Prostate Cancer Screening

Google Search “Prostate Cancer”

• “Google Health” prostate cancer (OK)• “Should All Men Be Screened for Prostate

Cancer?” ABC news

Prostate Cancer Review

• Most common non-dermatologic malignancy in US men

• 2nd most common cause of cancer related death in US men

• 218 K new cases/ year in US detected• 23 K deaths/ year estimate by ACS in 2006• PSA approved 1986• Mortality peaked in 1991, now declining

Incidence

Mortality

Prostate Screening Review

• Prostate cancer screening is controversial• Positive screening considered potentially

harmful– PSA anxiety– Physical risks of biopsy

• Prostate cancer treatment is controversial

Where we should all agree

• “Screening” implies asymptomatic men • Men with a less than 10-15 year life

expectancy should not be screened– In general in US men>75– Men with terminal illness– Men with life threatening illness

• Don’t get PSA as inflammation marker

Notes about PSA• Serine protease• Chymotrypsin like• Normal function is to liquefy semen to facilitate

spermatozoa movement• The U.S. Food and Drug Administration (FDA) has

approved the use of the PSA test along with a digital rectal exam (DRE) to help detect prostate cancer in men 50 years of age or older.

• Medicare covers annual testing starting age 50.

DRE is Important

PSA as a test

• 75% sensitive– Why DRE needed

• 25% specific– 1/4 to 1/3 have positive biopsy– (20-56% FP mammogram over 10 years)

PSA: Different Views

• > 4 abnormal• Age adjusted:– 40s > 2.5 abnormal– 50’s> 3.5 abnormal

• PSA velocity:– >0.75 ng/ml/yr abnormal– >0.35 ng/ml/yr abnormal

Studies relating mortality

• PCLO: multicenter prospective RCT in US:– Annual screening (6 years PSA, 4 DRE) – “usual treatment” (40% were screened)

• ERSPC: multicenter prospective RCT in Europe:– Annual Screening vs no screening– More varied screening frequency

• Note traditionally screening supported in US not in Europe….

Studies relating mortality: PLCO

Studies relating mortality

Studies relating mortality

Studies relating mortality: ERSPC

Studies relating mortality: ERSPC

Studies relating mortality: ERSPC

NNS to prevent 1 death 1410 (although only 1 study)

Studies relating mortality: ERSPC

• Subsequent paper estimated difference after non compliance (20%- screening arm) and contamination (30% of control arm) were excluded

• In this analysis 30% reduction of mortality.

Just for perspective….

• Same search: Cholesterol screening mortality cochrane: 12 papers, none about cholesterol screening

• 2007 Cochrane Review (update from 2004): No evidence to support dietary modification in type 2 DM (some for exercise)

• USPHTF does not recommend for or against screening women not at increased CAD risk for lipid disorders.

Breast Cancer

Breast Cancer

NNS to prevent 1 death> 50 1224

NNS to prevent 1 death <40 1792

Summary• Do evaluate men with symptoms• Prostate Cancer Screening of asymptomatic men is controversial

– Discuss with patients– If done, do a DRE too!

• If abnormal screen, refer to us– We can counsel about R/B/A biopsy– We can counsel about over and under treatment

Useful Resources

• http://www.cancer.gov/cancertopics/factsheet/detection/PSA

• http://www.ahrq.gov/clinic/uspstf/uspsprca.htm

• http://seer.cancer.gov/statistics/types.html