Prostate cancer screening in high-risk men: African American Hereditary Prostate Cancer Study Network

BACKGROUND: There are scant data available on prostate cancer screening among high-risk African American men with positive family histories. It is important to determine whether or not their screening rates differ from those in the general population. METHODS: This study computed rates of previous digital rectal examination (DRE) and prostate-specific antigen (PSA) screening for prostate cancer in cancer-free (unaffected) relatives age 40-69 years from African American families that had four or more men with prostate cancer. The rates for these 134 high-risk African American men from the African American Hereditary Prostate Cancer Study (AAHPC) were compared with nationwide estimates obtained from participants in the 1998 and 2000 National Health Interview Survey (NHIS), for which the numbers of demographically comparable subjects were 5583 (4900 Caucasians, plus 683 African Americans) and 3359 (2948 Caucasians, 411 African Americans), respectively. RESULTS: Men in the AAHPC cohort (with a strong positive family history) had significantly less screening than both African Americans and Caucasians in the NHIS cohorts. Only about one-third (35%) of the men in the AAHPC unaffected cohort had ever had a DRE, and only about 45% of them had ever received a PSA test. These rates were much lower than those obtained for African American men in the NHIS: 45% for DRE and 65% for PSA. These discrepancies increased with age. CONCLUSIONS: Older African American men with positive family histories report surprisingly low rates of DRE and PSA screening compared with their counterparts in the NHIS surveys. At-risk men need to be informed of the benefits and limitations of prostate cancer screening and actively involved in decision-making for or against prostate cancer screening.     

The American Cancer Society National Prostate Cancer Detection Project. Findings on the detection of early prostate cancer in 2425 men.

The American Cancer Society National Prostate Cancer Detection Project (ACS-NPCDP) is a multidisciplinary, multicenter effort to assess the feasibility of early prostate cancer detection by digital rectal examination (DRE), transrectal ultrasound (TRUS), and prostate specific antigen (PSA) assay. By June 1990, 2425 men not previously suspected of having prostate cancer had been examined in ten participating clinical centers according to the project protocol. Three hundred ninety-six men (16.3%) were recommended for biopsy on the basis of TRUS or DRE. An analysis of the results of 330 completed biopsies showed 52 cancers detected by DRE and/or TRUS. Forty-four (84.6%) of the men with cancer had positive TRUS examination results compared with 33 (63.5%) with positive DRE. Five additional cancers were discovered as a result of elevated PSA levels. The overall detection rate was 2.4% and this rate varied by age. The detection rate in men 55 to 60 years of age was 1.3% and this rose to 3.3% in men older than 65 years of age. The estimated sensitivity was significantly greater for TRUS compared with DRE (77.2% versus 57.9%; P less than 0.05). The estimated specificity of DRE was greater than that of TRUS (96.3% versus 89.4%; P less than 0.01). The positive predictive value (PPV) for the tests varied as a function of patient and disease characteristics. The overall PPV was 28.0% for DRE and 15.2% for TRUS. The occurrence of elevated PSA levels significantly increased the PPV of both TRUS and DRE. The majority of cancers detected were at early stages. These preliminary data suggest the feasibility of using these techniques to promote cancer control, but additional data and follow-up are needed to assess the significance of the results.     

Prostate-specific antigen levels in 1695 men without evidence of prostate cancer. Findings of the American Cancer Society National Prostate Cancer Detection Project.

The American Cancer Society National Prostate Cancer Detection Project is a prospective, multidisciplinary, and multicenter trial to assess the potential for early detection of prostate cancer by transrectal ultrasonography (TRUS), digital rectal examination (DRE), and serum prostate-specific antigen assay (PSA). By November 1990, 2805 men between the ages of 55 and 70 years with no known signs or symptoms of prostate cancer were enrolled in the study, which is planned to run for 5 years. Annual TRUS, DRE, and PSA tests were done on these subjects, and biopsies were recommended for suspicious lesions when detected. To study the performance of PSA testing in presumed normal subjects, all men were eliminated who had (1) prostate cancer detected on their initial examinations and proven by biopsy or (2) cancer detected during the year or subsequent examinations. Additionally, all men with TRUS or DRE findings that were interpreted as suspicious for cancer but who are being followed and have not yet had biopsies done were removed from this series. This left a unique, extensively screened group of 1695 men who were free of prostate cancer, as far as could be determined. Analyses of the PSA levels in this large population in the appropriate age range for increasing risk of prostate cancer revealed several important findings. First, there was a direct relationship between serum PSA levels and estimated prostate volume for both the currently available monoclonal and polyclonal PSA assays. Individuals with benign prostatic hyperplasia and larger gland volume have a higher normal limit of PSA than men with normal gland volume. Second, analyses showed no relationship between age and PSA levels or between symptoms of prostatism and PSA levels independent of gland enlargement. It was concluded that volume-adjusted upper limits of normal PSA can be determined for different levels of specificity desired. This information may be applicable to the use of PSA in men not already suspected of having prostate cancer and may increase its effectiveness as a tool for early detection.     

