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Prostate Cancer Screening Risk Management

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Prostate Cancer Screening Risk ... Ejaculation ~ for 48hrs Exercise ~ for 48hrs PR exam ~ for 1wk Prostate Biopsy ~ for 6wks UTI ~ for months BPH Prostate Cancer ... – PowerPoint PPT presentation

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Title: Prostate Cancer Screening Risk Management


1
Prostate CancerScreening Risk Management
2
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3
  • 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?

4
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

5
Pathophysiology
  • 95 Adenocarcinomas
  • 4 TCC
  • 70 peripheral
  • 15 central zone
  • 15 Transitional zone
  • T1-4
  • Gleason score

6
Risk Factors
Age
7
  • FH
  • 1st degree rel. ? 2x risk
  • Above rel lt60 ? 4x risk
  • Diet
  • Lycopenes selenium decrease risk
  • Calcium increases risk
  • Obesity

8
Ethnicity
  • Black African/ Caribbean ? highest risk
  • White
  • Asian ? Lowest risk

9
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

10
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
11
  • 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

12
Why do we not have a screening programme?
13
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

14
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

15
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?
19
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

27
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

28
Question time
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