1. Prostate Cancer Screening

2. Google Search “Prostate Cancer” “Google Health” prostate cancer (OK) “Should All Men Be Screened for Prostate Cancer?” ABC news

3. Prostate Cancer Review Most common non-dermatologic malignancy in US men 2 nd most common cause of cancer related death in US men 218 K new cases/ year in US detected 23 K deaths/ year estimate by ACS in 2006 PSA approved 1986 Mortality peaked in 1991, now declining

4. Incidence

5. Mortality

6. Prostate Screening Review Prostate cancer screening is controversial Positive screening considered potentially harmful – PSA anxiety – Physical risks of biopsy Prostate cancer treatment is controversial

8. Where we should all agree “Screening” implies asymptomatic men Men with a less than 10-15 year life expectancy should not be screened – In general in US men>75 – Men with terminal illness – Men with life threatening illness Don’t get PSA as inflammation marker

9. Notes about PSA Serine protease Chymotrypsin like Normal function is to liquefy semen to facilitate spermatozoa movement The U.S. Food and Drug Administration (FDA) has approved the use of the PSA test along with a digital rectal exam (DRE) to help detect prostate cancer in men 50 years of age or older.DRE Medicare covers annual testing starting age 50.

10. DRE is Important

11. PSA as a test 75% sensitive – Why DRE needed 25% specific – 1/4 to 1/3 have positive biopsy – (20-56% FP mammogram over 10 years)

12. PSA: Different Views > 4 abnormal Age adjusted: – 40s > 2.5 abnormal – 50’s> 3.5 abnormal PSA velocity: – >0.75 ng/ml/yr abnormal – >0.35 ng/ml/yr abnormal

13. Studies relating mortality PCLO: multicenter prospective RCT in US: – Annual screening (6 years PSA, 4 DRE) – “usual treatment” (40% were screened) ERSPC: multicenter prospective RCT in Europe: – Annual Screening vs no screening – More varied screening frequency Note traditionally screening supported in US not in Europe….

14. Studies relating mortality: PLCO

15. Studies relating mortality

17. Studies relating mortality: ERSPC

19. NNS to prevent 1 death 1410 (although only 1 study)

20. Studies relating mortality: ERSPC Subsequent paper estimated difference after non compliance (20%- screening arm) and contamination (30% of control arm) were excluded In this analysis 30% reduction of mortality.

21. Just for perspective…. Same search: Cholesterol screening mortality cochrane: 12 papers, none about cholesterol screening 2007 Cochrane Review (update from 2004): No evidence to support dietary modification in type 2 DM (some for exercise) USPHTF does not recommend for or against screening women not at increased CAD risk for lipid disorders.

22. Breast Cancer

23. NNS to prevent 1 death> 50 1224 NNS to prevent 1 death <40 1792

24. Summary Do evaluate men with symptoms Prostate Cancer Screening of asymptomatic men is controversial – Discuss with patients – If done, do a DRE too! If abnormal screen, refer to us – We can counsel about R/B/A biopsy – We can counsel about over and under treatment

25. Useful Resources http://www.cancer.gov/cancertopics/factshee t/detection/PSA http://www.cancer.gov/cancertopics/factshee t/detection/PSA http://www.ahrq.gov/clinic/uspstf/uspsprca.h tm http://www.ahrq.gov/clinic/uspstf/uspsprca.h tm http://seer.cancer.gov/statistics/types.html