Prostate-specific antigen, digital rectal examination, and transrectal ultrasound in predicting the probability of cancer.

Over a 4 1/2 year period, 1,940 asymptomatic men were entered in a prostate cancer detection program consisting of digital rectal examination (DRE), prostate-specific antigen (PSA), and transrectal prostate ultrasound (TRUS). Four hundred and sixteen biopsies were performed resulting in the diagnosis of 79 cancers; 82% had clinically organ confined tumors. A recommendation for biopsy was made in 260 (62%) based on the TRUS alone, 55 (13%) by DRE alone, 92 (22%) when the DRE and TRUS were both abnormal, and in 9 (2.2%) cases when only PSA levels were elevated. The DRE, PSA, and TRUS were abnormal in 1,261 (65%), 989 (51%), and 1,552 (80%) of the patients with cancer, respectively. Prostate cancer detection increased as the serum PSA level increased above 4 ng/ml. The positive predictive value of both DRE and TRUS were significantly influenced by an elevated PSA, (P = .042 and P less than .00005, respectively). The results of this study support the idea that, although the prostate cancer detection rate is influenced by these three modalities and the detection rate of localized disease can be improved by early detection programs, its effect on mortality rates remains undefined at this time.     

Screening for prostate cancer

Screening for prostate cancer has shown great promise in its ability to detect prostate cancer at a curable stage; however, significant problems exist with respect to our knowledge of its impact on prostate cancer mortality. For the properly informed patient with at least a 10-year life expectancy, it would seem that early detection efforts utilizing digital rectal examination (DRE) and serum prostate-specific antigen (PSA) determination are beneficial. Considerable controversy abounds about early detection and screening and will continue until definitive proof of decreased prostate cancer mortality as a result of effective early detection and treatment regimens is demonstrated. Until then, all men with at least a 10-year life expectancy should be counseled as to the potential benefits and risks. The salient literature is reviewed and commentary made as to the benefits of screening methods that can be invoked as well as their limitations and potential liabilities.     

The relationship of prostate-specific antigen to digital rectal examination and transrectal ultrasonography. Findings of the American Cancer Society National Prostate Cancer Detection Project.

The participating institutions of the American Cancer Society National Prostate Cancer Detection Project did 520 biopsies on 2425 men over a 3.5-year period. A total of 88 cancers were confirmed pathologically, 93% of which clinically were organ confined. In 324 men (62.3%), a recommendation for biopsy was made based solely on the results of transrectal ultrasonography (TRUS); in 69 patients (13.3%), solely on the digital rectal examination (DRE); in 116 patients (22.3%), on abnormal DRE and TRUS examinations; and in 11 patients (2.1%), in whom DRE and TRUS were normal, on elevated prostate-specific antigen (PSA) levels. The TRUS was abnormal in 80.6% of men found to have cancer, and the PSA level and DRE were abnormal for 67% and 50% of cancers, respectively. The influence of PSA level on cancer detection increased as the serum level increased above 4 ng/ml. The positive predictive values of both the DRE and TRUS were influenced significantly by the presence of an elevated PSA level (P = 0.044 and P less than 0.001, respectively). The results of this ongoing multicenter study support the following statements: (1) the prostate cancer detection rate is influenced by this diagnostic triad and (2) the detection rate of organ-confined disease can be improved substantially by early detection programs.     

Digital rectal examination versus transrectal ultrasound in detection of prostate cancer. Preliminary results from a study of a randomly selected population.

