Early Detection Guidelines

• Prostate Cancer Canada (PCC) advises men and their doctors take the time to discuss the merits of prostate specific antigen (PSA) blood testing followed by a digital rectal examination (DRE) for the early detection of prostate cancer

• We also strongly recommend that, beginning at age 40 men consider the following schedule for prostate cancer monitoring using the PSA blood test

EARLY DETECTION OF PROSTATE CANCER

EARLY DETECTION OF PROSTATE CANCER

• AGE 40: Establish a baseline PSA value. While the threat of prostate cancer is minimal at this age, it also precedes the onset of benign prostatic hyperplasia (BPH), the natural enlargement of the prostate that commonly occurs with age. The onset of BPH often results in rising PSA levels over time, and can be confused with the onset of prostate cancer.

• Unless your resulting baseline PSA score is of concern to your doctor, the PSA test need only be repeated every 5 years until age 50

• Men at higher risk of prostate cancer (i.e. Men whose father and/or brother developed prostate cancer and/or those of African or Caribbean descent) should begin annual PSA and DRE monitoring at age 40

• AGE 50: All men should begin annual or semiannual PSA monitoring if they have not yet done so• A minimal increase in PSA levels against your baseline score often

requires no further action until your next annual test• A significant increase should prompt a discussion with your doctor

or urologist about follow up PSA blood tests• The PSA blood test not only helps to diagnose prostate cancer, but

also helps monitor for recurrence of prostate cancer after treatment• The PSA blood test allows a patient and his doctor to monitor if

cancer is suspected, if lifestyle changes have had an impact or if cancer has regressed or spread

• Combining the results of a PSA blood test with a DRE increases both the diagnostic power and the accuracy of these early detection methods

EARLY DETECTION OF PROSTATE CANCER

• Like most cancer diagnostic tools, the PSA blood test comes with its pros and cons

• However, men deserve the right to make their own informed decisions regarding the state of their health – even if that decision is to forego or delay treatment

• Regular PSA blood tests and digital rectal examinations (DRE) are required to assess the likelihood of cancer

• The PSA blood test is neither a test for prostate cancer nor an indicator of the type of prostate cancer. PSA levels in the blood increase when the size of the prostate or the number of prostate cells increases

PSA DISCUSSION

• When deciding whether to take the test, men should consider the pros and cons and take into account age, risk factors and general health

Pros• Research has shown that a rapid rise in PSA levels over months or

years is a very strong sign of aggressive prostate cancer• By the time a man develops advanced prostate cancer, his PSA is

almost always very high• Widespread testing results in early diagnosis – at the stage when the

chances of a cure are good, with more options for treatment• The test may not be foolproof but it is the best early detection tool we

currently have

PSA DISCUSSION

Cons• Sometimes increased PSA blood levels are present when clinically

insignificant prostate cancers exist • These tumors may never become life threatening• A high PSA level can also signify non-cancerous conditions• Biopsying these men and treating their cancers may in some cases cause

more harm than good

• Normal PSA levels are arbitrary• Sometimes PSA levels may be below normal levels even when cancer is

present

PSA DISCUSSION

• The PSA blood test checks the blood for minute quantities of an enzyme called prostate specific antigen or PSA

• A higher than normal amount of PSA in the blood is a possible indicator of prostate cancer

• Although other conditions of the prostate, such as benign prostatic hyperplasia and prostatitis can also elevate PSA levels

• The general guidelines for PSA values are:• PSA level in nanograms per millilitre (usual description for average

man)• 0 to 4 ng/ml Within the normal range• 4 to 10 ng/ml Elevated• 10 to 20 ng/ml Moderately elevated• Greater than 20 ng/ml Highly elevated

WHAT DO THE NUMBERS MEAN?

• A high PSA reading does not necessarily mean that you have prostate cancer

• Many factors can contribute to an abnormally high level of PSA in the blood, and the general guidelines presented are usually adjusted for some of these factors:• Age

• Aging increases the amount of PSA in the blood, so normal PSA levels are adjusted for age

• Race• A man's race affects his risk of developing prostate cancer and the

amount of prostate specific antigen that is within the normal range

WHAT DO THE NUMBERS MEAN?

