Prostate Cancer Screening Risk Management

1. Prostate CancerScreening Risk Management

3. Prostate cancer • European Study – Screening and Prostate-Cancer Mortality a Randomised Trial • Why do we not have a screening programme? • How do we manage PSA concerns?

4. Prostate Cancer • Most common cancer in males • 2nd most common case of cancer deaths in males • 5 yr survival • 1971-1975  31% • 2000-2001  71%

5. Pathophysiology • 95% Adenocarcinomas • 4% TCC • 70% peripheral • 15% central zone • 15% Transitional zone • T1-4 • Gleason score

6. Risk Factors Age

7. FH • 1st degree rel.  2x risk • Above rel <60  4x risk • Diet • Lycopenes + selenium decrease risk • Calcium increases risk • Obesity

8. Ethnicity • Black African/ Caribbean  highest risk • White • Asian  Lowest risk

9. Prostate Specific Antigen Elevated by: Ejaculation ~ for 48hrs Exercise ~ for 48hrs PR exam ~ for 1wk Prostate Biopsy ~ for 6wks UTI ~ for months BPH Prostate Cancer • Glycoprotein • Released from normal and malignant cells • Size • Age

10. Prostate Specific Antigen Benefits Limitations Not specific No ca in 2/3 of elevated PSA Anxiety provoking Detection of clinically insignificant cancers May be falsely reassuring Approx 1/6 normal PSA may have prostate cancer Not helpful in identifying aggressive tumours • Nice and easy • Early detection • Repeat testing valuable Raaijmakers et al 2004

11. Investigations Treatment Options Watchful waiting Active Monitoring Radical Prostatectomy Radiotherapy (ext beam / brachytherapy) High intensity focused USS Cryotherapy Hormonal therapy • Trans Rectal USS • TRUS guided biopsy • CT • MRI

12. Why do we not have a screening programme?

13. Screening and Prostate-cancer Mortality in a Randomised European Study – NEJM Mar 2009 • Multicentre Trial – Italy, Finland, Sweden, Netherlands, Belgium, Switzerland, Spain • 1990 - 2006 • 182,000 men 50-74 yrs • 4 yearly PSA vs control • Outcome = Mortality rate

14. Results • Median follow up 9 years • 82% acceptance of screening • Cumulative incidence of prostate ca • Screening group 8.2% • Control group 4.8% • Mortality • Screening group ~ 3/1000 • Control group ~ 3.7/1000 • Rate ratio 0.8

15. Conclusions • 20% reduction in deaths • To prevent 1 death: • Screen 1410 • Treat 48 additional px • Rate of over diagnosis as high as 50% NEJM Volume 360:1320-1328 J Natl Cancer Inst 2003;95:868-878

18. Why do we not have a screening programme?

19. Screening programme principles • The condition should be an important health problem. • The natural history of the disease should be adequately understood. • There should be a latent stage of the disease. • There should be a test or examination for the condition. • The test should be acceptable to the population. • There should be a treatment for the condition. • There should be an agreed policy on who to treat. • Facilities for diagnosis and treatment should be available. • The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole. • Case-finding should be a continuous process, not just a "once and for all" project.

21. PSA Informed Choice Programme

26. Future • PSA factors • Velocity • Density • Proportions • Prostate Cancer 3 PCA3

27. Further Info • http://www.cancerscreening.nhs.uk/index.html • http://info.cancerresearchuk.org/cancerstats/types/prostate/?a=5441 • http://content.nejm.org/cgi/content/full/NEJMoa0810084#R30

28. Question time