Prostate Biopsy Avoidable in Some Elderly Men with High PSA

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Prostate biopsies can be avoided in men older than 75 years who have PSA levels above 20 ng/mL because it is highly probable prostate cancer (PCa) will be detected and conservative treatment recommended, Scottish researchers concluded.

Michael Nomikos, MD, and colleagues at the Western General Hospital in Edinburgh, U.K., studied 293 men over 75 years of age who underwent prostate biopsies. These men had a mean age of 82.6 years and a mean PSA level of 30.37.

The overall PCa incidence was 73.7%. PCa was detected in 91% of men older than 75 with a PSA level above 20, the researchers reported in Urologia Internationalis (2010; published online ahead of print). Additionally, 92.7% of these men received hormonal deprivation therapy. The sensitivity and specificity of an abnormal digital rectal examination (DRE) for detecting PCa in men with a PSA value below 20 was 69.2% and 60.3%, respectively, the study found.

In addition, among men older than 75 but younger than 80 who had PSA values between 20 and 40 and normal DRE, prostate biopsy revealed that 23% had benign disease.

The authors noted that prostate biopsies are still useful in fit men older than 75 but younger than 80 with a PSA level below 20 who can still be potential candidates for treatment with curative intent.

Among men aged 76-79, the positive biopsy rate was 55.6%, 63.8%, and 85.2% for those with PSA levels of 0.1-10, 10.1-20, and greater than 20, respectively. Among men aged 80-84, the rates were 72.7%, 70.6%, and 94.9%. Among those aged 85 and older, the rates were 66.7%, 85.7%, and 100%.

Men older than 75 years with a PSA level above 20 and an abnormal DRE “can safely avoid biopsies as these will not influence treatment,” the authors wrote. “Diagnosis can be made with a reasonable accuracy by using a combination of PSA and DRE.”

Prostate biopsies in elderly men are justified only among those aged 76-79 with PSA levels below 20 and minor comorbidities, “as this is the group of patients who could benefit from radical treatment.”

The authors noted that men with a life expectancy of less than 10 years are seldom candidates for treatment with curative intent. “Radical treatment is rarely offered men with limited life expectancy as the risk of prostate cancer death is not substantially reduced, with the treatment-associated morbidity is higher in older men,” they observed.

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