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PATHOLOGY
Detection
of Life-Threatening Prostate Cancer with Prostate-Specific Antigen Velocity
during a Window of Curability
Carter HB, Ferrucci L, Kettermann A, Landis P, Wright EJ, Epstein JI,
Trock BJ, Metter EJ
Department of Urology, Johns Hopkins School of Medicine, Baltimore, Maryland,
USA
J Natl Cancer Inst. 2006; 98: 1521-7
- Background:
Prostate-specific antigen (PSA) level is typically used as
a dichotomous test for prostate cancer, resulting in over diagnosis
for a substantial number of men. The rate at which serum PSA levels
change (PSA velocity) may be an important indicator of the presence
of life-threatening disease.
- Methods:
PSA velocity was determined in 980 men (856 without prostate cancer,
104 with prostate cancer who were alive or died of another cause, and
20 who died of prostate cancer) who were participants in the Baltimore
Longitudinal Study of Aging for up to 39 years. The relative risks (RRs)
of prostate cancer death and prostate cancer-specific survival stratified
by PSA velocity were evaluated in the three groups of men by Cox regression
and Kaplan-Meier analyses. Statistical tests were two-sided.
- Results:
PSA velocity measured 10-15 years before diagnosis (when most men had
PSA levels below 4.0 ng/mL) was associated with cancer-specific survival
25 years later; survival was 92% (95% confidence interval [CI] = 84%
to 96%) among men with PSA velocity of 0.35 ng/mL per year or less and
54% (95% CI = 15% to 82%) among men with PSA velocity above 0.35 ng/mL
per year (P < 0.001). Furthermore, men with PSA velocity above 0.35
ng/mL per year had a higher relative risk of prostate cancer death than
men with PSA velocity of 0.35 ng/mL per year or less (RR = 4.7, 95%
CI = 1.3 to 16.5; P = 0.02); the rates per 100,000 person-years were
1240 for men with a PSA velocity above 0.35 ng/mL per year and 140 for
men with a PSA velocity of 0.35 ng/mL per year or less.
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Conclusions:
PSA velocity may help identify men with life-threatening prostate cancer
during a period when their PSA levels are associated with the presence
of curable disease.
- Editorial
Comment
PSA velocity may help monitor patients in a period of “watchful
waiting”. Due to rising frequency of prostate cancer detected
in clinical stage T1c a higher number of cases have criteria for “insignificant”
cancer and patients may elect “watchful waiting”. The term
“insignificant” is not proper because it may imply that
the tumor is latent (dormant or indolent). Unfortunately there is no
marker for the biologic behavior of prostatic adenocarcinoma. The best
term is “minimal volume carcinoma” and some predictive criteria
include absence of Gleason grade 4 or 5, a maximum of 2 cores showing
tumor and no more than 50% of the area of the core involved. Clinical
stage must be T1c and PSA density less than 0.15 ng/mL (1). During the
period of “watchful waiting” besides PSA velocity, free/total
PSA should also be monitored and, very important, an annual needle prostatic
biopsy. The reason for the biopsy is to detect an eventual change in
extension and/or Gleason grading.
References
1. Bastian PJ, Mangold LA, Epstein JI, Partin AW: Characteristics of insignificant
clinical T1c prostate tumors. A contemporary analysis. Cancer. 2004; 101:
2001-5.
Dr. Athanase Billis
Full-Professor of Pathology
State University of Campinas, Unicamp
Campinas, São Paulo, Brazil
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