J. Jacques Carter, MD, MPH Assistant Professor of Medicine Department of Medicine Harvard Medical School Beth Israel Deaconess Medical Center Boston, Massachusetts PHEN Medical Advisor

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J. Jacques Carter, MD, MPHAssistant Professor of
MedicineDepartment of MedicineHarvard Medical
SchoolBeth Israel Deaconess Medical
CenterBoston, MassachusettsPHEN Medical
Advisor
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PROSTATE CANCER

• The Screening Controversy
• The Screening Controversy

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Prostate Cancer

• Most commonly diagnosed visceral Cancer in men
• 30 of all Cancers in men
• 220K cases yearly
• 30K deaths yearly

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Lifetime risk of Developing CaP is 13-17 (1
in 6)

• Survival is multifactorial, especially the extent
  of tumor at the time of diagnosis
• 5-year survival with cancer confined to the
  prostate (localized) or just regional is spread
  is 100
• Only 31.9 if diagnosed with distant metastases

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Possible Benefit of Screening?

• A screening program that could identify
  asymptomatic men with aggressive localized tumors
  might be expected to reduce prostate cancer
  morbidity and mortality

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Why the Controversy???

• Effectiveness of Treatment remains uncertain
• No studies have yet proven a survival benefit
  with screening
• Considerable Data showing potential harms from
  aggressive treatments

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Prostate Specific Antigen

• Glycoprotein produced by prostate epithelial
  cells
• May be elevated with Prostate Cancer
• Also elevated with BPH, prostatitis
• Other causes of elevation
• Value is lowered by some medications

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Positive Predictive Value

• A test performance statistic
• Refers to the PROPORTION of men with an elevated
  PSA who really have prostate cancer

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• The PPV value for a PSA greater than 4.0 is 30
  
• For a PSA between 4.0 10.0, the PPV is 25
• This increases to 42 64 for PSAs greater
  than 10.0

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March 2009Mortality Results from a
Randomized Prostate-Cancer Screening Trial
N Eng J Med 2009
3601310-9Report of the Prostate, Lung,
Colorectal, and Ovarian (PLCO) Cancer Study
Group 76K participants randomized to
screening or control groups Conclusion
No significant difference in mortality between
the two study groups
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August 2009Prostate Cancer Diagnosis and
Treatment After the Introduction of
Prostate-Specific Antigen Screening
1986-2005 J Natl Cancer Inst 2009 1011-5

• Drs. Welch (VA Outcomes Group Dartmouth) and
  Albertsen (UConn) looked at data from NCIs SEER
  Program on prostate cancer incidence beginning
  one year before PSA introduction. Noted that an
  additional 1.3m men were diagnosed with CaP, with
  1m undergoing definitive treatment
• Reported a major increase incidence of younger
  men being diagnosed, especially age 50-59, and
  under age 50.
• Concluded that PSA screening resulted in more
  than 1m ADDITIONAL men being diagnosed and
  treated . Most of this excess incidence must
  represent overdiagnosis

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Beth Israel Deaconess Medical CenterBoston
Massachusetts