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David Plaut: Off the Cuff

PSA Kinetics

Published August 6, 2014 2:56 PM by David Plaut

For the past few decades, many clinicians have used the change in PSA over a 1 or 2 year period to determine whether a biopsy was needed (for example when my PSA increased by more than the limit at that time, I was encouraged to have a biopsy. I did.) 

There has historically been considerable uncertainty about PSA kinetics for decisions about biopsy and initial treatment. It turns out that calculation of PSA velocity and doubling time is far from straightforward. More than 20 different methods have been proposed, and many of these give quite divergent results. There is clear evidence that PSA kinetics are critical for understanding prognosis in advanced or relapsed prostate cancer. However, PSA kinetics have no value for men with an untreated prostate: neither PSA velocity nor doubling time have any role in diagnosing prostate cancer or providing a prognosis for men before treatment.

Given current data on PSA velocity and doubling time, Vickers et al. proposed somewhat middle of the road these recommendations:

  1. High PSA velocity is not an indication for biopsy;
  2. for men with a low total PSA but a high PSA velocity, consideration should be given to measuring PSA at a shorter interval;
  3. men with an indication for biopsy should be biopsied irrespective of PSA velocity;
  4. changes in PSA after negative biopsy findings do not determine the need for repeat biopsy;
  5. monitoring PSA over time can aid judgment in decisions about biopsy, as informed by the clinical context;
  6. PSA velocity is uninformative of risk at diagnosis;
  7. high PSA velocity is not an indication for treatment in men on active surveillance;
  8. PSA velocity at the time of recurrence should be entered into prediction models (or "nomograms") to aid patient counseling.

References

  1. Br J Med Surg Urol. 2012 Jul 1;5(4):162-168.
  2. Urology. 2014 Mar;83(3):592-6
posted by David Plaut

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