Prevelance of prostate cancer: Autopsy series have shown a least small prostate cancers in 29% of men 30-40 years old and 64% of men 60-70 years old; the lifetime risk for men for getting prostate cancer (Pca, PCa, PC, or CaP) is 1 in 6². Until the 1980s, this usually-asymptomatic malignancy was not diagnosed until symptomatic and incurable⁷.

Early detection preserves the broadest array of management choices: The screening use of the PSA test beginning in the mid-1980s has revolutionized the ability to detect prostate cancer early and has shifted the stage of the cancers sharply to an earlier stage⁷. Yet, an early study showed that nearly half of the expected cancers are not detected (see table below) by biopsies when the threshold for diagnostic action is between 3 & 3.9 ng/ml². By 2002, it had become a new conventional practice to use age-adjusted normal ranges. In 2012, we have saturated the population with screening to the point that active surveillance is now a very legitimate "initial management" decision if it seems that the tumor is an "indolent lesion of epithelial origin" (a so-called IDLE⁷ tumor). Biomarkers heralding indolence or aggressiveness will become valuable.

Technical: Some argue about which test method is best; of utmost importance, however, is that a lab verify and properly control an adequate test system. And, because the multiple test system products may "test" against slightly different PSA forms, it is best if one has testing in the same lab each time. This test refers most commonly to "total PSA [tPSA]". But be aware¹ that the serine protease PSA circulates in serum in multiple molecular forms consisting of free (unbound to other proteins) PSA (fPSA) and various proteins (about 75% is irreversibly bound to the protease inhibitor alpha-1 antichymotrypsin in a covalent 1:1 molar ratio that creates an enzymatically inactive complex). And there are other complexes. Most of free PSA exists as 3 isoforms (BPSA, proPSA, & "intact fPSA"¹).

PSA parameters used: The tPSA value as a numerator can be divided by gland volume and thereby relate the tPSA level to gland size...the calculation producing the "PSA density" or PSAD (a normal value being less than 0.10 to 0.15...below 0.15 is comforting, 0.15-0.18 is concerning, & 0.18 or higher warrants a biopsy) where values greater than 0.15 are said to increase the odds that the patient has prostate cancer¹. "PSA velocity" attempts to account for the very steady tendency for PSA to gradually rise with age and increasing BPH (benign gland enlargement)¹; other causes of increasing PSA are cancer or prostatitis. It is of greatest help when one has at least three tPSA results over a period of at least 2 years¹. One is more concerned that a rising PSA is due to prostate cancer if the increase is greater than 0.75 ng/mL per year¹, the NCCN guideline "normal" being no greater than 0.5 in 2007³(and Dr. Catalona expecting in 2007 that this will be reduced to a cutoff of 0.35-0.4 ng/mL/year...noting that there is a high death rate among those with a velocity of 2ng/mL/yr or higher in the year prior to diagnosis³).

EPCA & EPCA-2 apparently failed as reliable tests, HERE.

PCA3 = prostate cancer antigen 3 (a synonym is DD3)(HERE) coded by the same PCA3 gene; it is a noncoding mRNA over-expressed (increased) in prostate acinar cancer cells and causing PCA3 elevation in the test. It is present at about a 34-fold concentration compared to either (1) normal or (2) BPH prostate and not present in other tissues or malignancies⁶. As of mid-2011, we are not sure if any other abnormalities (such as PIN) cause elevations. So, clear-cut elevations are a significant clue that a man's prostate gland has greater odds of harboring cancer. A normal value does NOT indicate that the gland is cancer free (for many reasons, the cells containing the PCA3 may not have dislodged & made it into the specimen container). The higher the PCA3 result, the less comforting is a decision toward active surveilance rather than some treatment.

RATIOS for testing: For this PCA3 test and the TMPRSS2:ERG which follows, a ratio of acinar-cell-related markers is needed so as to adjust for the sampling variables unavoidable by cancers being in different gland locations and differing percentages of gland involvement.

