Worry when prostate cancer tissue reaches the pathologist
By Ryan DuBosar
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Better detection of prostate cancer means that diagnosis has become inevitable in most men, reported Oliver Sartor, MD, of Tulane University.
Dr. Sartor, a professor of cancer research in the departments of medicine and urology at Tulane, led two Thursday sessions on “Controversies in Prostate Cancer: Screening, Evaluation of the Rising PSA, and Effects of Anti-Androgen Treatment.”
Improved detection—prostate-specific antigen (PSA) testing and core biopsies instead of a digital rectal exam (DRE)—created a higher “incidence rate” of prostate cancer starting by 1992, Dr. Sartor said. The biggest risk associated with cancerous prostate tissue, he quipped, is its finding its way to the pathologist’s microscope.
“A lot more men have the disease than are ever destined to die from it,” Dr. Sartor said.
Autopsy results show that more than half of men over age 50 have prostate cancer. Clinically, about 17% of men over age 50 are diagnosed with it and about 3% die from it. (Despite the impact of early diagnosis on lowering mortality, prostate cancer is the second-leading cause of cancer death in men, behind lung cancer.)
A comparison of transurethral resection of the prostate and biopsy detection among more than 18,000 men with normal PSA and DRE results—“a low-risk group”—showed that 25% of that population had prostate cancer [N Engl J Med. 2003;349:213-22].
Key points
Dr. Sartor's take-home message addressed ways to approach diagnosing patients at risk for prostate cancer.
- PSA can be used to diagnose prostate cancer earlier, but many patients may never need treatment.
- Debate continues on the proper PSA level to trigger biopsy, but over 4.0 ng/mL in a patient with a life expectancy of greater than 10 years is reasonable. Lower PSA cutoffs are justified in men younger than age 50. PSA in serum at age 40 predicts future risk of prostate cancer.
- Treatment must be highly individualized.
- Prognostic tables are available to guide decisions. A Google search can find them easily.
Risk factors include:
- increasing age
- sub-Saharan African ancestry
- having brothers and fathers with prostate cancer
- genetic mutations: 8q24, 17q12, 17q24 SNPs, RNASEL mutations and a novel (XMRV) retrovirus, and the breast cancer gene, BRCA2.
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Autopsy and detection
Age at autopsy and detection of prostate cancer.
| Age | Incidence (%) |
| 20-30 | 2 |
| 31-40 | 29 |
| 41-50 | 32 |
| 51-60 | 55 |
Source: Sakr et al. In Vivo. 1994;8:439-43.
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