PSA levels of 4.0 - 10 ng/ml and negative digital rectal examination: antibiotic therapy versus immediate prostate biopsy

Abstract

Purpose: The management of mildly elevated (4.0-10.0 ng/ml) prostate specific antigen (PSA) is uncertain. Immediate prostate biopsy, antibiotic treatment, or short term monitoring PSA level for 1-3 months is still in controversy. Materials and Methods:We conducted a retrospective chart review of patients in a large community practice (2003 -2007) who had PSA levels between 4.0-10 ng/mL without any further evidence of infection. Data was gathered regarding patient's age, whether standard antibiotic therapy (10-14 days of ofloxacin or ciprofloxacin) had been administered before the second PSA measurement, results of a second PSA test performed at 1-to 2-month intervals, whether a prostate biopsy was performed and its result. Results: One-hundred and thirty-five men met the study inclusion criteria with 65 (48.1%) having received antibiotics (group 1); the PSA levels decreased in 39 (60%) of which, sixteen underwent a biopsy which demonstrated prostate cancer in 4 (25%). Twenty-six (40%) patients of group 1 exhibited no decrease in PSA levels; seventeen of them underwent a biopsy that demonstrated cancer in 2 (12%). The other 70 (51.9%) patients were not treated with antibiotics (group 2); the PSA levels decreased in 42 (60%) of which, thirteen underwent a biopsy which demonstrated prostate cancer in 4 (31%). In the other 28 (40%) patients of group 2 there was no demonstrated decrease in PSA, nineteen of these subjects underwent a biopsy that demonstrated cancer in 8 (42%).Conclusions: There appears to be no advantage for administration of antibacterial therapy with initial PSA levels between 4-10 ng/mL without overt evidence of inflammation.

Antimicrobial Therapy for Asymptomatic Patients with Elevated Prostate-Specific Antigen: Can the Change in Prostate-Specific Antigen Reliably Guide Prostate Biopsy Decisions?

“…Indeed in a study by Shimomura et al [20] , among 88 patients with histopathologic NIH type IV prostatitis, 7 (8%) patients also had prostate cancer. We have already discussed the finding of prostate cancer in 20-31% of patients with a significant decrease in PSA in a number of series [8,9] including ours.…”

“…This is consistent with our finding of prostate cancer in 4 patients despite a significant decrease in their PSA level after the levofloxacin course. Two other relevant studies by Shtricker et al [8] and by Baltacı et al [9] evaluated the effects of antimicrobial treatment on PSA and prostate cancer detection in patients with elevated PSA (4-10 ng/ dl) and normal DRE without necessarily a diagnosis of NIH type IV prostatitis. Shtricker et al [8] retrospectively reviewed a community practice database and noted that repeat PSA was lower in 60% of patients whether they received antibiotics (65 patients) or not (70 patients), and that prostate cancer was diagnosed in 25-31% of their patients with a PSA decline.…”

“…Two other relevant studies by Shtricker et al [8] and by Baltacı et al [9] evaluated the effects of antimicrobial treatment on PSA and prostate cancer detection in patients with elevated PSA (4-10 ng/ dl) and normal DRE without necessarily a diagnosis of NIH type IV prostatitis. Shtricker et al [8] retrospectively reviewed a community practice database and noted that repeat PSA was lower in 60% of patients whether they received antibiotics (65 patients) or not (70 patients), and that prostate cancer was diagnosed in 25-31% of their patients with a PSA decline. Baltacı et al [9] prospectively evaluated 100 men after a 20-day ofloxacin course and found that despite a significant decrease in mean total PSA (6.05 8 1.44 and 5.55 8 1.65 ng/ml before and after treatment, respectively) and a decrease in % free PSA and PSA density, overall 23 of the 100 men (23%) had prostate cancer and the reductions in these parameters (apart from % free PSA) were not significantly different between patients with and without cancer.…”

“…Screening for and treatment of asymptomatic prostatitis has been suggested to improve the positive predictive value of PSA for detecting prostate cancer and to decrease the number of unnecessary biopsies [3] . A few studies have suggested a 2-to 4-week course of antibiotic treatment (different agents) for asymptomatic patients with elevated PSA before a prostate biopsy procedure is initiated [4][5][6] , while others concluded there was no benefit to such an approach [7][8][9] . In the current study, we assess the effect of a 4-week course of levofloxacin on total PSA level in asymptomatic men with elevated PSA, and we evaluate the implications of observed PSA changes on prostate biopsy decision.…”

Does an Inflammatory Pattern at Primary Biopsy Suggest a Lower Risk for Prostate Cancer at Repeated Saturation Prostate Biopsy

“…Shtricker et al [23] did not find any correlation between PSA reduction after antibiotic therapy and risk of detecting cancer at subsequent prostate biopsy in 135 patients with PSA between 4 and 10 ng/ml. Recently, Dirim et al [24] reported that percent free PSA was more helpful in suggesting PCa when elevated PSA values persisted after antibiotic therapy.…”