"PCA3" is usually reported as a simple number (but the lab-reported value is actually as a ratio of PCA3 to PSA, both parameters by mRNA analysis within that specimen of prostatic-fluid-urine mixture from the DRE). While often advertized as a "simple urine test", it is actually a VERY non-simple, limited, first-voided urine immedatey following a specialized digital rectal exam (DRE), current code words in some labs call the particular DRE an "attentive DRE", for the specific purpose of obtaining prostate fluid (with cancer cells) delivered by 3 deep digital strokes of each of the two prostate lobes so that intraprostatic fluid is pushed into the bladder with the urine but DOES NOT become too dilute with too much urine. The obtaining office staff (or the lab, if quickly handy) must (1) quickly mix the specimen and pipette two mL into each Aptima-kit transport tube (which contains RNA integrity maintaining & stabilizing transport fluid) & keep refrigerated to the local lab (which may then freeze the tubes for frozen delivery to the out-of-state reference lab) and (2) fill out patient case clinical details listed on the requisition. Our lab sends out through ARUP who currently (as of 2010-2011) uses Avero Diagnostics. (ARUP PSA & PCA3 decision tree here)

TMPRSS2:ERG gene fusion, the most common variant of ETS gene rearrangements in prostate cancer = The TE test specimen is obtained exactly as with PCA3 & tested as a ratio as with PCA3⁵. It holds forth the hope of helping to acurately discern cancer cases OK for active surveilance from those (significantly elevated TMPRSS2:ERG levels) needing undelayed treatment⁵. Ventana has produced the corresponding IHC histology marker, ERG which correlates with the ERG gene rearrangemnet demonstrable by FISH.

Abstract⁴: "Greater than 50% of PSA-screened prostate cancers harbor fusions between the transmembrane protease, serine 2 (TMPRSS2) and v-ets erythroblastosis virus E26 oncogene homolog (avian) (ERG) genes. Here, we report a clinical-grade, transcription-mediated amplification assay to risk stratify and detect prostate cancer noninvasively in urine. The TMPRSS2:ERG fusion transcript was quantitatively measured in prospectively collected whole urine from 1312 men at multiple centers. Urine TMPRSS2:ERG was associated with indicators of clinically significant cancer at biopsy and prostatectomy, including tumor size, high Gleason score at prostatectomy, and upgrading of Gleason grade at prostatectomy. TMPRSS2:ERG, in combination with urine prostate cancer antigen 3 (PCA3), improved the performance of the multivariate Prostate Cancer Prevention Trial risk calculator in predicting cancer on biopsy. In the biopsy cohorts, men in the highest and lowest of three TMPRSS2:ERG+PCA3 score groups had markedly different rates of cancer, clinically significant cancer by Epstein criteria, and high-grade cancer on biopsy. Our results demonstrate that urine TMPRSS2:ERG, in combination with urine PCA3, enhances the utility of serum PSA for predicting prostate cancer risk and clinically relevant cancer on biopsy." (Gen-Probe, Inc. has licensed the technology & hopes to offer the test later in 2012.) BUT, a recent review notes sources that say prognostication of aggressiveness of tumor is not that certain⁸. However, that same review notes value of finding this TE rearrangement (TER) as those with it had an increased rate of death by disease at 12 years of follow up⁸.

Prostate cancer gene expression profile by rt-PCR: This test uses FFPE prostate biopsy cores, and the test is developed by Health Discovery Corp. and first offered by Clarient and now under world-wide licensing by NeoGenomics. With 90% agreement with expert prostate cancer pathologists, the test supposedly separates prostate cancer cases that are grade 3 or higher from those of lower grade (and possibly of lower risk). If the core biopsies (which seldom represent more than a minute fraction of the cancer in a gland) fail to sample the highest-grade cancerous area in the gland, then a gene-expression-based treatment decision can be sorely discordant and leave patient and physician in a treatment decision quandry and "false negative" as to the worse cancer that had not yet been sampled!

Epigenetic cancer periphery changes detection by some sort of methylation testing of extracted DNA is being advertized as of April 2012 in the FFPE samples tested by the ConfirmMDx assay.

