Defining the optimal prostate-specific antigen threshold for the diagnosis of prostate cancer

Prostate-specific antigen (PSA)-driven testing for prostate cancer is common around the world. There is uncertainty about its proper use in diagnosing prostate cancer. This review describes the background of the addressed problem and summarizes relevant, recent findings reported during 2008.

Available data suggest that the performance characteristics of PSA do not permit the identification of a valid cutoff value that balances sensitivity and specificity in indicating a biopsy of the prostate. However, biopsy in all men by age would only lead to unacceptably high biopsy and detection rates. Data reported in this study show that within the population of men aged 55-75 years, 80% have PSA values of less than 3.0 ng/ml and 87% below 4.0 ng/ml. Data from European Randomized Study of Screening for Prostate Cancer, Rotterdam suggest that, on the basis of a 12-year follow-up period, biopsy in men with PSA values of less than 3.0 ng/ml can safely be delayed. Several of the studies suggest that in following such men, other risk factors such as prostatic volume, previous screens and biopsies, rectal examination, age and family history may be helpful in decision making. Molecular markers, which may replace PSA or identify selectively indolent, aggressive prostate cancer, are under investigation.

At this time, PSA cutoff values (>2.5, 3.0 or 4.0 ng/ml) provide a reasonable balance between excessive detection rates and the risk of missing relevant prostate cancer. Men presenting with PSA values of 2.0-3.0 ng/ml should be reexamined more frequently. Available nomograms applying risk modifiers should be used specifically in this category of men.