Prostate cancer screening in the Tyrol, Austria: experience and results

This article summarises the experience and results of different prostate ca rcinoma screening projects using total prostate specific antigen (PSA) and per cent free PSA as the initial test. Of the 21 078 volunteers 1618 (8%) h ad elevated PSA levels. Of these men 778 (48%) underwent biopsies: 197 (25% ) biopsies were positive for prostate carcinoma and 135 (17%) underwent rad ical prostatectomy. 95 were found to be organ-confined. A PSA cut-off of 2. 5 ng/ml in men aged 45-49 years and of 3.5 ng/ml in men aged 50-59 years re sulted in an 8% increase in the detection rate of organ-confined disease. 2 84/2272 men (13 %) had elevated PSA levels and prostate carcinoma was detec ted in 62 men (3 %). All patients underwent radical prostatectomy and histo logical examination revealed organ-confined tumour in all but 8 men. 98/340 men (29 %) had biopsies positive for carcinoma: 28 of these patients (29%) had carcinoma that originated in the transition zone only. In the retrospe ctive study, receiver operating characteristic curve analysis showed that b y using a per cent free PSA of less than 18% as a biopsy criterion, 37% of the negative biopsies could be eliminated although 94% of all carcinomas wo uld still be detected. In the first prospective study, 106/158 men (67%) wi th elevated PSA levels below 10.0 ng/ml were further evaluated and 37 (35%) prostate carcinomas were detected. By using 3 per cent free PSA of <22% as a biopsy criterion. 30% of the negative biopsies could be eliminated altho ugh 98% of the carcinomas would still be detected. in the second prospectiv e study, 120/465 men (26%) with total PSA levels between 1.25 and 6.49 ng/m l and a per cent free PSA < 18% were further evaluated and 27 (23%) were fo und to have prostate carcinomas. Receiver operating characteristic curve an alysis for PSA transition zone (TZ) density showed that by using a PSA tran sition zone density of > 22 nd/ml/cc as a biopsy criterion, 24.4% of negati ve biopsies could be avoided without missing a single carcinoma. In the pre screening era the incidence of Tla Grade 1 and 3 carcinomas was 3.1% and th e incidence of Tla and Tlb Grade 3 carcinoma was 2.3% whereas in the years after the establishment of PSA-based screening the incidence was 4.6 and 1. 03% respectively. The rate of organ-confined tumours increased from 28.7% i n 1993 to 65.7% in 1997. In this evaluation a new approach, to proceed with a prostate biopsy bused upon the: individual risk of having prostate cance r rather than a single PSA cut-off point was developed. High total PSA leve ls, PSA density and PSA transition zone density correlated significantly wi th high Gleason scores, capsular penetration, a high percentage of cancer i n the prostatectomy specimen and a high cancer volume. In this evaluation a ll of the 95 patients with PSA levels below 3.99 ng/ml who underwent radica l prostatectomy showed clinically significant, organ-confined prostate canc er with negative surgical margins. The results of this evaluation suggest t hat older men have larger tumour volumes compared with younger men with the same PSA levels. These data suggest that PSA-based screening with low PSA cut-off values increase the detection rate of clinically significant, organ confined and potentially curable prostate cancer. Per cent free PSA and PS A transition zone density provide an additional diagnostic benefit over tot al PSA. (C) 2000 Elsevier Science Ltd. All rights reserved.