Selecting men who will benefit from prostate cancer screening is a priority in both the general population and in renal transplant candidates. With advances in immunosuppression, renal transplant recipients now have excellent outcomes. Even so, the mortality rate is significantly higher than aged matched counterparts in the general population.1
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After cardiovascular disease, malignancy is the second highest cause of death in transplant recipients.2 Age, type of allograft and comorbidities all have an effect on patients’ survival after renal transplant. Given these complex issues and competing risks, the lack of set guidelines for prostate cancer screening in this population is not surprising. Our study surveyed members of the American Society of Transplant Surgeons (ASTS) on prostate cancer screening and treatment practices at their institutions.
A majority of respondents to the survey reported institutional guidelines for prostate cancer screening (71%) yet there was variation in reported age to start screening and PSA threshold for biopsy. Nonetheless, the most common responses parallel frequently used values in the general population (50 for age to start screening and 4 mg/dl for cutoff for biopsy). A high percentage of respondents (73%) base the time to be placed back on the waitlist after prostate cancer treatment on the patient’s cancer risk. This current trend is promising given previous recommendations of a 2 to 5 year cancer-free wait period that would significantly delay a life saving transplant in patients with very low risk of cancer recurrence.
Active surveillance was developed to help reduce the burden of overtreatment of prostate cancer. Men with low risk disease are closely monitored for progression and those who are stable are spared the potential morbidity of definitive treatment. We found that a high percentage of respondents to our survey (67%) were accepting of active surveillance as an option for men diagnosed with prostate cancer and candidates for renal transplant. There is surprising given the paucity of data on how untreated prostate cancer behaves in an immunosuppressed environment. Recent advances such as, multi-parametric magnetic imaging studies and personalized risk assessment tests may help to select and follow these patients. There may also be benefit in collaboration and development of a registry for this specialized group to establish the safety of active surveillance in transplant recipients.
Our study was limited by a low overall response rate but there was representation of every UNOS region. Survey questions were also generalized in an attempt to keep the survey short and increase response rate, which may unfairly characterize responses based on individualized or risk based screening approaches. Our study is the first attempt to characterize the practice patterns of prostate cancer screening and treatment in men eligible for renal transplant in the U.S. Further discussion and the creation of consensus panels are needed to determine optimal benefit in this complex and changing population.
1. Arend, S. M., Mallat, M. J., Westendorp, R. J. et al.: Patient survival after renal transplantation; more than 25 years follow-up. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, 12: 1672, 1997
2. Briggs, J. D.: Causes of death after renal transplantation. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, 16: 1545, 2001