The diagnostic impact of UK regional variations in age‐specific prostate‐specific antigen guidelines

Light, Alexander; Burns-Cox, Nicholas; MacCormick, Angus; John, Joseph B; McGrath, John; Gnanapragasam, Vincent

doi:10.1111/bju.15484

Cited by 4 publications

(3 citation statements)

References 8 publications

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“…Across England, for instance, we recently reported at least 10 different PSA age-reference ranges being used which affected both referral likelihood and diagnosis of csPCa. 21 In the current study, despite more accurate biopsy methods, the diagnostic performance of PSA reference ranges did not add value to single PSA cut-offs. We find that this is likely due to a very variable relationship between age and prostate volume and by association, different levels of endogenous PSA expression.…”

Section: Discussioncontrasting

confidence: 62%

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Re-evaluating the diagnostic efficacy of PSA as a referral test to detect clinically significant prostate cancer in contemporary MRI-based image-guided biopsy pathways

Lophatananon

Light

Burns-Cox

et al. 2021

Journal of Clinical Urology

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Introduction: Modern image-guided biopsy pathways at diagnostic centres have greatly refined the investigations of men referred with suspected prostate cancer. However, the referral criteria from primary care are still based on historical prostate-specific antigen (PSA) cut-offs and age-referenced thresholds. Here, we tested whether better contemporary pathways and biopsy methods had improved the predictive utility value of PSA referral thresholds. Methods: PSA referral thresholds, age-referenced ranges and PSA density (PSAd) were assessed for positive predictive value (PPV) in detection of clinically significant prostate cancer (csPCa – histological ⩾ Grade Group 2). Data were analysed from men referred to three diagnostics centres who used multi-parametric magnetic resonance imaging (mpMRI)-guided prostate biopsies for disease characterisation. Findings were validated in a separate multicentre cohort. Results: Data from 2767 men were included in this study. The median age, PSA and PSAd were 66.4 years, 7.3 ng/mL and 0.1 ng/mL2, respectively. Biopsy detected csPCa was found in 38.7%. The overall area under the curve (AUC) for PSA was 0.68 which is similar to historical performance. A PSA threshold of ⩾ 3 ng/mL had a PPV of 40.3%, but this was age dependent (PPV: 24.8%, 32.7% and 56.8% in men 50–59 years, 60–69 years and ⩾ 70 years, respectively). Different PSA cut-offs and age-reference ranges failed to demonstrate better performance. PSAd demonstrated improved AUC (0.78 vs 0.68, p < 0.0001) and improved PPV compared to PSA. A PSAd of ⩾ 0.10 had a PPV of 48.2% and similar negative predictive value (NPV) to PSA ⩾ 3 ng/mL and out-performed PSA age-reference ranges. This improved performance was recapitulated in a separate multi-centre cohort ( n = 541). Conclusion: The introduction of MRI-based image-guided biopsy pathways does not appear to have altered PSA diagnostic test characteristics to positively detect csPCa. We find no added value to PSA age-referenced ranges, while PSAd offers better PPV and the potential for a single clinically useful threshold (⩾0.10) for all age groups. Level of evidence: IV

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Section: Discussioncontrasting

confidence: 62%

“…For men aged ⩾ 70 years, we used the most common guidance from Cancer Alliances, that is, PSA of ⩾ 5 ng/mL. 21…”

Section: Methodsmentioning

confidence: 99%

Re-evaluating the diagnostic efficacy of PSA as a referral test to detect clinically significant prostate cancer in contemporary MRI-based image-guided biopsy pathways

Lophatananon

Light

Burns-Cox

et al. 2021

Journal of Clinical Urology

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“…This led to significant variation in care for patients with suspected prostate cancer in England. 8 The updated 2021 version of NG12 continues to advise the use of age-adjusted PSA ranges and specified what these levels should be (see Table 1 ). These recommendations are based on indirect evidence from PSA screening trials as there are no published studies of the diagnostic accuracy of PSA in a primary care setting to date.…”

Section: Current Clinical Guidancementioning

confidence: 99%

Diagnosis of prostate cancer in primary care: navigating updated clinical guidance

2023

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PROSTATE CANCER IN THE UKProstate cancer became the most common cancer diagnosed in males in the UK in 2018, with around 52 300 new cases. 1 The COVID- 19 pandemic impacted prostate cancer diagnoses more than any other tumour type and up to 14 000 fewer prostate cancer cases were detected in the first 2 years of the pandemic than would be expected based on long-term trends. 2,3 This was thought to be in part due to fewer patients coming forward to their GP with symptoms warranting an urgent suspected cancer ('2-week wait') referral or to discuss opportunistic prostate-specific antigen (PSA) screening. Early-stage diagnosis (stage I/II) of clinically significant prostate cancer is crucial for improving outcomes for patients with prostate cancer. Five-year survival for patients with prostate cancer diagnosed at stage I or II is close to 100%, whereas for patients diagnosed at stage IV, around 50 out of every 100 men -around 50% -will survive their cancer for 5 years or more after they are diagnosed. 4 The delays in prostate cancer diagnosis for thousands of patients as a result of the pandemic could have significant long-term effects. This will make achieving the NHS Long Term Plan aim of diagnosing 75% of patients with early-stage cancer by 2028 all the more difficult. 5 The vast majority of patients with prostate cancer are diagnosed following a referral from their GP. Over half of these patients are referred via the 2-week wait pathway, and another quarter following a routine GP referral to urology. 6 Prostate cancer diagnoses following emergency presentation are an uncommon occurrence. 6 Prostate cancer is usually suspected in primary care with either an abnormal digital rectal examination (DRE) of the prostate or an elevated PSA level. The presence of one of these clinical features is an indication for a 2-week wait referral according to National Institute for Health and Care Excellence (NICE) guidance 12 (NG12).

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Natural History of Patients with Prostate MRI Likert 1-3 and Development of RosCaP: a Multivariate Risk Score for Clinically Significant Cancer

Orecchia

Nardi²,

Fletcher³

et al. 2023

Clinical Genitourinary Cancer

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The diagnostic impact of UK regional variations in age‐specific prostate‐specific antigen guidelines

Cited by 4 publications

References 8 publications

Re-evaluating the diagnostic efficacy of PSA as a referral test to detect clinically significant prostate cancer in contemporary MRI-based image-guided biopsy pathways

Re-evaluating the diagnostic efficacy of PSA as a referral test to detect clinically significant prostate cancer in contemporary MRI-based image-guided biopsy pathways

Diagnosis of prostate cancer in primary care: navigating updated clinical guidance

Natural History of Patients with Prostate MRI Likert 1-3 and Development of RosCaP: a Multivariate Risk Score for Clinically Significant Cancer

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