In a study of 2,400 randomly selected men (age 55-70 years) for early detection of prostate cancer the authors have compared the diagnostic value of digital rectal examination (DRE), transrectal ultrasound (TRUS) and prostate specific antigen (PSA). Altogether 62 prostate cancers were detected, corresponding to a detection rate of 3.5% but by use of DRE the detection rate was only 2.3%. The study showed that TRUS added significantly to the detection rate. If radical surgery is restricted to stages T1 and T2A, the combined use of DRE and TRUS detected twice as many cases fit for this treatment than DRE alone. The authors advocate randomized studies for evaluation of early radical treatment of prostate cancer. Before results of such studies have appeared they recommend methodological studies aimed at development and enhancement of the accuracy of the diagnostic tools.     

Combined use of prostate-specific antigen derivatives decreases the number of unnecessary biopsies to detect prostate cancer.

The authors evaluated the prostate cancer detection rate in Turkish patients with prostate-specific antigen (PSA) levels of 4 ng/ml to 10 ng/ml and who had normal digital rectal examination (DRE) findings. They also aimed to evaluate the value of PSA density and percent free PSA in minimizing unnecessary prostate biopsies for these PSA ranges. This prospective study included 134 consecutive men referred for early prostate cancer detection or lower urinary tract symptoms. All men underwent transrectal ultrasound with systematic sextant needle biopsies. The ability of PSA density and percent free PSA to improve the power of PSA in the detection of prostate cancer was evaluated with statistical analyses as well as receiver operating characteristics curves. Among the 134 men, 124 (92.5%) had a benign histology and 10 (7.5%) had cancer diagnosed on the initial biopsies. Despite the disappointing results in regard to the sensitivity and specificity of PSA derivatives alone, the combination of PSA density and percent free PSA significantly increased the area under the curve compared with the use of each test alone. To increase the specificity of PSA in this patient population, the authors recommend combining two PSA derivatives in deciding whether to perform a biopsy. In a PSA range of 4 ng/ml to 10 ng/ml and with normal DRE, a percent free PSA < 21% and a PSA density > 0.18 yields highest specificity with 90% sensitivity.     

PCA3: from basic molecular science to the clinical lab

Prostate cancer is the second leading cause of cancer deaths in men in the United States. Use of the serum prostate specific antigen (PSA) test to screen men for prostate cancer since the late 1980s has improved the early detection of prostate cancer, however low specificity of the test translates to numerous false positive results and many unnecessary biopsies. New biomarkers to aid in prostate cancer diagnosis are emerging and prostate cancer gene 3 (PCA3) is one such marker. PCA3 is a noncoding RNA that is highly over-expressed in prostate cancer tissue compared to benign tissue. A non-invasive test for PCA3 was developed using whole urine collected after a digital rectal exam (DRE). Numerous clinical studies have demonstrated the utility of PCA3 for the diagnosis of prostate cancer and some studies suggest that PCA3 may also have prognostic value. The use of PCA3 in combination with serum PSA and other clinical information enhances the diagnostic accuracy of prostate cancer detection and will enable physicians to make more informed decisions with patients at risk for prostate cancer.     

Prostate Cancer Ambassadors: Enhancing a Theory-Informed Training Program for Informed Decision-Making

Despite the high burden of prostate cancer in African American communities, there is a paucity of knowledge about prostate health. This paper describes the enhancement of a curriculum for training lay health advisors, called prostate cancer ambassadors, on informed decision-making for prostate cancer screening. Adult learning theory informed the structuring of the training sessions to be interactive, self-directed, and engaging. Trainings were developed in a manner that made the material relevant to the learners and encouraged co-learning. The research team developed strategies, such as using discussions and interactive activities, to help community members weigh the pros and cons of prostate-specific antigen (PSA) screening and to make an informed decision about screening. Furthermore, activities were developed to bolster four social cognitive theory constructs: observational learning, self-efficacy for presenting information to the community and for making an informed decision themselves, collective efficacy for presenting information to the community, and outcome expectations from those presentations. Games, discussions, and debates were included to make learning fun and encourage discovery. Practice sessions and team-building activities were designed to build self-efficacy for sharing information about informed decision-making. Topics added to the original curriculum included updates on prostate cancer screening, informed decision-making for screening, skills for being a lay health advisor, and ethics. This dynamic model and approach to lay health advisor (ambassador) training is flexible: while it was tailored for use with prostate cancer education, it can be adjusted for use with other types of cancer and even other diseases.     

Family history, perceived risk, and prostate cancer screening among African American men.

