Prostate Cancer Screening Risk Management

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Prostate CancerScreening Risk Management
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• 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?

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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

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Pathophysiology

• 95 Adenocarcinomas
• 4 TCC
• 70 peripheral
• 15 central zone
• 15 Transitional zone
• T1-4
• Gleason score

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Risk Factors
Age
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• FH
• 1st degree rel. ? 2x risk
• Above rel lt60 ? 4x risk
• Diet
• Lycopenes selenium decrease risk
• Calcium increases risk
• Obesity

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Ethnicity

• Black African/ Caribbean ? highest risk
• White
• Asian ? Lowest risk

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Prostate Specific Antigen

• Elevated by

• Glycoprotein
• Released from normal and malignant cells
• Size
• Age

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

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Prostate Specific Antigen

• Benefits

• Limitations

• Nice and easy
• Early detection
• Repeat testing valuable

• 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
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• Investigations

• Treatment Options

• Trans Rectal USS
• TRUS guided biopsy
• CT
• MRI

• Watchful waiting
• Active Monitoring
• Radical Prostatectomy
• Radiotherapy (ext beam / brachytherapy)
• High intensity focused USS
• Cryotherapy
• Hormonal therapy

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Why do we not have a screening programme?
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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

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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

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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 3601320-1328
J Natl Cancer Inst 200395868-878
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Why do we not have a screening programme?
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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.

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PSA Informed Choice Programme
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Future

• PSA factors
• Velocity
• Density
• Proportions
• Prostate Cancer 3 PCA3

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Further Info

• http//www.cancerscreening.nhs.uk/index.html
• http//info.cancerresearchuk.org/cancerstats/types
  /prostate/?a5441
• http//content.nejm.org/cgi/content/full/NEJMoa081
  0084R30

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