• The PSA blood test, especially when combined with a digital rectal examination (DRE), is a good indicator of the possibility of prostate cancer

• The PSA blood test does not predict either the presence or absence of prostate cancer, but it does alert men and their physicians to the possibility of the presence of an early-stage cancer in the prostate

• Still, there is considerable controversy over the value of the PSA blood test

RELIABILITY OF THE PSA BLOOD TEST

• The medical community calls a higher than normal PSA level with no evidence of prostate cancer a “false positive”

• Some researchers estimate that 20% of prostate cancers would be missed if doctors relied only on PSA blood test results

• In other words, one out of every five men tested would have prostate cancer and a normal PSA level

• A PSA level in the normal range with the presence of prostate cancer is called a “false negative”

• There is also a misconception that the PSA blood test is not accurate

RELIABILITY OF THE PSA BLOOD TEST

• The PSA value is not diagnostic for prostate cancer• It should be used in conjunction with clinical evaluation, digital rectal

examination and other laboratory tests or imaging techniques• If the PSA value is inconsistent with clinical evidence, additional testing

is suggested to confirm the result• Confirmation of prostate cancer can only be determined by prostatic

biopsy

RELIABILITY OF THE PSA BLOOD TEST

• Physicians have made refinements to the PSA blood test and to the analysis of PSA blood test results to improve its reliability as an indicator of prostate cancer

• Doctors now consider the speed at which PSA levels rise• How quickly PSA levels double in amount (PSA doubling time)• The sort of prostate-specific antigen in the blood (free versus total PSA)• The amount of PSA in relation to the size of a man's prostate (PSA density)

• PSA doubling time• PSA doubling time relates PSA levels to a specific period of time• It measures the time it takes for your PSA value to double• Sometimes, PSA doubling time is helpful in prebiopsy guesses about

whether a man has cancer and whether this cancer is likely to be aggressive or to have spread

REFINEMENTS

• Percentage of Free to Total PSA (% of PSA)• This measurement is a ratio comparing the amount of free PSA to the total

amount of PSA in the blood• Free PSA travels alone in the blood; it is not bound to any other blood

proteins• This unbound or free PSA comes from BPH, not prostate cancer

• The higher a man's percentage of free PSA, the less likely it is that prostate cancer is to blame

• Testing for free PSA (called % of PSA in some medical reports) is useful for men whose PSA level falls between 4 and 10 - the grey area in which BPH could be the culprit

• Readings of greater than 25 per cent free PSA (25 % of PSA) indicate that much of the elevated PSA is caused by BPH

REFINEMENTS

• A reading of under 10% suggests that prostate cancer is causing this elevation and that this cancer is probably large and in need of immediate treatment

• PSA density (PSAD)• This measurement compares the size of a man's prostate, which is

determined by a transrectal ultrasound (TRUS), with his PSA level• The doctor simply divides the PSA value by the size (or mass) of the

prostate. For example, if your PSA level is 4 and the size of your prostate in grams is 32, you would divide 4 by 32 to get a PSA density of 0.125

• Usually, a PSA density under 0.07 is considered fairly safe, (depending on age and ethnicity) one between 0.07 and 0.15 could be attributable to either BPH or prostate cancer, and one above 0.15 indicates an increased likelihood that cancer is present. Prostate volume measurements, and thus PSA densities, are subject to TRUS operator/interpreter variability

REFINEMENTS

• Benign prostatic hyperplasia (BPH) and prostatitis can also increase the amount of PSA found in a man's blood

• BPH, a non-cancerous enlargement of the prostate, can elevate PSA levels because a larger prostate manufactures more prostate-specific antigen

• Also, any prostate condition can weaken the tissues in the prostate gland, allowing more PSA to leak into the blood

• Usually, PSA levels caused by BPH do not go as high as those caused by prostate cancer, nor do the levels tend to rise as quickly

• However, most likely, if you have a higher than normal PSA level or one that is steadily rising, your doctor will discuss the value of having a prostate biopsy to determine whether cancer or some other condition is to blame

OTHER CONDITIONS OF THE PROSTATE

• Prostatitis, an inflammation of the prostate, can also affect PSA levels• Because this inflammation can break down tissues in the prostate

gland, it can enable quite a bit of prostate-specific antigen to escape fairly quickly into the blood

• An acutely inflamed or infected prostate can increase a man's PSA level to 100 nanograms per millilitre (ng/ml) or higher

• After treatment for prostatitis, it can take up to six months for PSA levels to return to normal

OTHER CONDITIONS OF THE PROSTATE

Early Detection is key!

To protect yourself, discuss your prostate health and benefits of early detection with your doctor.