BACKGROUND: Many African American men have two major risk factors for prostate cancer. By ethnicity alone, they have twice the risk of Euro-American men of developing prostate cancer. Having a family history (brother or father with prostate cancer) also doubles their risk. The major hypotheses tested in this study are that men with a family history perceive their risk to be higher, are more worried about getting prostate cancer, and are more likely to have used cancer screening tests than men without such a history. METHODS: A sample of 208 African American men, ages 40 to 74 years, were recruited through relatives or friends whose prostate cancer diagnosis was reported to the California Cancer Registry during the years 1997 to 2001 and from churches and African American social groups. Following a screening interview to determine eligibility, 88 men with self-reported, first-degree family history of prostate cancer and 120 without such history were interviewed by telephone. Logistic regression was used to create models of perceived risk, prostate cancer worries, receipt of a digital rectal exam, and/or prostate-specific antigen (PSA) testing. RESULTS: Men with a self-reported family history of prostate cancer did not perceive their risk as higher than men without a family history, nor did they report more cancer worries. They were more likely to report having a recent PSA test, but not a digital rectal exam. Having a higher than average perceived risk was associated with younger age, a college education, and lower mental well-being, and reporting more prostate cancer worries and being more likely to have had a recent PSA test. CONCLUSIONS: Although there continues to be controversy about PSA testing, these data suggest that African American men at above-average risk are inclined to be screened.     

Value of Prostate Cancer Screening in a Comprehensive Community Cancer Center

Early detection of prostate cancer may help decrease cancer deaths from this disease despite the increased incidence of prostate cancer. In 1990 and 1991 we conducted one-day “screens” for prostate cancer. This analysis was undertaken to determine the value of the screening procedures for detecting prostate cancer in the community. A total of 579 men, aged 39-84 years (mean 58 years), were evaluated by digital rectal examination (DRE) by a urologist, serum prostate specific antigen (PSA) determination by monoclonal antibody assay, and completion of a detailed questionnaire. Forty-eight percent had not seen a physician in over 2 years; 17% had a 1st- or 2nd-degree relative with prostate cancer. There was a 25% “suspicious” rate including 76 (13%) men with abnormal DRE only, 48 (8%) with abnormal PSA only, and 21 (4%) with abnormal DRE and PSA. Patients with findings suspicious for cancer were recontacted by telephone at 2-month intervals for 6 months to determine outcome because subsequent diagnostic management was at the discretion of practicing physicians. By 6 months, 84% of patients with abnormal findings had seen a physician as recommended. Of the 76 with abnormal DRE only, 11 were biopsied and only one cancer was found (9%). Of 48 with an elevated PSA only, 19 were biopsied; 11 (58%) had cancer (9/9 positive transrectal ultrasound) and 8 had no cancer at biopsy (5/5 negative transrectal ultrasound). Of 21 with both tests suspicious, 11 were biopsied and 9 had cancer (82%). Thus, by 6 months after each screen there was a 3.5% overall cancer detection rate for the whole population screened, a 67% positive biopsy rate among those with an elevated PSA, a 45% positive biopsy detection rate among those with an abnormal DRE, and a 51% positive biopsy rate among all those biopsied. Eighty percent of the PSA elevations were between 4.1 and 10.0 ng/ml. This screening experience yielded several new diagnoses of prostate cancer, and the use of serum PSA levels and ultrasoundguided biopsy was associated with a high positive biopsy rate for cancer.     

前列腺癌的早期诊断

目的：评价前列腺癌早期诊断的方法及提高对一些基本诊断方法的认识。方法：对１９９１－１９９９年诊治的７０例早期前列腺癌所应用的基本诊断技术进行分析。结果：７０例患者中,６４例（９１．４％）ＤＲＥ（直肠指诊）发现前列腺异常。６６例患者接受ＰＳＡ（前列腺特异抗原）检查,其中ＰＳＡ〉４ｎｇ／ｍｌ者５２例（７８．８％）。６６例患者接受ＴＲＵＳ（经直肠前列腺Ｂ超）检查,其中５４例（８１．８％）发现异常。若将２     

Detection of prostatic carcinoma: the role of TRUS, TRUS guided biopsy, digital rectal examination, PSA and PSA density

