FOIU 2018: A PSA Threshold of 1.5 ng/ml for Further Diagnostic Tests - FOR

Tel Aviv, Israel (UroToday.com) Leonard Gomella, MD, debated why a PSA cutoff of 1.5 ng/ml should be used. He began with presenting data demonstrating that from 1990 to 2009, PSA has helped to diagnose more localized prostate cancer (PC) and decreased the metastasis rate. PSA screening has caused a reduction in mortality (Figure 1).

Figure 1- Mortality trends with PSA screening:
Figure1_MortalityTrends_PSAScreening.png
Approximately 93% of PSA tests are done by family medicine and internal medicine practitioners.  Therefore, it is our task as urologists, to educate these physicians about PSA screening. Dr. Gomella suggest a new algorithm where primary physician refer patients to urologist when PSA rises above 1.5 ng/ml, regardless of age. 

When assessing lab results of PSA tests, only 27% of PSA tests were more than the cutoff of 1.5 ng/ml. Dr. Gomella reported a study assessing men under the age of 50, with a single PSA test above 1.5 ng/ml predicting a higher risk for prostate cancer 25 years later.1 Furthermore, another study assessing 21,500 men above the age of 40 with a PSA between 0-4 ng/ml, found that there is a 15-fold increased risk for developing PC, with a 19-fold risk for African-Americans. (Figure 2).2

Figure 2 – Increased risk of prostate cancer with a PSA above 1.5 ng/ml:
Figure2_RIsk_Men<50_PSA>1.5.png
PSA above 1.5 ng/ml has also been shown to be a surrogate marker for :

  • BPH
  • PC
  • Long-term PC risk
  • Evaluate - does not necessarily mean that all these patients need to be biopsied
  • Additional PC markers need to be used to determine whom to biopsy (Figure 3).
Figure 3 – Prostate cancer markers:
Figure3_PCa_Markers.png
Dr. Gomella concluded his presentation with a proposed algorithm incorporating PSA, and PC markers (Figure 4).

Figure 4 – Proposed algorithm for using PSA cutoff of 1.5 ng/ml:
Figure4_Algorithm_PSACutoff_1.5.png
Presented by:  Leonard Gomella, MD, FACS, Thomas Jefferson University, Philadelphia, PA, USA

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan  at the 2018 FOIU 4th Friends of Israel Urological Symposium, July 3-5. 2018, Tel-Aviv, Israel

References:
1. Djulbegovic Mia, et al. BMJ 2010
2. Ping T et al. J. Urol 2010
3. Lilja H, et al. Cancer. 2011
4. Goldberg H. et al. J Urol 2018

Read the Opposing Side: A PSA Threshold of 1.5 ng/ml for Further Diagnostic Tests - AGAINST
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