Remember also that cancer is not usually associated with symptoms of BPH.
Remember also that cancer is not usually associated with symptoms of BPH. Symptoms of BPH result from having hypertrophy of the glandular tissue in the periurethral area and cancer usually involves the posterior lobes. So most people with cancer and having symptoms of prostatism simply have both. They don’t have prostatism symptoms as a result of having the malignancy.
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This would be one algorithm for screening that I think is reasonable. Now there has been a lot of argument about PSA level for screening and particularly whether it actually translates into any mortality advantage. There is no question that it is a sensitive test but what does it all mean? A large study from Canada that appeared to show a mortality reduction through the use of PSA screening in Canadian men. If we assume for the moment that there is a value to PSA screening in terms of how you would use this test, I would recommend something like this algorithm. That is, once you are going to start screening patients, and that would vary perhaps with the age and risk that a patient has. If you are going to start screening and the patient is normal risk without a family history, you could probably start screening – if you were going to do this and you believe in it – at about age 50. For patients who have a family history and are at high risk probably start a screening type of algorithm at perhaps age 40. The combination again of digital rectal exam and PSA I think is the way to go. Clearly if both of these are normal you would just simply re-screen the patient a year later. What more often happens is you have a normal rectal exam but the PSA is abnormal. In that situation I think a transrectal ultrasound can be a very useful way to look at the prostate. When you do that you may find that the ultrasound is normal and in that case if the PSA elevation is limited you may choose either random biopsies or further observation to see what’s going on and whether the PSA velocity or density is changing much over the observation period. If the ultrasound is normal but the PSA level is very high, probably biopsies would be indicated. In situations where the ultrasound is abnormal, obviously biopsy is necessary. In the situations where the digital exam is abnormal and the PSA is abnormal also, you would go on to biopsy. So the key thing here is to use these two things together and then if the PSA is abnormal, move on to an ultrasound and move accordingly from that. If the rectal exam and PSA are abnormal, move directly on to a biopsy type of procedure. Again, I think if you were going to screen, you would probably begin this sort of protocol at about age 50 in a normal risk person and perhaps age 40 in a high risk individual.
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Prostatic ultrasound. Here is the needle being put into an area of malignancy. It’s a nice technique for doing guided biopsies. I think ultrasound screening is not an appropriate first level test. I think the ultrasound should be reserved for evaluating abnormalities in either the PSA or digital rectal exam and shouldn’t be part of the first step in screening patients for this disease.