Clarity on PSA density

User

Posted 23 Aug 2023 at 12:28

Hi everyone and I'm a new member of this excellent website.

As per the title of this thread, I am seeking some advice on the significance of prostate-specific antigen density (PSAD); the ratio of serum PSA level to prostate volume.

At 65, I have been diagnosed with prostate cancer, after a raised PSA led to MRI and then TRUSS biopsy. The full results are:

PSA series: 11.6 (Nov 2022), 12.6, 12.9 (April 2023) and 13.9 (last week 18/09)

MRI: prostate volume 31cc; suspicious lesion PI-RADS 5; contained in capsule

DRE: T2 on examination

Biopsy: 18 cores; Gleason 3+3=6; 3 cores on left, no tumour on right

Although I have a low risk tumour by histology, and that it is localised, the MDT team are saying that the PSA level is high, given the low prostate volume and they are suspicious that there might be something missed in the biopsy, or that the activity of the cancer cells is higher than indicated by histology.

They are recommending radical prostatectomy (robotic assisted) as first option in the list, although also including brachytherapy and active surveillance.

The priority seems to hinge on the PSAD. Undoubtedly the trajectory of the serial PSA measurements suggests it is rising over 9 months, strengthening the case for some kind of intervention eventually. However I read in the toolkit from this site that overall the risk is:

CPG 2
You will be in this group if you have a T stage of
1 or 2 and one of the following:
• Gleason score is 3 + 4 = 7 (grade group 2), or
• PSA 10 to 20 ng/ml.
This means your cancer is likely to grow slowly
and unlikely to spread. Your treatment options
may include active surveillance, surgery or
radiotherapy with hormone therapy.

...though I have a lower Gleason score.

Does anyone have any perspective on the value of PSAD, and whether it really affects the order of recommendations?

Many thanks in advance.

User

Posted 23 Aug 2023 at 21:43

PSA is not a very useful diagnostic test, but it is a fairly cheap one. The reason it is not useful is the baseline of PSA varies so much from person to person. Once you have an idea of someone's normal PSA values, it becomes more useful, so it is good for monitoring the disease, and in your case the (slow) steady rise suggests cancer.

One reason everyone's baseline PSA is different is the different size of the prostate. So PSAD takes this into account. An average prostate is 25cc a slightly worrying PSA is 3.0 in an average prostate. So if someone comes on here and says they have a PSA of 9.0 and a prostate volume of 80cc, I tell them not to be too worried.

The differences in PSA aren't just caused by prostate size or cancer. It seems to vary for mamy other reasons too.

I am surprised they are drawing any conclusions about the severity of your cancer based on your PSA which is moderately high, but not off the scale.

Dave

User

Posted 24 Aug 2023 at 20:40

It took nearly 7 years of monitoring between my first and second biopsy before my PSA density hit a level which my (excellent) consultant said would/should trigger the need for the 2nd biopsy.

His experience was that most people who breached a PSA density of 15% and also had a rising PSA, (however slow it may be) had a good chance of returning a positive biopsy albeit hopefully at an early stage. This trend seemed to also be despite what mpMRI's might be showing (or in my case not showing - I was PIRADS 2 and no visible lesions)

My prostate size was 40cc so the magic PSA number for me to breach was 6.0. When I clocked in at 6.55, I had the 2nd biopsy and sure enough 2 of 24 cores taken from a TP biopsy came back positive as gleason 3+4.

It's interesting that your MDT think your PSA density (approx 44% I think) might indicate something more sinister than the biopsy picked up but the biopsy is best tool of diagnosis and as Dave said, anything PSA based is always going to be less definitive in my opinion.

So I understood that PSA density read in conjunction with a pattern of rising PSA levels was useful in so far as it might prompt a biopsy when one wouldn't otherwise be suggested but as far as using it to grade the severity of the cancer, I'd be surprised if it was more indicative than the biopsy OR the MRI.

Ultimately, you now have the confirmed diagnosis and even if the gleason score is slightly off or they missed some of the disease (a risk with any biopsy), it sounds like they've got it early and believe it be contained so either RARP or Brachy would seem to be more than appropriate and neither really has any better chance of being curative than the other.

Unfortunately, it's that awful time now where you have to decide which one you're more comfortable with. Good luck!

User

Posted 28 Aug 2023 at 22:51

PSA density isn't something we read about much on here. Although I've read that Gleason pattern 4 gives off significantly more psa than Gleason pattern 3. Gleason pattern 3 gives off only a small amount more than normal cells. There was a study that worked out a specific density. I can't quickly find it although I know I stored it somewhere.

Another thing is that they know the suspected size of your lesion. So if it's small with Gleason pattern 3 and your prostate isn't particularly large then 14 is probably higher than they expect. They haven't told you the size of the lesion, nor did they initially tell me, although the surgeon wrote it in his letter to my GP. You could ask.

My Gleason was increased post operation after they saw it in the lab. That isn't too unusual.

PSA isn't that good a measure on its own but it gives clues and together with other information creates a likely conclusion. Nothing is certain and the numerous factors make it that you can't precisely read from one person to another.

Regards Peter

User

Posted 29 Aug 2023 at 12:34

I had similar readings to you, but with no suspicious PIRADS or breakout. PSA was 10. On my initial urology consultation following an MRI my PSAD wasn't mentioned until I got the follow-up letter, which said it was high at 37%. I had no idea what this meant until I researched it a little. I have a small (25cc) prostate so I guess this can lead to high PSAD scores. When I next met another consultant he felt that while AS was still an option my high PSAD meant that it was more possible that the cancer might grow sooner rather than later, but it was up to me whether I had a biopsy. We decided to go ahead with the biopsy because of this, which turned out to be the right decision. I had 3+4 and T2b, so elected for Brachytherapy, which was done ten days ago.

So for me PSA Density was a material consideration for the decision on treatment timing and by extension what treatments were available.

Edited by member 29 Aug 2023 at 12:37 | Reason: Not specified

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