1. Prostate Cancer One of the commonest causes of death in the Western World USA 2005 – 232,090 new cases – 30,350 deaths Lifetime risk of disease 16.6% Lifetime risk of death 3.4%

2. Prostate Cancer BAUS Cancer Registry 2004 – 14,858 new cases >70% well / mod differentiated 66% T1/T2 CUH – 150+ new diagnosis per year.

4. Deaths related to age

5. Epidemiology Dietary factors – Increased risk with increased fat – Phytoestrogens reduce risk – Selenium, lycopenes are protective No definite evidence for formal recommendations

6. PSA Useful in detection, staging and monitoring of prostate cancer Prostate specific but not cancer specific Other causes of elevated PSA – BOH, urinary retention, catheter – Prostatitis – Urological intervention – Sexual activity

7. Diagnosis and Staging DRE PSA TRUS and biopsy MRI Bone Scan Partins Tables (PSA, DRE, Biopsy data) PSA 34KDa

8. TRUS and Biopsy

9. Multi parametric MRI

13. MRI Fusion biopsies - TP

14. Does PSA Testing Influence the Natural History of Prostate Cancer

22. Summary RCT data does not support routine screening Screening aids earlier diagnosis and detect cancer at earlier stage Screening does not have a significant impact on mortality Cost: testing, over treatment, adverse effects, QoL Therefore discussion at individual level for PSA testing

23. PSA Confused? – I am!!

24. The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188 1. For men aged 50-69 years, level 1 evidence shows that psa testing reduces the incidence of metastatic prostate cancer and prostate cancer specific mortality rates. – Population screening not recommended but well informed men should be fully counselled about the positive and negative aspects of psa testing.

25. The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188 2. Prostate cancer diagnosis must be uncoupled from prostate cancer intervention – Screening allows diagnosis of high risk cases within the window of curability – Many with low risk disease do not need aggressive treatment – Active surveillance protocols need to be standardised and validated

26. The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188 3. PSA testing should not be considered on its own, but rather as part of a multivariable approach to early prostate cancer detection – Consider: Age, ethnicity, FHx, PMHx, DRE findings F:T, PCA3, biomarkers

27. The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188 4. Baseline PSA testing for men in their 40s is useful for predicting the future risk of prostate cancer and its aggressive forms – Median psa for men 40-49yr = 0.5-0.7ng/ml – The higher above median the greater risk of later developing life-threatening disease – Baseline psa test in 40s has value for risk stratification

28. The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188 5.Older men in good health with a > 10 year life expectancy should not be denied PSA testing based on their age. – Men should be assessed on an individual basis rather than applying an arbitrary chronological age prohibiting testing.

29. The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188 Summary: There is no right answer Individual based shared decision making process. Increase in AS “treatment or non-treatment decisions can be made once cancer is found, but not knowing about it in the first place surely burns bridges”

30. CUH – Urology, ahead of the field Early OPD Same day MRI Full counselling Move towards targeted biopsies Individual based shared decision making process