Prostate cancer in India -Screening

BY: Dr Niti Raizada - 18 Nov-2021

The number of cases of Prostate Cancer in India each year are 34,500.It is the 12th common cause of cancer in our country and forms 2.6% of all cancers. About 50% of all Prostate cancer patients diagnosed die of the disease.

It’s the sixth common cause of cancer amongst men globally.

Interestingly, prostate cancer is actually a spectrum of disease and not all men diagnosed with prostate cancer require treatment. The detection of early prostate cancer includes detecting both slow-growing and aggressive or fast-growing prostate cancer. The challenge is to minimise over-treatment of indolent cancers by biologic characterisation. Identification and selective treatment of aggressive cancers should result in significant decrease in morbidity and mortality while limiting adverse effects on quality of life.

Screening for Prostate Cancer

The guidelines focus on appropriate counselling of the pros and cons before putting any patient on early detection program. At this juncture there is no clear consensus on when to start or stop screening, and at what intervals to conduct screening or biopsy. However regular screening is recommended for highest risk subset of cases.

The baseline evaluation includes first:- history and physical examination.

•    The history primarily focuses on family history of first-degree relatives or second-degree relatives.
•    Personal history of another cancer or of a high-risk germline mutation including BRCA or HOXB 13 mutation.
•    African ancestry has a higher risk of prostate cancer in young population.
•    Medication like 5-Alpha1 reductase- finasteride or dutasteride are known to decrease PSA by approximately 50% and so PSA values need correction.
•    Testing beyond 75 years of age is generally not recommended. For high-risk individuals PSA Screening and DRE starts at 40 years of age and done annually.
•    For an average risk patient age 45 to 75 years is the screening period.

So when to do a biopsy? When PSA is greater than 3 ng/ML and a very suspicious DRE, further evaluation with a multi-parametric MRI and/or a biopsy is indicated. Normally a trans-rectal ultrasound-guided biopsy is done.

Biopsy result could be either cancer or it could be intraductal carcinoma without invasion, there could be atypia suspicious of cancer, or a high-grade prostatic intraepithelial neoplasia (PIN)or it could be benign. Based on these results, treatment is planned.

Few things about PSA 

PSA is a Glycoprotein secreted by prostate epithelial cells. It is not a cancer-specific marker. Total PSA greater than 10 ng/ML has a 67% chance of being diagnosed as cancer on biopsy. For PSA between 4 and 10, there is a 20% likelihood of prostate biopsy being positive. PSA can be increased due to infection, instrumentation like cystoscopy or TURP, or trauma. Certain drugs like finasteride or dutasteride can reduce the value of PSA. Also ketoconazole or certain herbal drugs can reduce the value.

US preventive task force mandates to discuss pros and cons with the patient prior to advising serum PSA.There is a concept of stage migration and early PSA assessment can increase longevity due to early diagnosis. PSAV is PSA velocity measured over 3 different values in 18 months. Unbound or free PSA (f-PSA) as a ratio of total PSA is also an FDA approved measure.

DRE As a stand-alone test has limited value.

So in summary, the basic principle is to use methods of early detection based on overall physical examination and history of the individual. General health, the comorbidities, life expectancy and patient preferences always have to be kept in mind while using a detection program.

About the author:

Director, Medical Oncology & Hemato-Oncology, 
Fortis Group of Hospitals, 

Partners & Associates