Prostate Screening in the New Millennium Dr Pamela Ajayi MD PathCare

The Prostate Gland

Why screen? "Prostate cancer comes in a number of forms, some aggressive and some not…“ "Prostate cancer comes in a number of forms, some aggressive and some not…“ “…but the bottom line about prostate cancer testing is that we cannot counsel patients about next steps for cancer that we do not know exists.“ “…but the bottom line about prostate cancer testing is that we cannot counsel patients about next steps for cancer that we do not know exists.“

What is screening? A screening test separates apparently healthy persons who probably have a disease from those who probably do not. A screening test separates apparently healthy persons who probably have a disease from those who probably do not.

Screening Digital Rectal Examination Digital Rectal Examination LumpsLumps HardnessHardness Increased sizeIncreased size

Screening Blood test to measure PSA is considered the most effective test currently available for the early detection of prostate cancer. Blood test to measure PSA is considered the most effective test currently available for the early detection of prostate cancer. PSA Levels PSA Levels (N: <4ng/ml) (B: ng/ml) (A: >10ng/ml)

PSA PSA levels can be often elevated in the presence of prostate cancer and in other prostate disorders. PSA levels can be often elevated in the presence of prostate cancer and in other prostate disorders. prostate infection / inflammation prostate infection / inflammation benign prostatic hyperplasia (BPH) benign prostatic hyperplasia (BPH) recent ejaculation recent ejaculation Digital rectal examination (DRE) Digital rectal examination (DRE) **Elevated PSA levels do not necessarily mean you have cancer! mean you have cancer!

Also… Prostate cancer can also be present in the complete absence of an elevated PSA level, in which case the test result would be a false negative. Prostate cancer can also be present in the complete absence of an elevated PSA level, in which case the test result would be a false negative.false negativefalse negative Obesity has been reported to reduce serum PSA levels. Obesity has been reported to reduce serum PSA levels.

Free PSA Most PSA in the blood is bound to serum proteins. Most PSA in the blood is bound to serum proteins. A small amount is not protein bound and is called free PSA. A small amount is not protein bound and is called free PSA. In men with prostate cancer the ratio of free (unbound) PSA to total PSA is decreased. In men with prostate cancer the ratio of free (unbound) PSA to total PSA is decreased. The risk of cancer increases if the free to total ratio is less than 25%.The risk of cancer increases if the free to total ratio is less than 25%. The lower the ratio the greater the probability of prostate cancer.The lower the ratio the greater the probability of prostate cancer. Measuring the ratio of free to total PSA appears to be particularly promising for eliminating unnecessary biopsies in men with PSA levels between 4 and 10 ng/mL levels Measuring the ratio of free to total PSA appears to be particularly promising for eliminating unnecessary biopsies in men with PSA levels between 4 and 10 ng/mL levels

Recommendations: American Urological Association: Early detection and risk evaluation of prostate cancer should be offered to well-informed men 40 years of age or older who have a life expectancy of at least 10 years. Early detection and risk evaluation of prostate cancer should be offered to well-informed men 40 years of age or older who have a life expectancy of at least 10 years. The future risk of prostate cancer is closely correlation to a man's PSA score; a baseline PSA level above the median for age 40 is a strong predictor of prostate cancer.The future risk of prostate cancer is closely correlation to a man's PSA score; a baseline PSA level above the median for age 40 is a strong predictor of prostate cancer. “ In regard to biopsy, a continuum of risk exists at all values, and major studies have demonstrated that there is no safe PSA value below which a man appears to be reassured that he does not have biopsy-detectable prostate cancer. Therefore, the AUA does not recommend a single PSA threshold at which a biopsy should be obtained. Rather, the decision to biopsy should take into account additional factors, including free and total PSA, PSA velocity and density, patient age, family history, race/ethnicity, prior biopsy history and co-morbidities. Additionally, the AUA statement emphasizes that not all prostate cancers require active therapy and that not all prostate cancers are life- threatening. The decision to proceed to active therapys is one that men should discuss in detail with their urologists to determine whether active therapy is necessary, or whether surveillance appears to be an option for their prostate cancer. Additionally, the Best Practice Statement clarifies many key points about the use of PSA in therapy selection and post-treatment follow up of patients with prostate cancer: “ In regard to biopsy, a continuum of risk exists at all values, and major studies have demonstrated that there is no safe PSA value below which a man appears to be reassured that he does not have biopsy-detectable prostate cancer. Therefore, the AUA does not recommend a single PSA threshold at which a biopsy should be obtained. Rather, the decision to biopsy should take into account additional factors, including free and total PSA, PSA velocity and density, patient age, family history, race/ethnicity, prior biopsy history and co-morbidities. Additionally, the AUA statement emphasizes that not all prostate cancers require active therapy and that not all prostate cancers are life- threatening. The decision to proceed to active therapys is one that men should discuss in detail with their urologists to determine whether active therapy is necessary, or whether surveillance appears to be an option for their prostate cancer. Additionally, the Best Practice Statement clarifies many key points about the use of PSA in therapy selection and post-treatment follow up of patients with prostate cancer:

