Official publication of Rawalpindi Medical University
Diagnostic Accuracy of Serum Prostate Specific Antigen and Gleason Score in Determining the Presence of Skeletal Metastasis in Prostate Cancer Patients: a Pakistani Perspective

Supplementary Files



Bone metastasis, bone scan, Gleason score, prostate cancer, prostate specific antigen

How to Cite

Nasir T, Aamer SN, Waqar S, Omer W. Diagnostic Accuracy of Serum Prostate Specific Antigen and Gleason Score in Determining the Presence of Skeletal Metastasis in Prostate Cancer Patients: a Pakistani Perspective. JRMC [Internet]. 2023 Apr. 1 [cited 2023 Jun. 5];27(1). Available from:



To determine the cut-off values for serum Prostate Specific Antigen and Gleason score for predicting bone metastasis of Prostate cancer.


This diagnostic accuracy study was conducted in Pakistan Institute of Medical Sciences (PIMS), Islamabad from 2015 to 2018. 330 patients of Prostate cancer were enrolled in the study. Prostate Specific Antigen (PSA) and Gleason Scores (GS) were determined using commercially available ELECSYS® assays in the Modular Analytics E170 (Roche Diagnostics) and histopathology respectively. Tc99m methylene diphosphonate (MDP) was used to perform the Bone scan. Any correlation between these variables was nvestigated to determine a cut-off value for PSA and GS.


Out of the total 330 patients included in the sample, BS was positive for metastasis in 186 (56.4%) patients and negative in 144 (43.6%) patients. Amongst these 186 positive patients, 5 (2.7%) had PSA < 20 ng/ml, 174 (93.5%) had PSA between 20 and 90 ng/ml, and 9 (4.8%) had PSA > 90 ng/ml. Out of the 144 patients with negative BS, 142 (98.6%) had PSA < 20ng/ml. Only 2 (1.4%) had PSA in the range of 20 and 90 ng/ml, while none had PSA > 90 ng/ml. In the 147 patients with PSA < 20 ng/ml, 142 (96.6%) did not have any skeletal metastases. Of the 183 patients with PSA > 20 ng/ml, 181 (98.9%) had positive bone scans. Using a cut-off value of 20 ng/ml for serum PSA, 142 unnecessary scans would have been unnecessary.

Out of the 186 patients with positive bone scan (BS), 3 (1.6%) patients had GS < 7, 160 (86.0%) patients had GS between 7 and 9, and 23 (12.4%) patients had GS > 9. Out of the 144 patients with negative BS, 84 (58.3%) had GS < 7, 60 (41.7%) had GS between 7 and 9, and none of the patients had a GS more than 9. Of the 87 patients with GS < 7, 3 (3.4%) patients had a positive BS while 84 (96.6%) patients had a negative BS. Of the 243 patients with GS > 7, 183 (75.3%) had a positive BS while 60 (24.7%) patients had a negative GS. These results indicate that a GS > 7 cannot be reliably used to rule in the need for a BS in patients with Prostate cancer.






Our study reports that serum PSA < 20 ng/ml can be safely used to omit a bone scan. It also suggests that Gleason Score < 7 nullifies the need to conduct a bone scan. However, serum PSA is a better and more reliable indicator of bone metastases as it has better sensitivity and specificity values as compared to GS. If these results are applied in hospitals all over the country, we can significantly reduce the burden on our resources and prevent unnecessary, low-yield diagnostic tests from being carried out.


Francis JC, Swain A. Prostate Organogenesis. Cold Spring HarbPerspect Med [Internet]. 2018;8(7):a030353. DOI: 10.1101/cshperspect.a030353

Prostate cancer statistics [Internet]. WCRF International. 2022 [cited 2022 May 15].

Ahmad Z, Qureshi A, Idrees R, Aftab K. Prostatic carcinoma: a Pakistani perspective. Asian Pac J Cancer Prev. 2009;10(2):323–4.

Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424. DOI: 10.3322/caac.21492

Rawla P. Epidemiology of prostate cancer. World J Oncol [Internet]. 2019;10(2):63–89. DOI: 10.14740/wjon1191

Keller ET, Zhang J, Cooper CR, Smith PC, McCauley LK, Pienta KJ, et al. Prostate carcinoma skeletal metastases: cross-talk between tumor and bone. Cancer Metastasis Rev. 2001;20(3–4):333–49. DOI:

Carlin BI, Andriole GL. The natural history, skeletal complications, and management of bone metastases in patients with prostate carcinoma. Cancer [Internet]. 2000;88(12 Suppl):2989–94. DOI: 10.1002/1097-0142(20000615)88:12+<2989::aid-cncr14>;2-h

Lin Y, Mao Q, Chen B, Wang L, Liu B, Zheng X et al. When to perform bone scintigraphy in patients with newly diagnosed prostate cancer? a retrospective study. BMC Urology [Internet]. 2017;17(1). DOI: 10.1186/s12894-017-0229-z

Mittal B, Harisankar C, Bhattacharya A, Singh S, Mandal A, Kamaleshwaran K. Predictive value of serum prostate specific antigen in detecting bone metastasis in prostate cancer patients using bone scintigraphy. Indian Journal of Nuclear Medicine [Internet]. 2012;27(2):81. DOI: 10.4103/0972-3919.110683

Zaman MU, Fatima N, Sajjad Z. Metastasis on bone scan with low prostate specific antigen (≤ 20 ng/mL) and Gleason’s score (< 8) in newly diagnosed Pakistani males with prostate cancer: should we follow Western guidelines. Asian Pac J Cancer Prev. 2011;12(6):1529–1532.

McArthur C, McLaughlin G, Meddings R. Changing the referral criteria for bone scan in newly diagnosed prostate cancer patients. The British Journal of Radiology [Internet]. 2012;85(1012):390-394. DOI: 10.1259/bjr/79184355

Sanjaya I, Mochtar C, Umbas R. Correlation between Low Gleason Score and Prostate Specific Antigen Levels with Incidence of Bone Metastases in Prostate Cancer Patients: When to Omit Bone Scans?. Asian Pacific Journal of Cancer Prevention [Internet]. 2013;14(9):4973-4976. DOI: 10.7314/apjcp.2013.14.9.4973

Manohar PR, Rather TA, Khan SH. Determination of the optimal cut-off value of serum prostate-specific antigen in the prediction of skeletal metastases on technetium-99m whole-body bone scan by receiver operating characteristic curve analysis. World J Nucl Med [Internet]. 2020;19(3):255–9. DOI: 10.4103/wjnm.WJNM_77_19

Wei L-H, Chiu J-S, Chang S-Y, Wang Y-F. Predicting bone metastasis in prostate cancer patients: Value of prostate specific antigen. Tzu Chi Med J [Internet]. 2008;20(4):291–5.

Creative Commons License

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

Copyright (c) 2023 Wafa Omer