A Framework for the Identification of Men at Increased Risk for Prostate Cancer

Purpose: We assessed the risk of prostate cancer over time, and the implications for screening strategies and potential risk reduction approaches to provide a framework for clinical use of this approach concordant with the use of prostate specific antigen as a marker of current prostate cancer risk. Materials and Methods: A comprehensive review of the relevant literature was performed. In this article the phrase risk of/for prostate cancer refers to the risk of developing prostate cancer. Results: Prostate specific antigen is the single most significant predictive factor for identifying men at increased risk for prostate cancer. A suspicious digital rectal examination, a family history of prostate cancer, the presence of high grade prostatic intraepithelial neoplasia or atypical small acinar proliferation and black ethnicity are also important predictive factors, while larger prostate volume and a previous negative biopsy are negative predictors. For men of screening age (50 to 70 years) a prostate specific antigen of greater than 1.5 ng/ml is a marker for greater than average risk up to 8 years (7.5-times greater risk vs 1.5 ng/ml or less). This prostate specific antigen threshold for a man at above average risk can be modified by the presence of other predictive factors. It should be lower for men with a prostate volume less than 40 cc, black ethnicity or a family history of prostate cancer. For younger men with longer followup a lower prostate specific antigen may be considered. Conclusions: The risk of prostate cancer can be estimated in individual men primarily using prostate specific antigen, but also using prostate volume, previous biopsy status, family history and ethnicity. Men at increased risk warrant enhanced surveillance and in the future may also be candidates for active risk reduction strategies.