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Prostate CancerScreening
Risk Management
Ben Inch
• 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
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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