Are we overlooking stage a prostate cancer in patients treated for benign prostatic hyperplasia with medical or minimally invasive modalities?

Our objective was to assess the likelihood of overlooking the diagnosis of prostate cancer (PCA), using current screening methods, in patients treated for benign prostatic hyperplasia (BPH) with medical or minimally invasive treatment modalities, which do not produce tissue specimens for histologic review. To appraise this, we examined the impact of the preoperative use of prostatic specific antigen (PSA) in combination with transrectal ultrasound (TRUS) and systematic sextant prostate needle biopsy (PNbx) on the subsequent incidence of stage A PCA in patients undergoing transurethral resection of the prostate (TURP). After excluding all patients found to have PCA during pretreatment screening, 485 patients who underwent TURP for presumed BPH from 1976 to 1994 were reviewed. From 1976 to 1989, PSA was not used for pretreatment screening, and stage A PCA was diagnosed in 11.4% of 317 patients. In 1990 and 1991, pretreatment screening included PNbx obtained under ultrasound guidance for PSA of 15.0 ng/ml or greater. Stage A PCA was diagnosed in 14.2% of 63 patients. From 1992 to 1994, pretreatment screening included systematic sextant PNbx performed for PSA greater than 4.0 ng/ml, and stage A PCA was diagnosed in 2.8% of 105 patients. The difference in incidence of stage A PCA between the first two groups and group three was significant (p = 0.021), as it was the difference in incidence of stage A₂ (P = 0.037). For stage A₁, the difference did not reach statistical significance (p = 0.089). Our findings suggest that systematic sextant PNbx for PSA greater than 4.0 ng/ml significantly reduces the risk of overlooking prostate cancer in patients undergoing treatment of BPH with modalities that do not provide tissue specimens.