1. Prostate Cancer Screening Risk Management Ben Inch

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 2 nd 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 – 1 st degree rel.  2x risk – Above rel <60  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 Glycoprotein Released from normal and malignant cells Size Age Elevated by: 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 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

11. 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

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 360:1320-1328 J Natl Cancer Inst 2003;95:868-878

18. 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.

21. PSA Informed Choice Programme

26. Future PSA factors – Velocity – Density – Proportions Prostate Cancer 3 PCA3

27. Further Info http://www.cancerscreening.nhs.uk/index.ht ml http://www.cancerscreening.nhs.uk/index.ht ml http://info.cancerresearchuk.org/cancerstats/ types/prostate/?a=5441 http://info.cancerresearchuk.org/cancerstats/ types/prostate/?a=5441 http://content.nejm.org/cgi/content/full/NEJ Moa0810084#R30

28. Question time