Prostate Cancer Screening: What Do You Think, Doc?

Katie S Murray, DO, MS, FACS

Assistant Professor

Department of Surgery-Division of Urology

I have no disclosures to report.

Pre-Presentation Question #1

What is the lifetime risk of prostate cancer in an American male?

a. 0-10%

b. 10-20%

c. 20-30%

d. 30-40%

e. >40%

Pre-Presentation Question #2

What is the definition of benefit when describing prostate cancer treatment and care?

a. Cancer specific survival

b. Overall survival

c. Erectile function

d. Urinary function

e. Control of symptoms

f. All of the Above

Pre-Presentation Question #3

What is the risk of death from prostate cancer in long-term follow up of patients diagnosed with low risk disease?

a. >30%

b. 20-30%

c. 10-20%

d. 2-10%

e. <2%

Qeustion 4

• T/F

• AA race is a risk factor for CaP

• TRUE

Question 5

• Guidelines recommend Prostate cancer screening be a shared decision between patients and physicians.

• TRUE

Objectives

• Descrbie and understand changes in cap epidemiology

• Define controversies in prostate cancer screening

• Understand advances in prostate cancer screening including other testing and imaging

Objective #1: Prostate Cancer Epidemiology

[Jemal, 2012]

PSA

Era

Trends in Cancer Incidence and Death Rates Among Males

Prostate Cancer • Most common cancer in American Men

• 241,740 new cases in 2012 (up from 186,320 in 2008)• 29% of all new male cancer cases• 1 in 6 lifetime probability of being diagnosed (16.5%)

• Second most common cause of Male Cancer Death• 28,170 overall deaths • 9% of all male cancer deaths• 5-year survival is >90% (68% in 1977; 83% in 1989)• Mortality declined 3% per year in Caucasians and 3.5% per year for African

American men between 2004 and 2008• PSA Testing and Improved Treatments

Cancer Facts and Figures, 2012.

Why is PSA Screening Controversial?Pros Cons

PSA screening may help you detect prostate cancer early. Some prostate cancers are slow growing and never spread beyond the prostate gland.

Cancer is easier to treat and is more likely to be cured if it's diagnosed in the early stages of the disease.

Not all prostate cancers need treatment. Treatment for prostate cancer may have risks and side effects, including urinary incontinence, erectile dysfunction or bowel dysfunction.

PSA testing can be done with a simple, widely available blood test.

PSA tests aren't foolproof. It's possible for your PSA levels to be elevated when cancer isn't present, and to not be elevated when cancer is present.

For some men, knowing is better than not knowing. Having the test can provide you with a certain amount of reassurance —either that you probably don't have prostate cancer or that you do have it and can now have it treated.

A diagnosis of prostate cancer can provoke anxiety and confusion. Concern that the cancer may not be life-threatening can make decision-making complicated.

The number of deaths from prostate cancer has gone down since PSA testing became available.

PSA testing has lowered deaths, but the number may not be substantial enough to justify the cost and possibility of harm to the person undergoing the testing.

PSA Screening2009: 2 large screening studies were published

• European study: PSA test reduced prostate cancer deaths• American study: PSA test did not reduce prostate cancer deaths

2012: US Preventative Task Force recommended against routine PSA screening for all men

2017: Publication of combined analysis of European + American study (238,000 men) with more results

• PSA test reduced prostate cancer deaths

2018: Publication of British study (400,000 men) • Getting a single PSA test did not reduce prostate cancer deaths

PSA Screening

2018: US Preventative Task Force recommends PSA screening• “For men aged 55 to 69 years, the decision to undergo periodic PSA-based

screening for prostate cancer should be an individual one and should include discussion of the potential benefits and harms of screening with their clinician.”

“Shared Decision Making”

American Urological Association (AUA) Guidelines

• Against PSA screening in men under age 40 years

• Does not recommend routine screening in men between age 40 to 54 years at average risk

• Age 55 to 69 years: Recommends shared decision-making based on man’s values and preferences

• Routine screening interval of 2 years may be preferred over annual

• Does not recommend routine PSA screening in men >70 years or with <10-15 year life expectancy

Opinions on Shared Decision Making

European Randomized Study of Screening for Prostate Cancer (ERSPC)

Schröder et al. NEJM 2012; 366:981-90

European Randomized Study of Screening for Prostate Cancer

Schröder et al. NEJM 2012; 366:981-90

[Schroder, 2014]

Cu

mu

lati

ve h

azard

of

pro

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te

can

cer

mo

rtali

ty

Years following randomization (PSA screening)

