Rapid advancement in treatment and surgical techniques for solid organ transplant means many transplant recipients—about half of whom are over age 50—now live well past middle age. As a result, men who receive kidney, liver, and heart transplants are facing issues related to aging, including screening and treatment for prostate cancer. The potential impact of immunosuppression on tumor biology should always be considered in men who are candidates for or who have had a solid organ transplant.

In the past, there has been controversy over whether immunotherapy associated with transplant increases men’s risk for prostate cancer, as it does with other solid malignancies. However, there is no compelling evidence that immunosuppression affects development of prostate cancer, according to a review published in Reviews in Urology led by Herbert Lepor, MD, the Martin Spatz Chair of the Department of Urology and chief of urology at NYU Langone. Dr. Lepor is also director of Smilow Comprehensive Prostate Cancer Center, part of Perlmutter Cancer Center at NYU Langone.

“The effectiveness of immunotherapy appears to be related to the mutational load of the disease, and prostate cancer has a low level of mutation,” says Dr. Lepor. “It appears that prostate-specific antigen screening is as reliable in transplant candidates as in the general population and that most patients can be safely screened and managed under the usual standards of care.”

Prostate Cancer Screening and Detection

Current guidelines from the American Society of Transplantation recommend prostate cancer screening all male transplant candidates or recipients age 50 or older with a life expectancy of at least 10 years—the same as for the general population. The recommendation is based on studies showing that while transplant is associated with higher rates of certain malignancies—particularly bladder and kidney cancer and melanoma—it does not appear to affect development of prostate cancer.

At NYU Langone, PSA screening is mandatory for transplant candidates according to current guidelines. However, research indicates that screening is inconsistent nationwide, according to the review. One study found that PSA screening recommendations were followed for only 64 percent of patients at a high-volume transplant center, and another survey of major U.S. transplant centers found that only 79 percent had established guidelines for PSA screening.

“The effectiveness of immunotherapy appears to be related to the mutational load of the disease, and prostate cancer has a low level of mutation,” says Dr. Lepor. “It appears that prostate-specific antigen screening is as reliable in transplant candidates as in the general population and that most patients can be safely screened and managed under the usual standards of care.”

“Prostate cancer screening saves lives, especially in men who have clinically significant cancers,” notes Dr. Lepor. “NYU Langone has pioneered the use of biomarkers, MRI, and MRI-guided biopsy to improve the sensitivity and specificity of PSA screening for the detection of significant disease. It’s best to identify prostate cancers before kidney transplant in particular, as kidney transplant can increase the technical challenges of a radical prostatectomy.”

PSA level appears to be a reliable indicator of risk, even for men with end-stage kidney disease (ESKD) and liver failure, researchers found. However, certain factors should be taken into account for transplant patients.

Clinicians treating men with ESKD should consider measuring PSA before hemodialysis, which can result in elevated values, the authors suggest. They also note that PSA testing may not be reliable in men with severe liver failure as the liver metabolizes PSA and values are often lower in patients with cirrhosis compared with the general population. As a precaution, they recommend testing before and after liver transplant.

For men with concerning PSA levels, along with other risk factors such as family history, NYU Langone urologists routinely order multiparametric MRI (mpMRI), which has been shown to detect aggressive disease more reliably than systemic biopsy.

In the presence of elevated biomarkers, patients with a PI-RADS (Prostate Imaging Reporting and Data System) score of 2 or higher should receive mpMRI fusion target biopsy with a bilateral systemic biopsy, the authors state. Transperineal saturation biopsy is recommended for those with a PI-RADS score of 1 and a PSA velocity and biomarkers highly suspicious for aggressive cancer.

Prostate Cancer Treatment Considerations

In general, clinicians can safely manage transplant patients with diagnosed prostate cancer similarly to the general population, using shared decision-making to guide treatment decisions and taking into account life expectancy, comorbidities, complications, and impact on quality of life.

However, controversy persists around the timing of transplants following prostate cancer treatment, notes Robert Montgomery, MD, DPhil, director of the NYU Langone Transplant Institute, and H. Leon Pachter, MD, Professor of Surgery and newly appointed chair of the Department of Surgery. Current kidney transplant guidelines suggest waiting two years, but that timing has been challenged by Kidney Disease Improving Global Outcomes guidelines, which recommend proceeding immediately after successful treatment.

“Most recommendations for delaying transplant are based on small studies and do not show an association between having prostate cancer and increased mortality,” says Dr. Montgomery. “However, prolonging wait times for transplant could adversely impact survival.”

At NYU Langone, urologists recommend immediate transplant following definitive treatment for low- to intermediate-risk prostate cancer and waiting one year in the case of higher-risk disease if PSA is undetectable.

If prostate cancer is diagnosed after transplant, evidence supports performing open or laparoscope radical prostatectomy. Large studies involving patients diagnosed following kidney transplants indicate that PSA scores, severity of disease, and postsurgical complications are on par with those in the general population, the review found, although special care must be taken to avoid damage to transplanted organs from surgery and radiation.

“Overall, we found that while precautions should always be taken in this vulnerable population, most transplant patients can be successfully managed under general guidelines,” says Dr. Lepor. “Screening, detection, or treatment should not be influenced by the impact of immunosuppression on the biology of the disease.”