The purpose of this study was to evaluate the efficacy of various diagnostic tests including transrectal ultrasound (TRUS), TRUS guided biopsy, digital rectal examination (DRE), prostate specific antigen (PSA), and prostate specific antigen density (PSAD) in detecting prostatic carcinomas. One hundred and thirty-four men underwent TRUS guided random, or directed and random sonographic biopsies of the prostate. The mean age was 64.67 (range, 31- 88) years. Indications for biopsy were abnormal findings suggesting prostatic carcinoma on DRE or increased levels of PSA, defined as 4.0 ng/ml or greater in a monoclonal antibody assay. PSAD was calculated by dividing the serum PSA in ng/ml to the volume of the entire prostate in cm3. The biopsy results were grouped as benign, malign and, prostatitis. The patients were also divided into three groups according to their PSA values. Of the 134 patients evaluated, 31 (23.1%) had prostate adenocarcinoma, 89 (66.4%) had benign prostatic tissue, hyperplasia or prostatic intraepithelial neoplasia, and 14 (10.4%) had prostatitis. The mean PSA and PSAD of the carcinoma group were significantly higher than those of the noncancer group. In the group of patients with PSA levels between 4 and 10 ng/ml, abnormal TRUS or DRE increased cancer detection rate, where neither PSA nor PSAD was capable of discriminating the patients with and without cancer. PSAD did not prove to be superior to the other diagnostic tests in this study. We recommend biopsy when either TRUS or DRE is abnormal in patients with PSA levels between 4 and 10 ng/ml. In the patients with PSA levels greater than 10 ng/ml, biopsy is indicated whatever the findings on TRUS or DRE are, since cancer detection rate is high.     

Prostate cancer mortality in Connecticut, Iowa and New Mexico African American men

We sought to assess trends in prostate cancer incidence, treatment and mortality in African American men by means of analysis of prostate cancer data from three states, Connecticut, Iowa and New Mexico, all participants in the Surveillance, Epidemiology, and End Results (SEER) Program. Compared with levels before prostate specific antigen (PSA) testing, prostate cancer incidence increased in all three states after widespread testing. For men diagnosed with localized or regional prostate cancer, the respective increases in radical prostatectomy in Connecticut, Iowa, and New Mexico were 3.2, 2.3, and 4.9 times pre-test levels. Age-standardized mortality in Connecticut and Iowa increased slightly; in New Mexico the 104.7 deaths per 100,000 in 1979-1986, 62.1 in 1987-1990, dropped to 47.6 in 1991-1998, an amount of decline that was statistically significant. Introduction of PSA testing influenced early detection and treatment of prostate cancer in all three states. Although decline in prostate cancer mortality in New Mexico over time may be linked with use of the PSA test and definitive therapy, the relationship among these factors, and thus the proper treatment for the early stages of this condition, is unclear on the basis of these data.     

High prevalence of screening-detected prostate cancer among Afro-Caribbeans: the Tobago Prostate Cancer Survey.

Risk for prostate cancer is high among African Americans.We hypothesized that risk for prostate cancer is also high in other populations of African descent. Our objective was to determine the screening-detected prevalence of prostate cancer in the predominantly Afro-Caribbean population on the island of Tobago. Male residents, ages 40-79 years, were invited to participate in a population-based screening for prostate cancer using serum prostate-specific antigen (PSA) and digital rectal exam (DRE). Men with elevated PSA (>or=4 ng/ml) or abnormal DRE were offered an ultrasound-guided sextant biopsy of the prostate gland. Men (2484), ages 40-79 years, underwent prostate cancer screening between September 1997 and June 2001. Mean age was 55.9, SD was 10.6 years, and median was 54 years. Mean serum PSA was 14.8 ng/ml, SD was 376 [excluding 4 values >or= 2 SD above the mean (1,112, 1,317, 1,818, and 18,330 ng/ml) mean PSA was 5.5 ng/ml and SD was 29.6], and median PSA was 1.2 ng/ml. Elevated PSA and/or abnormal DRE were observed in 31% (759 of 2484) overall, and in age groups 40-49 (87 of 843, 10%), 50-59 (201 of 729, 28%), 60-69 (262 of 584, 45%), and 70-79 (209 of 328, 64%). Of 681 men biopsied, 259 (38%, or 10% of the 2484 screened) were diagnosed with prostate cancer. Age-specific rates of screening detected prostate cancer were: 1%, ages 40-79 years; 7%, ages 50-59 years; 18%, ages 60-69 years; and 28%, ages 70-79 years. These screening results indicate a very high screening-detected prevalence of prostate cancer in this population of West African descent. These data support the hypothesis that populations of African descent share genetic and/or lifestyle factors that contribute to their elevated risk for prostate cancer.     