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Associations with PSA level not elevated:

1. a man negative for Pca

2. a man positive for Pca

3. bed rest can cause a decrease

4. exercise

5. digital rectal exam (DRE)

Associations with elevated PSA levels:

1. acute bacterial prostatitis
   .
2. prostate cancer.
3. "PSA bounce" may be seen in seed-implant PSA follow-up...in as many as 35% of patients. Within a year or two after seed implantation (median 18 months), the PSA having been down, starts to rise for 12 months or more, the median PSA increase being 0.4 ng/ml, with a range of 0.1 to 15.8 ng/ml. About 22 percent of the men had more than one bounce. Biopsies are problematic because cancer cells which have been shocked but not yet eliminated can be seen in the biopsy in "bounce" situations and don't really mean recurrence. A true cancer recurrence rise happens later, at a median of 30 months after seed implant.
4. chronic prostatitis of any variety: we had 12 excellent cores & complete info on a 53 y/o friend with rising PSA (his PSA velocity 1.16 [tend to biopsy if PSAV is above 0.6-0.75]) for a doubling time of 1.82 years (tend to biopsy when PSADT is 2 or less). TRUS showed a gland volume of 21.8cc for a PSA density of 0.27 (increased likelihood of cancer
   when above 0.15).
5. prostatic hyperplasia (BPH)

6. some men have a high level for no known cause

7. rarely, a man will carry antibodies toward a component of the test system reagent derived from another animal specie (a heterophile antibody)...all other factors staying equal, this type of elevation should be very stable.

8. acute urinary retention (can raise it for upwards of 6 weeks)

9. ejaculation (can raise it for 24-48 hours)

10. cystoscopy

11. prostatic massage

12. cycling

13. perineal or transrectal needle biopsy.

14. transrectal ultrasound.

15. transrectal resection of the prostate.

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Total PSA: Age bracket "normals":

Free & Total PSA

A general rule-of-thumb is that a free PSA < 15% raises concern for cancer and > 25% significantly favors hyperplasia (BPH).  This splitting of PSA into free and total works best when the total PSA is between 4 and 10, when using age bracket normal ranges, and in cases where the man's prostate digital rectal examination (DRE) is "normal" (for example, the effects of a small volume of cancer can be obscured amongst the effects of a gland quite enlarged by BPH). 

Probability of Prostate Cancer (For Men with Non-Suspicious DRE Results and PSA Between 4 and 10 ng/mL, by Patient Age)

General: (1) low free PSA, especially < 15% = concern for ca. (2) higher free PSA, especially > 25% = favor BPH.

REFERENCES:

1. ASCP Check Sample...Shariat SF, Roehrborn CG, Wians, FH, Update on PSA Testing for the Early Diagnosis of Prostate Cancer, Clinical Chem. 43(5):71-87. 2003.
2. Schroder FH, Kranse R, Verification Bias and the PSA Test: Is There a Case for a Lower Threshold for Biopsy?, NEJM 349(4):393-395.  24 July 2003.
3. CAP Today, April 2007.
4. Tomlins SA,...Siddiqui J, et. al., "PROSTATE CANCER: Urine TMPRSS2:ERG Fusion Transcript Stratifies Prostate Cancer Risk in Men with Elevated Serum PSA", Sci. Transl. Med. 3(94): 94, 3 August 2011, HERE.
5. Javed Siddiqui, M. S., personal communications, February 2012.
6. Loeb S and Partin AW, Review of the Literature: PCA3 for Prostate Cancer Risk Assessment and Prognostication, Rev Urol.,13(4): e191–e195, 2008, HERE.
7. Thompson IM & Klotz L, Editorial: Active Surveillance for Prostate Cancer, JAMA 304(21):2411-12, 1 December 2010.
8. Annual Review Issue, Prostate Cancer: Towards the Standardization and Synthesis of Morphology, Genetics, and Prognosis. Kristiansen G,Diagnostic and Prognostic Molecular Biomarkers for Prostate Cancer, 60(1):125-141, January 2012.
9. Park K, et. al., "Antibody-Based Detection of ERG Rearrangement-positive Prostate Cancer", Neoplasia 12(7):590-598, July 2010.
10. PCA3.org website HERE.

(posted 4/27/2007; latest addition 31 March 2012) [to prostate cancer topics index]