Risk Profiles and Treatment Patterns Among Men Diagnosed as Having Prostate Cancer and a Prostate-Specific Antigen Level Below 4.0 ng/mL

Background Despite controversy over the benefit of prostate-specific antigen (PSA) screening, little is known about risk profiles and treatment patterns in men diagnosed as having prostate cancer who have a PSA value less than or equal to 4.0 ng/mL.

Methods We used data from the Surveillance, Epidemiology, and End Results system to describe patient characteristics and treatment patterns in the cases of 123 934 men with newly diagnosed prostate cancer from 2004 to 2006. Age-standardized treatment rates were calculated in 5-year age strata. Logistic regression was used to quantify the odds ratios (ORs) of men with low- and high-risk disease and the use of radical prostatectomy (RP) or radiation therapy (RT).

Results Men with a PSA level of 4.0 ng/mL or lower represent 14% of incident prostate cancer cases. Fifty-four percent of men diagnosed as having prostate cancer and PSA levels lower than 4.0 ng/mL harbor low-risk disease (stage, T2a, PSA level, 10 ng/mL, and Gleason score, 6), but over 75% of them received RP or RT. Men with screen-detected prostate cancer and PSA values lower than 4 ng/mL were 1.49 (95% confidence interval [CI], 1.38-1.62) and 1.39 (95% CI, 1.30-1.49) times more likely to receive RP and RT, respectively, and were less likely to have high-grade disease than men who had non–screen-detected prostate cancer (OR, 0.67; 95% CI, 0.60-0.76).

Conclusions Most men diagnosed as having prostate cancer with a PSA threshold below 4.0 ng/mL had low-risk disease but underwent aggressive local therapy. Lowering the biopsy threshold but retaining our inability to distinguish indolent from aggressive cancers might increase the risk of overdiagnosis and overtreatment.

Yu-Hsuan Shao, PhD; Peter C. Albertsen, MD; Calpurnyia B. Roberts, PhD; Yong Lin, PhD; Amit R. Mehta, MD; Mark N. Stein, MD; Robert S. DiPaola, MD; Grace L. Lu-Yao, PhD

Arch Intern Med. 2010;170(14):1256-1261. doi:10.1001/archinternmed.2010.221

Symptoms and Risk Factors for Prostate Cancer


Different people have different symptoms for prostate cancer. Some men do not have symptoms at all.

Some symptoms of prostate cancer are—

•Difficulty starting urination.
•Weak, or interrupted flow of urine.
•Frequent urination, especially at night.
•Difficulty emptying the bladder completely.
•Pain or burning during urination.
•Blood in the urine or semen.
•Pain in the back, hips, or pelvis that doesn't go away.
•Painful ejaculation.
If you have any symptoms that worry you, be sure to see your doctor right away. Keep in mind that these symptoms may be caused by conditions other than prostate cancer.

Research has found risk factors that increase your chances of getting prostate cancer. These risk factors include—

•Age: The older a man is, the greater his risk for getting prostate cancer.1
•Family history: Certain genes (the functional and physical units of heredity passed from parent to offspring) that you inherited from your parents may affect your prostate cancer risk. Currently, no single gene is sure to raise or lower your risk of getting prostate cancer. However, a man with a father, brother, or son who has had prostate cancer is two to three times more likely to develop the disease himself.1
•Race: Prostate cancer is more common in some racial and ethnic groups than in others, but medical experts do not know why.
Researchers are trying to determine the causes of prostate cancer and whether it can be prevented. They do not yet agree on the factors that can influence a man's risk of developing the disease, either positively or negatively. Some of the factors under study include—1 2 3 4

•Vitamins, minerals, and herbal supplements.
•Diets high in animal fat, especially polyunsaturated fat.
•Men's hormone levels.
•Environmental agents (pesticide residues on foods, and industrial and occupational exposures).
1Bostwick DG, Burke HB, Djakiew D, Euling S, Ho SM, Landolph J, Morrison H, Sonawane B, Shifflett T, Waters DJ, Timms B. Human prostate cancer risk factors. Cancer 2004;101(10 Suppl):2371–2490.

2Vainio H, Bianchini F, eds. IARC Handbooks of Cancer Prevention, Vol 6: Weight Control and Physical Activity. Lyon, France: IARC Press; 2002.

3Curry S, Byers T, Hewitt M, eds. Fulfilling the Potential of Cancer Prevention and Early Detection.

4Platz EA, Giovannucci E. Prostate Cancer. In: Schottenfeld D, Fraumeni JF, eds. Cancer Epidemiology and Prevention, 3rd ed. New York, NY: Oxford University Press, 2006.

Prostate-specific antigen: An evolving role in diagnosis, monitoring, and treatment evaluation in prostate cancer.

Prostate specific antigen (PSA) was introduced as a prostate cancer screening tool more than 20 years ago. However, there is continuing debate regarding its utility in screening for prostate cancer. Mass screening is costly, may result in the diagnosis and treatment of prostate cancers that never become clinically significant, and the evidence of a subsequent reduction in mortality is inconclusive. In addition to its role in screening, PSA is also used to monitor the progression of the disease, both localized and metastatic.

Although the evidence is contradictory, PSA is still an important tool for monitoring patient progression following treatment of definitive localized prostate cancer. However, its use in monitoring castrate-resistant prostate cancer (CRPC) is more controversial, particularly in the context of novel targeted treatments, which may have little impact on PSA levels. These issues highlight the urgent need to identify prostate cancer biomarkers that will improve early disease detection, increase accuracy of diagnosis, determine the aggressiveness of disease, and monitor treatment efficacy, particularly in late-stage disease.

This review discusses the key issues associated with the use of PSA as an early screening tool for prostate cancer, as a prognostic marker to measure disease progression in both early- and late-stage prostate cancer, and as a surrogate endpoint in clinical trials with new agents. Copyright © 2009 Elsevier Inc. All rights reserved.

Payne H, Cornford P.

Department of Oncology, UCLH NHS Foundation Trust, London, United Kingdom.