Health and Prostate

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Casefinding

Casefinding for prostatic cancer is the responsibility of family physicians, and the two tests available to them are digital rectal examination (DRE) and prostate-specific antigen. The arbitrary threshold value of 4.0 µg/L for prostate-specific antigen is most frequently used to distinguish normal from abnormal values. Depending on tumour location, DRE has a false-negative rate of 50% to 60%. Larger, rapidly growing cancers with poor prognosis are most likely to be found by digital rectal examination. Studies have shown that DRE does not significantly increase rates of detection over prostate-specific antigen testing.

A limitation of prostate-specific antigen testing is that PSA levels are elevated during both benign and malignant diseases of the prostate. Three percent to 21 % of patients with BPH have PSA levels greater than 10 µg/L. Benign prostatic hypertrophy is far more common than prostatic cancer. Even among patients with PSA values of 11 to 23 µg/L, there are three benign prostatic hypertrophy patients to every two with prostatic cancer. On the other hand, 38% to 48% of patients with organ-confined prostatic cancer, the ideal candidates for therapy with the best chances of being cured, have prostate-specific antigen levels in the normal range. These figures emphasize the overlap in concentration of prostate-specific antigen in patients with benign prostatic hypertrophy and prostatic cancer. Bernstein et al, using Shannon entrophy calculations to determine optimum decision levels, concluded that 11 to 23 µg/L PSA levels are probably an equivocal region in which the frequency of BPH is about 1.5 times that of prostatic cancer. For older men, the long natural history of PC and the risks of surgery make total prostatectomy undesirable, thus removing most of the reasons for casefinding.

Diagnosis

Definitive diagnosis and treatment of prostatic cancer are the responsibility of urologists, to whom patients are referred because of urinary symptoms requiring surgical evaluation, suspect findings on DRE, or elevated serum prostate-specific antigen. A serious drawback of PSA is its lack of specificity for prostatic cancer, resulting in the need for further investigation of false-positive results with transrectal ultrasound (TRUS) and biopsy. Transrectal ultrasound is expensive and has limitations. Prostatic biopsy (the criterion standard) remains the confirming test for prostatic cancer, but is invasive and subject to error; detection rates for prostatic cancer range from 0.3% to 14.5%.

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