2067 PROSTATE-SPECIFIC ANTIGEN SCREENING IN PATIENTS WITH END-STAGE RENAL DISEASE: CURRENT PRACTICES AND RECOMMENDATIONS

INTRODUCTION AND OBJECTIVES: Patients with end stage renal disease (ESRD) who are being evaluated for renal transplant (RT) need to have non-cutaneous malignancies excluded in order to be eligible for RT. There is no uniformly agreed upon PSA cut point to prompt prostate biopsy (PB) in this patient population. Though one could argue that small volume prostate cancer (PC) should be ignored in these patients, the current standard of care is to treat these patients with the intent to cure and perform subsequent RT after a suitable disease free interval. The purpose of this study is to evaluate PSA cut points and PC detection in patients with ESRD and pending RT. METHODS: A retrospective review was conducted of 820 patients at a single institution who are or have been on the RT waiting list and have also undergone a serum PSA test as screening for RT. After stratification by age at the time of screening, serum PSA levels from patients without evidence of PC were evaluated to determine a 95th percentile reference range for each age decade. Charts of patients who underwent a PB for PC based on their pre-transplant evaluation and their PSA levels (n=82) were reviewed to determine if the current screening indication is appropriate for patients with ESRD. RESULTS: The serum PSA 95th percentile reference ranges for patients with ERSD is 0.0 to 2.1 ng/mL at 40-49 years, 0.0 to 3.5 ng/mL at 50-59 years, and 0.0 to 4.7 ng/mL at 60-69 years. Mean age of all patients evaluated was 55 (20-77), of patients biopsied was 61 (39-77), and of patients diagnosed with PC was 64 (49-77). In patients with PSA between 2.5 and 4, the PC detection rate was 15.4%, with an additional 19.2% of patients having pre-malignant changes (atypical small acinar proliferation ASAP and high-grade prostatic intraepithelial neoplasia HGPIN). Overall, prostate biopsy for PSA greater than 2.5 showed PC in 29.3% of patients, pre-malignant lesions in 11.0%, and benign prostatic tissue in 59.8%. CONCLUSIONS: Patients with ESRD who are undergoing evaluation for RT have PSA reference ranges similar to those established for the non African-American US population. However, clinical use of a PSA cutoff of 2.5 ng/mL results in a significant detection rate of PC and pre-malignant lesions (40.3%) which affect RT candidacy. Given that current best practice mandates cancer free status prior to RT, lower PSA cutoff values should be considered to improve the sensitivity of PC detection in this patient population. We propose that a PSA of 2.5 ng/mL, the lowest standard cutoff typically utilized, be adopted as a pre-RT threshold for PB.