Negative influence of changing biopsy practice patterns on the predictive value of prostate-specific antigen for cancer detection on prostate biopsy

BACKGROUND: A correlation between prostate specific antigen (PSA) level and positive prostate biopsy rate was established in an era when biopsy practice patterns were different from what they are today. We evaluated if changes in biopsy practice patterns have affected the ability of PSA to predict cancer detection on prostate biopsy in the current era. METHODS: Of 3634 prostate biopsies performed from 1993-2005, 1607 met criteria for analysis. Biopsy data were divided into 3 time-cohorts (1993-1997, 1998-2001, and 2002-2005) to assess for practice patterns shifts and correlation between PSA and biopsy results. RESULTS: Significant changes in biopsy practice patterns included an increase in biopsy cores and more frequent use of PSA 2.5-3.99 ng/mL as a biopsy indication. In men with normal DRE, a moderate correlation between PSA and positive biopsy rate did exist from 1993-1997, but was subsequently lost. On multivariate analysis, PSA was not a significant predictor of biopsy result in men with normal DRE. CONCLUSIONS: Early in the PSA era, the predictive power of PSA depended on multiple factors: high prevalence of disease, higher prevalence of high-grade disease, and low likelihood of prostate cancer diagnosis in men with low PSA. Now, beyond the culling effect of increased biopsy incidence and with shifted biopsy practice patterns, the correlation between PSA and biopsy result is lost in men with normal DRE. Diagnosing a higher proportion of tumors in men with a PSA between 2.0-4.0 ng/mL has negatively influenced the predictive value of PSA for cancer detection.     

Prostate specific antigen as a clinical biomarker for prostate cancer: what's the take home message?

Prostate specific antigen (PSA) continues to be challenged as a legitimate clinical biomarker in early detection of prostate cancer due to lack of specificity for malignant transformation. Skepticism surrounding the utility of serum PSA as a clinical marker is not new and many questioned its initial use in widespread prostate cancer screening due to non-specific expression and low predictive value for cancer detection. Despite these initial concerns, serum PSA measurement along with digital rectal examination (DRE) is currently the accepted practice for prostate cancer screening in the United States with hundreds of thousands of men undergoing serum PSA measurement annually. In contrast to its role for early detection, serum PSA measurement as a surrogate for prostate cancer recurrence (biochemical failure) following curative intent therapy has consummate clinical utility in post-treatment surveillance. As thousands of men each year are aggressively treated for potentially curable prostate cancer, development of simple and effective diagnostic tools for detecting treatment failures should be an important area of biomedical and clinical investigation. We have constructed and tested a home-based prostate cancer surveillance device for use by patients to detect PSA from blood obtained by finger stick. Our initial results suggest that home based PSA testing is feasible and may have clinical utility in management of men treated for prostate cancer.     

Population-based screening for prostate cancer by measuring free and total serum prostate-specific antigen in Iran.

PURPOSE: To evaluate the natural background of prostate cancer in Iran a large population-based study of screening using total prostate-specific antigen (tPSA) and per cent free PSA (fPSA) as the initial test was performed. MATERIALS AND METHODS: For 9 years (1996 to 2004) in Tehran, Iran, 3670 Iranian men older than 40 years were mass checked by PSA-based screening. They were invited to have a digital rectal examination (DRE), serum PSA assay and transrectal ultrasonography (TRUS)-guided sextant prostate biopsy to see if the DRE was clinically suspicious of malignancy, the serum PSA was > or =2.1 ng/ml or free-to-total PSA (f/tPSA) ratio < or=15%. RESULTS: In 433 (11.8%) of screened males, tPSA levels exceeded the cut-off value of > or =2.1 ng/ml and 128 prostate cancers were diagnosed [positive predictive value (PPV) 29.6%] corresponding to an overall detection rate of 3.5%. Altogether 138 cancers were detected (detection rate 3.8%); none were stage M(1), three were stage N(+) and 4 stage T(3). A threshold tPSA of > or =2.1 ng/ml would have detected 128 cancers in 447 biopsied men (PPV 29%). There were 109 of 138 (79%) men with cancer who had an f/tPSA of < or =15%, while 152 of 305 (49.8%) with benign biopsies had a f/tPSA of < or =15%, which corresponds to a PPV of 30.8%. CONCLUSION: PSA-based screening with low PSA cut-off values increase the detection rate of clinically significant, organ confined and potentially curable prostate cancer. Further studies are warranted in order to determine the incidence and prevalence of prostate cancer in different ethnic groups.