Prostate CancerScreening

Risk Management

• 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?

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%

Pathophysiology

• 95% Adenocarcinomas• 4% TCC

• 70% peripheral• 15% central zone• 15% Transitional zone

• T1-4• Gleason score

Risk FactorsAge

• FH– 1st degree rel. 2x risk– Above rel <60 4x risk

• Diet– Lycopenes + selenium

decrease risk– Calcium increases risk

• Obesity

Ethnicity

• Black African/ Caribbean highest risk

• White• Asian Lowest

risk

Prostate Specific Antigen

• Glycoprotein• Released from normal and

malignant cells• Size• Age

Elevated by:

• Ejaculation ~ for 48hrs• Exercise ~ for 48hrs• PR exam ~ for 1wk• Prostate Biopsy ~ for 6wks• UTI ~ for months• BPH• Prostate Cancer

Prostate Specific Antigen

Benefits• Nice and easy• Early detection• Repeat testing valuable

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

Raaijmakers et al 2004

Investigations• Trans Rectal USS• TRUS guided biopsy

• CT• MRI

Treatment Options• Watchful waiting• Active Monitoring• Radical Prostatectomy• Radiotherapy (ext beam /

brachytherapy)• High intensity focused USS• Cryotherapy• Hormonal therapy

Why do we not have a screening programme?

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

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

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

http://theinspirationroom.com/daily/print/2009/7/prostate_slip.jpg

Why do we not have a screening programme?

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.

PSA Informed Choice Programme

Future

• PSA factors– Velocity– Density– Proportions

• Prostate Cancer 3 PCA3

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

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