• Significant reduction in prostate cancer

specific mortality with screening

• 27 men required to be detected and treated

to prevent 1 death

European Randomized Study of Screening for Prostate Cancer

13 Year Follow-Up

Screening and Treatment

• Screening increases detection of low-risk cancers

• Not all patients derive benefit from treatment• Surgery and Radiation

• Definition of benefit?• Overall Survival

• Cancer Specific Survival

• Progression and Symptoms

• Quality of Life

In the era of PSA-based screening, the percentage of prostate cancers

over-diagnosed is estimated to be as high as 23% to 67%1,2

[Welch, 2010; Gulati, 2011]

Over Detection=Potential for Over Treatment

% A

live

Age

Years following prostate cancer detection

• Paradigm shift: Deferment of Treatment

(Surgery/XRT)

• Men are observed carefully with serial examinations

… and at the first signs of higher-risk disease,

the cancer can be treated within the Window of

Opportunity for Cure

Active Surveillance (AS) for Localized Prostate

Cancer—An Attractive Option with Optimized QOL

• Gleason Grade

• Clinical Stage

• PSA Density

• Number of Cores Positive

• Percent of Core Positive

Active Surveillance eligibility criteria vary widely

among physicians, hospitals, and countries

SV

CZ

PZ TZ

Urethra

Base

Mid

Apex

SV

CZ

PZ TZ

Urethra

Base

Mid

Apex

SV

CZ

PZ TZ

Urethra

Base

Mid

Apex

Sextant12-coreextended

SaturationFigure 1

Biopsy techniques have relied on RANDOM

sampling of the prostate gland

Sextant

Saturation

12-core

Some clinically significant cancers are missed

because of sampling error of the biopsy, and

many men are diagnosed with clinically

insignificant disease.

Thanks for figure: Behfar Ehdaie, MD MPH

Advances in prostate imaging to better select patients

• Multiparametric MRI of prostate

Overall PPV: 98%

Sensitivity:

Gleason ≥7 (0.69-0.80)

<7 (0.27-0.47)

Volume >5mm (0.53-0.68)

≤5mm (0.13-0.37)

MR-targeted prostate biopsies improve detection of

clinically significant cancer compared to standard biopsy

MRI T2-weighted/

ADC sequences

Observational studies with long-term outcomes for active surveillance in prostate cancer patients

• What is active surveillance?• Everyone is aware that patient has a diagnosis of prostate cancer

• Close monitoring to defer treatment until indications are more concrete

• NOT watchful waiting

• Want to intervene within the window of cure

• Requires a complex conversation and understanding by patient/family members and his primary care physician

• 15 year cancer specific

survival

• Safe for men with low risk

prostate cancer

• 2.8% developed metastatic

disease

• 1.5% died of prostate cancer[Klotz, 2015]

• Patients Remaining

Untreated

• 5 years: 76%

• 10 years: 64%

• 15 years: 55%

[Klotz, 2015]

Although significant variation exists in identifying patients

eligible for active surveillance, detecting disease

progression is equally challenging

• Digital rectal exam

• Is this necessary?

• Serial prostate biopsy

• Risks involved

• Serum PSA changes

• How do we account for BPH changes

that occur with age?

• Adverse findings on MRI

• Sensitivity?

Tools to detect prostate cancer disease progression:

Why should we engage patients to consider Active Surveillance?

Very Low Risk

High Risk

Low-Intermediate Risk

[Hoffman, 2014]

The majority of men diagnosed with prostate cancer in the PSA-screening era are eligible for active surveillance

• 80% of physicians believe active surveillance is

underutilized

• 71% of physicians report their patients are not

interested in active surveillance

Barriers to widespread acceptance of active surveillance for

prostate cancer treatment

[Kim, 2014]

Education.

Lack of

knowledge

about AS

Attitudes and

beliefs.

AS is for older

men who are

not surgical

candidates

Fear.

Cancer will

spread

without

detection

Influence.

Partner/spouse

and family

member

preferences

Conceptual Framework of Barriers to Active Surveillance

Seek treatment.

Early aggressive treatment improves survival

Solutions?

Communication and Education

• Better selection for PSA Screening

• Multi-Disciplinary clinics to increase AS and its

adherence

• Genomic testing

• Gleason Nomenclature

Focus on interests as opposed to positions

Life Death

Surgery/

XRT

Active

Surveillance Quality

of Life

Survival

Urinary

symptoms

Sexual

Function Costs

As physicians we must work together to help our patients

Post-Presentation Question #1

What is the lifetime risk of prostate cancer in an American male?

a. 0-10%

b. 10-20%

c. 20-30%

d. 30-40%

e. >40%

Post-Presentation Question #2

What is the definition of benefit when describing prostate cancer treatment and care?

a. Cancer specific survival

b. Overall survival

c. Erectile function

d. Urinary function

e. Control of symptoms

f. All of the Above

Post-Presentation Question #3

What is the risk of death from prostate cancer in long-term follow up of patients diagnosed with low risk disease?

a. >30%

b. 20-30%

c. 10-20%

d. 2-10%

e. <2%

Intervention CohortThank You!

QUESTIONS?