PSA Levels In Younger Indian Men Lower, But Higher In 60-70 Age Group

Apollo Hospitals unveiled groundbreaking findings in a study 'Determining Age-Specific Prostate-Specific Antigen for Healthy Indian Men.' Led by Dr. N Ragavan and Dr. Sanjai Addla, the research involving nearly 100,000 men establishes new, tailored reference values for prostate-specific antigen (PSA), challenging Western standards. This significant development aims to redefine Prostate Cancer Screening Standards for Indian Men, ensuring more accurate diagnostics and treatment monitoring.

 In an exclusive interaction with BW Healthcare world ,Prof Sanjai Addla, Consultant Uro-oncologist, Apollo Hospitals, Jubilee Hills, Hyderabad  discusses groundbreaking findings from a recent study on PSA reference ranges for Indian men compared to Caucasians

Your study suggests lower PSA reference ranges for Indian men compared to Caucasians. How might this impact prostate cancer screening strategies in India?

Our study, involving over 100,000 healthy men, redefines PSA reference values for Indian men, considering the inadequacy of standards set in 1993. The 95th percentile was crucial, establishing normal PSA levels. Younger men (40-50 age group) exhibited lower values than previous references, while the 60-70 age group had higher levels. The robust data emphasizes the need for updated PSA reference values, urging individuals to adhere to the new benchmarks for more accurate health assessments

Given the observed lower prostate volume in Indian men, are existing biopsy techniques optimized for Indian patients? Can you discuss potential adaptations or alternatives?

The approach to prostate biopsies has evolved significantly and it has been very dynamic. Over the past 5 to 8 years, there have been notable advancements in both diagnosing and management of prostate cancer. The most recent advancement in our approach involves a recommendation for a procedure called Transperineal biopsy wherein we do the biopsy from the Perineum (area between the scrotum and back passage) which is much cleaner compared to the traditional transrectal biopsy where we conduct biopsies through the back passage, to examine the prostate. Now, we have technology to integrate an MRI into an ultrasound scan, so that any focus of cancer within the prostate can be directed and diagnosed accurately.

Furthermore, the advancements in medical research have substantially improved the prognosis and treatment outcomes for patients with stage 4 prostate cancer. The doubling of survival rates, extending the average life expectancy from 3-3.5 years to 7-7.5 years, showcases the remarkable progress made in preventing the inevitable progression of the disease.

The study highlights lower PSA reference ranges for Indian men. How would this influence the application of existing prostate cancer risk calculators in India? Would you advocate for developing India-specific risk models, and if so, what data points would be crucial for their development?

Can you elaborate on the potential role of genetic factors in shaping PSA levels and CaP risk in Indian men? Are there any ongoing studies in this area?

Genetics do play a role, especially in aggressive cancer, however it's a small component (around seven per cent). Lifestyle issues and environment are the biggest contributors of developing prostate cancer. The biggest contributory factor is the patients or the men being aware of the symptoms of prostate cancer. By the time any person has symptoms of prostate cancer, we have already missed the bus because cancer has spread to the bones, that's when we are picking it up. The best way to do it is by doing regular screening. There are ongoing studies with Apollo Hospitals to understand the genetics of Prostate cancer in India.

Given the rising CaP burden in India, what initiatives should be prioritized to enhance awareness, early diagnosis, and access to treatment for this disease?

The only way for us to make sure we pick up more cancers in the earlier stages is by regular health screening. If the cancer is picked up earlier, we can cure almost 90 per cent of these people. There is no way of preventing cancer. However, what we know is anybody who's obese or consumes high -calorie diet, processed meat or red meat is at much higher risk of cancer compared to a vegetarian diet. So, I would advise people to be aware of their body and consider getting health screening done on a regular basis.

Some studies suggest higher CaP incidence in urban India compared to rural areas. Does your study consider this disparity, and how can future research ensure broader representation?

People considered for our study were majorly from the urban population who had visited Apollo Hospitals for a master health check-up. However, considering we had included almost 1 lakh men in the study; we are confident that we have captured a significant number of healthy men from both, rural and Urban India to ensure that the reference values represent Indians at large.

Beyond ethnicity, what environmental or lifestyle factors might contribute to the observed differences in PSA levels and CaP prevalence between Indian and Western populations?

The low values of PSA would be related more to environmental and lifestyle factors rather than just the ethnicity. For example, if an Indian goes and lives in a western society, he would have lower incidence of prostate cancer compared to the western population. However, his children would have the same cancer incidence as the local population, because of the role that lifestyle plays in this. This is because the western lifestyle includes high calorie diet intake, highly processed food, refined sugar with not much physical activity and therefore, increasing obesity.

Considering the Indian context, what are your views on the benefits and limitations of PSA testing for CaP detection?

The objective of this study was to define the reference values for Indian population. We have defined the normal values suggesting investigations based on our own values; knowing very well that even with patients with elevated PSA, the chances of having no cancer are almost up to 70%. It is a start and only when we start investigating based on the current reference values, we will know whether we have altered the natural history of prostate cancer in India by picking up cancers in earlier stage.

Recent years have seen advancements in liquid biopsies for cancer detection. Do you see potential for applying these technologies to improve CaP diagnosis in India, especially with its unique risk profile?

Liquid biopsy does have potential for diagnosis of prostate cancer. However, it has not been established in prostate cancer specifically and definitely there are no significant publications on this aspect yet from India.

Given the potential disparity in CaP incidence between urban and rural India, do you think a one-size-fits-all screening approach is viable? Can you propose alternative or complementary screening strategies that could be more effective in underserved regions?

The objective of this study was not to define screening patterns for India with respect to Prostate Cancer. The study was done simply to highlight that when it comes to Prostate Cancer, Indian men are different to their Caucasian counterparts. As we see increasing incidence of lifestyle related cancers including prostate cancer in men and breast cancer in women, we have two device screening approach that would fit the Indian Society and then define different screening for urban and rural population.

Finally, what are your hopes for the future of prostate cancer research in India? What breakthroughs or improvements do you foresee on the horizon?

There has been a tremendous understanding as well as developments with respect to Prostate Cancer detection, diagnosis and management in India. Currently, almost all management strategies are based on evidence from Western societies and we do need to study these specifically in Indian population. Having said that, due to the access and adaptation of technology which is much earlier and easier in India, there would be a rapid stride based on Indian studies both in usage of machine learning and AI in the investigational and diagnostic pathway.