February 12th, 2018
Prostate cancer is the most common cancer among men in the United States. In 2018, experts anticipate over 165,000 new diagnoses with approximately 29,000 deaths from prostate cancer. Men living in the United States have a risk of developing prostate cancer over their lifetimes estimated at one in six. Approximately 80% of men who are diagnosed with prostate cancer undergo biopsy because of an unusual PSA level. Twenty percent of men diagnosed with prostate cancer had a biopsy because of an abnormality detected on a digital rectal exam.
When considering the alternatives to prostate biopsy if you have had an abnormal screening test, you should consider a number of factors before you and your urologist determine the best way to proceed.
Prostate cancer grows relatively slowly, and most men diagnosed with prostate cancer die of other causes before their prostate tumor is clinically advanced. If diagnosed when the tumor is confined to the prostate or with only local spread, 5-year survival is 100%, If the cancer metastasizes to distant sites, the prognosis is poor. Although clinical prostate cancer rarely occurs before the age of 40, it is likely that a significant percentage of men have hidden “occult” cancer. Based on autopsy studies worldwide, up to 31% of men 31-40 years of age have occult prostate cancer. The risk of prostate cancer increases with age, with men over the age of 65 in the highest risk group.
African American men have twice the risk of developing prostate cancer compared to white or Hispanic males. There is some evidence that prognosis is worse in African American men with prostate cancer, so early detection in this group could be life-saving. If you have a close male relative with the disease, your risk is increased. This can be linked to genetic mutations that are associated with increased risk. If your family history suggests you may be in a family group with genetic susceptibility, your doctor may recommend genetic evaluation.
Screening for prostate cancer has traditionally been performed by digital rectal exam and/or measurement of blood levels of prostate specific antigen (PSA). This antigen is produced by the epithelial cells of the prostate, so increased numbers of cells and any increased production results in elevated levels of PSA in men with prostate cancer, sometimes 5-10 years before the tumor is clinically apparent. Elevations of PSA can also occur because of benign disorders, like benign prostatic hyperplasia or prostatitis. A level above 4.0 ng/mL usually triggers further investigation. Your physician should re-check a level several months later to see if there is a change, since there are normal fluctuations. Experts worry that use of PSA has resulted in over diagnosis and overtreatment, including procedures performed when men have early stage prostate cancer that is unlikely to result in harm over their lifespan. If your PSA is between 4 ng/mL – 7.0 ng/mL, your doctor may suggest a prostate ultrasound before referral to a urologist.
If your PSA is greater than 7.0 ng/mL, a biopsy is more likely to be recommended. Some urologists are using prostate MRI, risk models, and genetic testing to gather enough information to recommend biopsy in high risk cases, while avoiding unnecessary biopsy and treatment while
Your doctor can use a number of calculations, or risk models, to determine the likelihood that your elevated PSA is due to cancer: benchmarking your PSA level against your age group will give a more accurate reflection of what your number means. The PSA density is another calculation used to determine whether or not your elevated PSA is appropriate for your prostate volume, which can be measured by ultrasound, MRI, or CT scan. The percentage of free PSA to total PSA gives your doctor additional information, as a low ratio is more likely to be associated with prostate cancer. The change in your PSA over time is called PSA velocity. Although some increase in PSA is expected with age, a rapid increase over a period of months to a year is concerning.
Men who have abnormalities on digital rectal exam should undergo biopsy, usually a transrectal biopsy using transrectal ultrasound guidance.
Your probable lifespan and plans for pursuing treatment should be considered before making the decision about whether or not to have a biopsy. It’s important to recognize that biopsies only sample and may miss areas of cancer, providing a falsely negative result.
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