Lowering PSA and PSA velocity: Are we doing the best thing

2 recent studies recommend lowering the psa velocity.
UroToday – Age Adjusted Prostate Specific Antigen and Prostate Specific Antigen Velocity Cut Points in Prostate Cancer Screening

beige_quote.bmpTraditional recommendations for prostate biopsy have included a total serum PSA of 4.0 ng/ml or greater and a PSA velocity of 0.75 ng/ml per year or greater. While recent trends have moved towards a PSA threshold of 2.5 ng/ml or greater in men younger than 65 years, specific recommendations for PSA velocity thresholds in younger men have not been agreed upon.
In the February issue of the Journal of Urology, Moul, Albala, and colleagues from Duke University report the results of a cohort of 33,643 men who formed part of a prostate cancer early detection study. Of these men, 11,861 patients were identified with 2 or more serum PSA values over a 2 year period. Total PSA and PSA velocity threshold values with the highest sensitivity and specificity for prostate cancer detection were identified for men 50 to 59 years old.
In men age 50 to 59 years, a serum PSA threshold for biopsy of 2.0 ng/ml or greater achieved the highest sensitivity (84%) when compared to thresholds of 2.5 ng/ml, 3.0 ng/ml, and 3.5 ng/ml with sensitivities of 82%, 79%, and 77%, respectively. The specificity of a PSA threshold of 2.0 ng/ml in these men was acceptable at 74.4%, which was not significantly different from the specificity of using a threshold of 2.5 ng/ml (80%).
Using a PSAv of 0.4 ng/ml/year in men age 50 to 59 years achieved a specificity of 84% and sensitivity of 72%, compared with a PSA threshold of 0.75 ng/ml with sensitivity and specificity of 70% and 84%, respectively.

UroToday – Prostate Specific Antigen Velocity Threshold for Predicting Prostate Cancer in Young Men:

beige_quote.bmpUsing a PSA velocity of 0.4 ng/ml/year or greater may enhance prostate cancer early detection especially in men with a total PSA lower than 2.5 ng/ml. A PSA velocity threshold of 0.4 ng/ml per year or greater was independently predictive of cancer irrespective of age, total PSA, family history of prostate cancer, or race. What was most dramatic was that this criterion had the strongest association to cancer in multivariate analysis, even in patients with a total PSA less than 2.5 ng/ml. Using a PSA velocity threshold of 0.4 ng/ml/year was found to have a sensitivity of 67%, specificity of 81%, positive predictive value of 16%, and negative predictive value of 98%.
This study suggests that using a PSA velocity biopsy threshold of 0.75 ng/ml/year for men younger than 60 years may be inappropriate. Using a PSA velocity of 0.4 ng/ml/year or greater may enhance prostate cancer early detection especially in men with a total PSA lower than 2.5 ng/ml.

Urologists at Georgetown, Northwestern, Washington University, and Duke have been advocating lowering the PSA velocity which should trigger the recommendation for a biopsy. I admit that I often perform a prostate biopsy on young healthy men with a PSA of 2.5 or a lower PSA velocity of 0.4. I am performing more biopsies and finding more cancers. You certainly can make the argument that waiting for a higher PSA may not diminish the cure rate and may find cancers that are more clinically significant.
I understand that some urologists do not believe in PSA as a screen for prostate cancer at all.
I am sure that one day we will have better screening tests that are more specific and probably more sensitive.
I wonder what people think of a prostate biopsy done as a baseline study. I would compare this to a screening colonoscopy which likely has a similar rate of complication (low), can be done under local anesthesia, and will find some prostate cancers that we are not finding now.
The major obvious downside would be putting most men through a biopsy which will not reveal cancer and finding cancer that may not need to be treated for months to years.
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