Transcript Prostate Cancer Risk Management

Prostate Cancer
Screening
Risk Management
• Prostate cancer
• European Study – Screening and ProstateCancer 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 Factors
Age
Figure 1.1: Numbers of new cases and age specific incidence rates,
8,000
1,000
Male rates
800
6,000
5,000
600
4,000
400
3,000
2,000
200
1,000
Age at diagnosis
85+
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
0
5-9
0
0-4
Number of cases
7,000
Rate per 100,000 population
Male cases
• 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
Figure 1.2: Age-standardised* incidence and mortality
rates for prostate cancer by world regions, 2002
Northern America
Australia/New…
Western Europe
Northern Europe
Caribbean
South America
Southern Africa
Southern Europe
Central America
World
Middle Africa
Western Africa
Eastern Europe
Eastern Africa
Western Asia
South-Eastern Asia
Northern Africa
South Central Asia
Eastern Asia
0
Incidence
Mortality
50
100
Rate per 100,000
150
Prostate Specific Antigen
Elevated by:
• Glycoprotein
• Released from normal and
malignant cells
• Size
• Age
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•
•
•
•
•
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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.ht
ml
• http://info.cancerresearchuk.org/cancerstats/
types/prostate/?a=5441
• http://content.nejm.org/cgi/content/full/NEJ
Moa0810084#R30
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