such time that the disease progresses to justify the commencement of palliative drug treatment in the form of androgen deprivation therapy (commonly referred to as hormone therapy).

There has also been a significant improvement in side effects associated with treatment for prostate cancer. The majority of men with very early stage prostate cancer are candidates for treatment that can spare both urinary and sexual function. Commonly, detractors against prostate cancer testing attempt to connect urinary incontinence and erectile dysfunction as being consequential certainties associated with prostate cancer testing.

Now on the issue of PSA blood testing, there have been quite polarized views on whether it should be performed or not. I have tried to avoid the word ‘screening’ because I think that most of us who have in the past supported this approach have moved very much towards selected testing on an individual basis where each man as an individual has the opportunity to participate in the decision to undergo testing or not.

I think that it is time that those who so vehemently oppose PSA testing acknowledge that an entity that is the second greatest cause of cancer related death in men is a major public health problem. It is also time to stop assertions that if a PSA test is abnormal that it leads to a high risk of complications with the biopsy and that should cancer be confirmed that it some form of aggressive intervention will invariably follow. Additionally, we have moved on from the outcomes of 20 years ago in that treatment is NOT invariably associated with incontinence and erectile dysfunction.

The answer for PSA testing lies somewhere between widespread population screening and totally opposing any form of testing at all. I am looking forward to those who have vehemently opposed any form of testing for prostate cancer to acknowledge this as well.

Concluding Comments

I am NOT in favor of indiscriminate population screening for prostate cancer. Men should be risk assessed as to whether the benefits of making a diagnosis of prostate cancer individually outweighs the attendant risks. Men should NOT be denied the right to participate in any discussion regarding a decision to undergo prostate cancer testing or not. I completely disagree with any assertion that there should no discussion about prostate cancer testing unless raised by the patient. When men are counseled on making a decision as to whether or not they wish to be tested, they should be given information that is relevant to their individual circumstances. The Melbourne Consensus Statement on Prostate Cancer Testing is a good place to start."

Follow Henry Woo on twitter @DrHWoo

Categories: Prostate Cancer

12
August
2013

Active surveillance for low grade prostate cancer

Active surveillance for low grade prostate cancer

Active surveillance for prostate cancer – The PRIAS project

Prostate cancer does not always need treatment. If the cancer does not look aggressive on pathological examination under the microscope, and if there is only a small amount of cancer found on biopsy, it may be sensible and safe to closely watch the cancer rather than treat it.

This is because such cancers may never cause problems for the patient, and may never progress. Further, all treatments for prostate cancer carry potential complications that can impact on a patient's quality of life; these side effects can be avoided by following active surveillance, in suitable people with low risk prostate cancer.

The decision not to treat is a complex one, and needs to take into account a number of different factors, including patient age, Gleason score, the amount of cancer, PSA, patient preference, and other factors.

What does active surveillance involve?

Rather than being a decision to do nothing, the choice for active surveillance is a decision to closely watch the patient with regular PSA tests and occasional re-biopsies. If there is any evidence that the cancer is becoming a problem during the surveillance period, treatment can be started.

Patients on active surveillance are closely monitored on a protocol (see PRIAS example, below) with regular PSA tests (3 to 6 monthly) and occasional re-biopsy (12 to 24 monthly).

Because the surveillance is frequent, it is unlikely that anything will be lost by delaying treatment if it becomes necessary, and indeed some quality of life may have been preserved, if treatment is delayed until it is necessary.

Putting things in context

Data form the James Buchanan Brady Urological Institute in the US indicates that a man in his 60s with low risk prostate cancer has the following risks:

  1. a 5% risk of dying from prostate cancer in the next 20 years
  2. a 60% risk of dying form another cause (not prostate cancer) in the next 20 years

The Prostate cancer Research International Active Surveillance (PRIAS) project.

Many studies have been undertaken to look at active surveillance, and there is currently an international project running, in which Australia is involved, called PRIAS. The aim of PRIAS is to provide a best evidenced-based protocol to help ensure men are watched closely and accurately on active surveillance. The project will also collect data from many countries over years, to help with designing active surveillance protocols for the future. The protocol is as follows:

Criteria for inclusion in active surveillance (PRIAS):

  1. Biopsy-proven prostate cancer (adenocarcinoma)
  2. Man should be fit for curative treatment (if ever needed)
  3. Clinical stage T1c or T2 (ideally T2a)
  4. Gleason 3+3=6 (not higher)
  5. No more than 2 cores positive from biopsy
  6. PSA density less than 0.2 (PSA divided by prostate size)
  7. PSA at diagnosis of less than 10
  8. Men must be prepared to attend follow-up visits
  9. Adequate original biopsy sample (generally 12 cores)

You can find out more about the PRIAS study by clicking this link

Categories: Prostate Cancer

11
August
2013

Prostate Health Index (phi) blood test for Prostate Cancer

Prostate Health Index (phi) blood test for Prostate Cancer

The phi – Prostate Health Index. This is a blood test now available that may help make the diagnosis of prostate cancer more accurately.

PSA and %freePSA are commonly used blood tests, which help identify men with prostate cancer. Although these tests can be useful in some men, the tests can be positive when no prostate cancer is present (or only a low risk prostate cancer is present), and the tests can be negative when an aggressive prostate cancer is present.

The phi, or Prostate Health Index test, is indicated in men with a PSA of 4-10. It uses an additional form of PSA (pro-PSA), and combines the reading with the PSA and %freePSA to produce a figure that may more accurately define a man’s risk of having an aggressive prostate cancer.

A recent study from large centres in the USA has demonstrated that:

  1. The phi can help to determine whether an elevated PSA is likely due to prostate cancer or benign changes.
  2. The ability of phi to correctly identify a man who does not have prostate cancer was greater than the PSA or %freePSA alone.
  3. The ability of phi to correctly identify a man with a significant prostate cancer was greater than the PSA or %freePSA alone.
  4. Using a phi value of 27 as a cut-off, 18% of men can avoid an unnecessary biopsy.

To read more details of this study, follow this link

It is important to realise that, while the phi test can improve the accuracy of blood tests for prostate cancer, it is not a perfect test, and is still subject to false-negatives and false-positives. It may be helpful for some, but not all men, and needs careful interpretation by a urologist, taking other findings into consideration.

The test is available in Australia, but there is no Medicare rebate, and it costs $95 (Aug 2013).

If you would like more information on the Prostate Health Index, please contact Nick Brook using the Web-form , or contact the Practice on 08 8267 1424.

Categories: Prostate Cancer

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