Men who wish to be screened for prostate cancer should have both a PSA test and a digital rectal exam (DRE). Men who wish to be screened for prostate cancer should have both a PSA test and a digital rectal exam (DRE). Family history, age, overall health and ethnicity should be combined with the results of PSA testing and physical examination in order to better determine the risk of prostate cancer. Family history, age, overall health and ethnicity should be combined with the results of PSA testing and physical examination in order to better determine the risk of prostate cancer.

Informed decision making Informed decision making occurs when a man— Informed decision making occurs when a man— Understands the nature and risk of prostate cancer.Understands the nature and risk of prostate cancer. Understands the risks of, benefits of, and alternatives to screening.Understands the risks of, benefits of, and alternatives to screening. Participates in the decision to be screened or not at a level he desires.Participates in the decision to be screened or not at a level he desires. Makes a decision consistent with his preferences and values.Makes a decision consistent with his preferences and values.

Understanding Prostate Cancer Signs and symptoms Signs and symptoms Risk factors Risk factors Diagnosis Diagnosis Treatment: Treatment: ComplicationsComplications BenefitsBenefits

Symptoms None None If symptoms appear, they can include: ■ blood in the urine; ■ blood in the urine; ■ the need to urinate frequently, especially at night; ■ the need to urinate frequently, especially at night; ■ weak or interrupted urine flow; ■ weak or interrupted urine flow; ■ pain or burning feeling while urinating; ■ pain or burning feeling while urinating; ■ the inability to urinate; ■ the inability to urinate; ■ constant pain in lower back, pelvis, or upper thighs. ■ constant pain in lower back, pelvis, or upper thighs.

Risk Factors Ethnicity Ethnicity Family History Family History Age Age Other factors: Other factors: SmokingSmoking DietDiet ExerciseExercise

Ethnic risk Increased risk Increased risk Increased mortality & morbidity Increased mortality & morbidity Possible reasons: ?Culture?Culture ?Environment?Environment ?Genetic?Genetic Prostate cancer death rates by race/ethnicity in males aged 45 and above. (CDC)

Diagnosing Prostate Cancer Screening Screening Ultrasound scan & Confirmatory Biopsy Ultrasound scan & Confirmatory Biopsy Gleason scaleGleason scale StagingStaging Radiology Radiology Bone scanBone scan CTCT MRIMRI

Types of Cancer Some prostate cancers become a serious threat to health by growing quickly, spreading beyond the prostate gland to other parts of the body, and causing death. Some prostate cancers become a serious threat to health by growing quickly, spreading beyond the prostate gland to other parts of the body, and causing death. Other prostate cancers grow slowly and never become a serious health threat or affect how long a man lives. Other prostate cancers grow slowly and never become a serious health threat or affect how long a man lives. **Doctors can’t always be sure what type of cancer is present in a particular case.

Treatment Brachytherapy Brachytherapy External Beam Radiation Therapy External Beam Radiation Therapy Hormonal Therapy Hormonal Therapy Radical Prostatectomy (?Laparoscopic) Radical Prostatectomy (?Laparoscopic)Complications ContinenceContinence Sexual functionSexual function

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