Approach to elevated PSA in the Family Practice Dr. Ho Siew Hong Consultant Urologist S H Ho Urology and Laparoscopy Centre Gleneagles Hospital

What do they have in common? Arnold Palmer Norman Schwartzkopf Rudolph Guiliani Harry Belafonte Nelson Mandela

PSA Prostate Specific Antigen Revolutionary tumour marker for prostate cancer Normal 0 – 4 mmol/L Highly sensitive, less specific (carcinoma in 20% - 30%)

Prostate Specific Antigen

Revolutionary tumour marker for prostate cancer

Normal 0 – 4 mmol/L

Highly sensitive, less specific (carcinoma in 20% - 30%)

Causes of raised PSA Carcinoma BPH Infection – prostatitist, cystitis Stones – prostatic Instrumentation or surgery – cystoscopy Digital rectal examination – does not cause any chances in PSA

Carcinoma

BPH

Infection – prostatitist, cystitis

Stones – prostatic

Instrumentation or surgery – cystoscopy

Digital rectal examination – does not cause any chances in PSA

Who should have a PSA check? Opportunistic screening Males > 40 years Lower urinary tract symptoms – obstructive, irritative Abnormal DRE Family history of Prostate Carcinoma Social – to allay patient’s concern

Opportunistic screening

Males > 40 years

Lower urinary tract symptoms – obstructive, irritative

Abnormal DRE

Family history of Prostate Carcinoma

Social – to allay patient’s concern

What to do with a raised PSA? All raised PSA must be evaluated Most cases require evaluation by a Urologist PSA trend can be observed in a small and selected group of patients, i.e. patients with history suggestive of infection

All raised PSA must be evaluated

Most cases require evaluation by a Urologist

PSA trend can be observed in a small and selected group of patients, i.e. patients with history suggestive of infection

How is raised PSA evaluated? Repeat test after a course of antibiotics, 2-3 weeks later Exclude infection – urinalysis, culture TRUS – transrectal ultrasound and biopsy

Repeat test after a course of antibiotics, 2-3 weeks later

Exclude infection – urinalysis, culture

TRUS – transrectal ultrasound and biopsy

Transrectal Ultrasound and Biopsy

Transrectal Ultrasound and Biopsy

Complications of TRUS Generally minimal Hematuria Hematospermia Per rectal bleeding UTI, sepsis (1 – 3%)

Generally minimal

Hematuria

Hematospermia

Per rectal bleeding

UTI, sepsis (1 – 3%)

Treatment Options for Early Prosate Carcinoma Organ confined disease, no involvement of lymph nodes or distant metastasis Watchful waiting Surgery Radiation

Organ confined disease, no involvement of lymph nodes or distant metastasis

Watchful waiting

Surgery

Radiation

Advanced Prostate Carcinoma Palliative Delay onset of symptoms Average life expectancy 2- 5 years

Palliative

Delay onset of symptoms

Average life expectancy 2- 5 years

Hormonal Manipulation Surgical orchidectomy * GnRH analogue e.g. Zoladex, Casodex * Anti-androgen e.g. cypoterone acetate Estrogen e.g. stilbesterol * 1 st line treatment

Surgical orchidectomy *

GnRH analogue e.g. Zoladex, Casodex *

Anti-androgen e.g. cypoterone acetate

Estrogen e.g. stilbesterol

* 1 st line treatment

PAW 2004 Singapore Informed consent form Answer IPSS and IIEF-5 forms Blood for serum total PSA (Tandem R assay Yang Hybritech technique) Central testing of serum total PSA: SGH No DRE Those with elevated serum total PSA (>4 ng/dl) advised TRUS-guided biopsy of the prostate Cancer detection rate (based on serum total PSA): 1.2 % (43/3415)

Informed consent form

Answer IPSS and IIEF-5 forms

Blood for serum total PSA (Tandem R assay Yang Hybritech technique)

Central testing of serum total PSA: SGH

No DRE

Those with elevated serum total PSA (>4 ng/dl) advised TRUS-guided biopsy of the prostate

Overview of the screened Population

Thank you

PAW 2004 Singapore Number of men who had biopsy and their PSA range 168/252 (66.6%) men who underwent TRUS-guided biopsy of the prostae 168 Total 7 (4.1%) 20.01 and above 26 (15.5%) 10.01 - 20.0 135 (80.4%) 4.01 - 10.0 No of subjects PSA level (ng/dl)

Number of men who had biopsy and their PSA range

168/252 (66.6%) men who underwent TRUS-guided biopsy of the prostae