Critical Discussion: Clinical Utility Of PSA Velocity And Doubling Time In Localized Prostate Cancer

Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology;  Cancer / Oncology
Article Date: 19 Jun 2008 - 2:00 PDT

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ORLANDO, FL (UroToday.com) - Dr. Akihiko Okuyama, Osaka, Japan moderated this panel. He is the President of the Japanese Urological Association. Dr. Moul's work on PSA dynamics was presented and discussed. PSAV and kinetics are utilized in many ways by physicians. It is used to assist in diagnosis and to monitor progression of disease.

Dr. Moul pointed out that risk stratification can employ PSAV and PSADT. PSAV is the linear change in PSA over time. PSADT is the log transformation of PSA over time. PSA kinetics were first described in 1991. Use of PSAV in screening was first described in 1992 by Carter. Men with CaP as opposed to BPH led to an initial cutpoint of 0.8ng/ml/y and more recently 0.35ng/ml/y. The NCCN guidelines employ PSAV in the decision to biopsy. Age related PSA cutoffs were analyzed in the Duke dataset.

Both total PSA and PSAV are affected by age, they showed. A cutpoint of 0.75ng/ml/y was good for men >70 years, but 0.6ng/ml/y was better for men ages 60-70. PSAV can be adjusted by total PSA also, which is altered by age. In younger men, it makes sense to lower the PSAV threshold, he said. PSAV is better understood in men with known CaP for evaluation of treatment types, salvage treatment and prognosis. He pointed to the Pound paper in 1999 that incorporated PSADT for risk stratification for type of CaP recurrence. D'Amico and Freedland have both contributed to the significant understanding of PSA kinetics and CaP recurrence and prognosis.

Dr. Vickers stated that use of PSA kinetics should be based upon good evidence. Does it add to standard predictors, he asked? The metric for this is the concordance index. Using PSAV in the clinic should only be done if it will help the patient. In his Malmo cohort study of 20,000 patients, the predictive accuracy of PSA alone was 0.771, the same as PSAV! They reassessed this for only high risk cancers and the result was still the same. After surgery, the prediction of metastasis and death, the addition of PSAV only improved the calculation slightly. However, PSADT and PSAV have many definitions and the outcome was significantly influenced by which one was used. Next they used the PCPT randomized database, but in that trial PSAV did not improve prediction, also noted in the ERSPC, Rotterdam study. He concluded that PSA dynamics after therapy are useful, but pretreatment PSA dynamics to predict outcome do not add to PSA alone.

Moderated by: Akihiko Okuyama, MD, at the Annual Meeting of the American Urological Association (AUA) - May 17 - 22, 2008. Orange County Convention Center - Orlando, Florida, USA.

Reported by UroToday.com Contributing Editor Christopher P. Evans, MD, FACS

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