Is the transitional zone biopsy specimen significant for prostate cancer detection? – Abstract | Prostate Cancer | UroToday | Urology Information

RESULTS: PCa was detected on biopsy in 192 39.8% patients. PCa was detected only in the TZ for 10 patients 5.2%, only in the PZ for 69 patients 35.9%, and in both the TZ and PZ for 113 patients 58.9%. Obtaining a biopsy only from the TZ resulted in a significantly lower cancer detection rate than obtaining the biopsy only from the PZ or from the combined PZ and TZ P < .05. High GSs ≥ 7 were found in 3 of 10 patients 30% with PCa detected in the TZ, 29 of 69 patients 42% with PCa detected in the PZ, and 90 of 113 patients 79.6% with PCa detected in the combined TZ and PZ. Among the patients with PSA levels < 10 ng/mL, none of the 4 patients with PCa detected only in the TZ had GSs ≥ 7; however, 14 of 41 patients 34.1% with PCa detected only in the PZ and 18 of 32 patients 56.3% with PCa detected in the combined TZ and PZ had GSs ≥ 7. Patients with a biopsy only from the TZ had significantly fewer GSs ≥ 7 than patients with a biopsy only from the PZ or from the combined PZ and TZ in this PSA rangeP < .05.CONCLUSION: It may be possible to omit a prostate biopsy from the TZ for patients with serum PSA < 10 ng/mL.

via Is the transitional zone biopsy specimen significant for prostate cancer detection? – Abstract | Prostate Cancer | UroToday | Urology Information.

A transition zone biopsy is when tissue is taken from the middle part of the prostate.  This part usually has benign elements from BPH and not cancer.  I usually biopsy the transition zone in patients that have had a negative biopsy and need a repeat biopsy for a rising PSA.

From memory, I have seen patients with transition only prostate cancer and have performed robotic prostatectomy on them.  The ones that had a surprising (more than we would expect) amount of prostate cancer were the ones with the PSA over 10.

I will continue to perform the prostate biopsy as I have done after this article, but will think of ways of looking into this more with my practice.  I do not think the morbidity of 2 extra transition zone biopsies is very different than a standard biopsy.  My standard biopsy currently has 12 cores with 2 extra cores from the anterior apex, which has led to a better cancer detection rate and I have used the presence of cancer at the apex to better delineate the amount of tissue I leave on the anterior prostate apex.

 

 

Risk of prostate cancer unaffected by antibiotic treatment

Source: MedWire News

The average age of the patients was 62.9 years. Average total PSA before and after treatment was 6.05 ng/ml and 5.55 ng/ml, respectively. On biopsy, 23% of patients had histologically proven prostate cancer. There were no significant differences between men with and without prostate cancer in age, pretreatment PSA, free PSA, percent free PSA, and PSA density.
Average total PSA, free PSA, and PSA density decreased after treatment in men with and without prostate cancer. But the reductions in total PSA and PSA density were not significant in prostate cancer patients and the reduction in free PSA in cancer-free patients was not significant.

This paper looked at treating patients with an elevated PSA and a normal rectal exam with antibiotics. The reason why this is important is that many urologists prescribe antibiotics for men with elevated PSA values and only biopsy them if the PSA is still elevated.

This study did not show a significant difference for men with and without prostate cancer for PSA changes. Both groups had a decline in PSA values.

This is not a conclusive study and the use of antibiotics is still an option in treating men with a high PSA. I personally like to start with a biopsy and not antibiotics in men that have never had a prostate biopsy.

Prostate Biopsy: Side Effects and Risks

UroToday – EAU 2007 – Session on Prostate Biopsy 1

The 7,074 biopsies were performed in 5,153 men. Minor complications included hematuria >1 day (13.8%), hematospermia (35.8%), and rectal bleeding (2.1%). Major complications were prostatitis, epididymitis, fever >38C, rectal bleeding >2 days, and urinary retention, all <1.0%. This study validates the safety of TRUS biopsy of the prostate.

This is a lower number than I would have guessed for blood in the semen (hematospermia), but a nice study to advise patients of possible side effects from a prostate biopsy.

This is what we need to consider when I asked the question of doing biopsies on everyone.

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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Quality of life after a negative biopsy


UroToday – “False-Positive” Prostate Cancer Screenings Assessed

“Men can discuss the pros and cons of getting a PSA test with their
doctors. However, once a man decides to go ahead and get a PSA test, if
its results are abnormal, he typically should have ongoing follow-up and
surveillance for prostate cancer,” Katz said.

Katz said that a strength of the UI study was that it did not rely on
volunteers. “Volunteers who sign up for a prostate cancer screening
study represent a different type of population than that comprised by
the individuals in our study, who were patients seen in the usual course
of care,” he said.

However, Katz noted, a limitation of the study is that the researchers
were not able to obtain baseline data on how the men originally felt
about their health prior to screening. In addition, the study focused
primarily on Caucasian men.

This is an interesting study, but I think it needs further investigation prior to making any definitive conclusions.
I think that a man who has a low PSA may have a better sexual outlook than a man who is offered screening and refuses. You would have to also follow the consequence of bringing up PSA screening with patients and look if just the discussion of prostate cancer is a detriment since it is usually picked up prior to there being any symptoms.

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