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Prostate cancer: summary of updated NICE guidance

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.f7524 (Published 08 January 2014) Cite this as: BMJ 2014;348:f7524

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Re: Prostate cancer: summary of updated NICE guidance

National Institute for Heath and Care Excellence (NICE) updated Guidelines (CG175) on prostate cancer in January 2014 1. The guideline does not address the issue of men who present with a raised Prostate Specific Antigen (PSA) in primary care who are symptom free and are not referred for further investigation.

The guidelines cater for PSA follow-up and kinetics with shared care protocols during active surveillance. Guideline 1.3.46 advises that serial PSA levels should be measured using the same assay technique. To quantify biochemical relapse, guideline 1.3.51 recommends that PSA doubling time should be estimated based on a minimum of 3 measurements over at least six months 2.

PSA exists in multiple isoforms and is measured by immunoassay on many platforms. Calibration standards differ with Hybritech calibrated assays giving values about 20% higher than the WHO IRP 96/670 standard for the same sample. Combining biological variation with an analytical variation of 5%, a difference greater than 20.5% is needed to be sure of real change in the PSA value and the 95th percentile critical difference is 45.8%. A single laboratory should be used for all PSA estimations on an individual patient to reduce false positives in disease monitoring. This should be included explicitly in NICE guidelines on prostate cancer treatment 2.

References
1. http://www.nice.org.uk/Guidance/CG175 (accessed 14th September 2014)
2. Graham J, Kirkbride P, Cann K, Hasler E, Prettyjohns M. Prostate cancer: summary of updated NICE guidance. BMJ. 2014 Jan 8;348:f7524. doi: 10.1136/bmj.f7524.
3. Tormey WP. The complexity of PSA interpretation in clinical practice. Surgeon. 2014 Jul 2. pii: S1479-666X(14)00051-1. doi: 10.1016/j.surge.2014.04.003.

William P. Tormey
Department of Chemical Pathology
Beaumont Hospital,
Dublin 9
Ireland
billtormey@gmail.com

There are no competing interests.

Competing interests: No competing interests

15 September 2014
William Tormey
Consultant Chemical Pathologist
Beaumont Hospital
Dublin 9, Ireland

Re: Prostate cancer: summary of updated NICE guidance

Combination of TRUS biopsies and mulitparametric MRI are two powerful investigations for diagnosing prostate cancers. But performing MRI as first investigation might in some cases prevent the need for traditional biopsies especially in those men with borderline biopsy indication who could have reassured without having invasive procedure.

Although, the use of pre biopsy MRI can serve as triage tool in those who might have significant cancer requires active treatment referred through two weeks wait. In addition, requesting the scan post biopsy commonly need six weeks before the artifacts disappeared. And this eventually can lead to breaches of the 62 days cancer treatment target time.

Competing interests: No competing interests

17 January 2014
Mohammed E EL Hadi
Urology SHO
Maya Harris
Warwick Hospital
Lakin Road .Warwick.CV34 5BW
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