Clinical implications of a positive prostate cancer screen in patients undergoing cardiac transplant evaluation
Background: Screening the general population for prostate cancer with prostate specific
antigen (PSA) testing continues to be controversial. Patients with advanced heart
failure undergoing evaluation for cardiac transplantation are often requested to undergo
prostate cancer screening, with guiding evidence generated from the general population.
The clinical implications of a positive ... read moreprostate cancer screening result in this patient
population has not been determined. Methods: A retrospective cohort study was performed
on all men that were referred to a cardiac transplant center between January, 2000 and
December, 2015. Patients were classified as having either a 'positive screen' (PSA
≥ 4ng/ml) or a 'negative screen' (PSA < 4ng/ml) at the point of initial
evaluation. The primary outcome of time to listing for cardiac transplant (days) was
calculated from the date of referral to the date of listing. A multivariable Cox
proportional hazards model was developed to assess the association between a positive
prostate cancer screening result and listing for cardiac transplantation. For patients
with a positive PSA screen individual chart review was performed to ascertain the
subsequent diagnostic evaluation and identify patients with a diagnosis of prostate
cancer. Results: Among the 704 patients included in our analysis, 66 men (9.4%) had a
positive prostate cancer screening result. Men with a positive prostate cancer screen
were approximately 4 years older (58.5 ± 8.7 years vs 54.1 ± 11.2 years), more
likely to have a diagnosis of ischemic cardiomyopathy (74% vs 53%) and to be on
mechanical support at the point of transplant evaluation (61% vs 16%). After adjusting
for age, renal function, clinical status at evaluation, history of COPD and the year of
evaluation, patients with a positive prostate cancer screen had a 42% reduced likelihood
for progressing to cardiac transplant listing compared to those with a negative screen
(HR 0.58, 95%CI 0.38-0.91). 4 patients with a positive prostate cancer screen had a
confirmed diagnosis of prostate cancer during the evaluation process, representing a
positive predictive value of PSA screening of 6.1% and cancer detection rate of 0.6%.
Conclusion: Serum PSA performs poorly as a screening modality for prostate cancer in men
undergoing a cardiac transplant evaluation, especially in those who are acutely unwell
at the point of evaluation. Patients with a positive screen have more adverse clinical
characteristics in addition to a reduced likelihood for progressing to listing for
cardiac transplant. Given the unique nature of the decision to perform prostate cancer
screening in this population, an individualized approach in particular with regards to
timing of PSA screening should be encouraged.
Thesis (M.S.)--Tufts University, 2018.
Submitted to the Dept. of Clinical & Translational Science.
Advisor: David Kent.
Committee: David DeNofrio, and Jason Nelson.
Keyword: Epidemiology.read less