Screening for Prostate Cancer Christopher R. Williams, MD Associate Professor, Division of Urology Director, Urologic Oncology and Robotic Surgery

NO RELEVANT DISCLOSURES

How common is prostate cancer? CA CANCER J CLIN 2017;67:7-30

Major Risk Factors Age Family history Race Incidence rises rapidly after age 50 Over 60% of new cases diagnosed in men over 65 Family history 1st degree relative with cancer more than doubles risk Brother > father Multiple relatives > single relative Multiple generations at early age > single generation at older age Race African-American men are more than twice as likely to die from prostate cancer than Caucasian men 1. http://www.cancer.org/cancer/prostatecancer 2. Carter BS. J Urol 1993; 150: 797.

Prostate Cancer screening Most effective method for detection is combined use of Prostate Specific Antigen (PSA) and Digital Rectal Exam (DRE) ~15% of men with cancer have PSA <4 PSA and DRE are complementary b/c they do not always detect the same cancers Thompson, NEJM, 2004

Serum PSA as a Screening Test for Prostate Cancer PSA accuracy in detecting cancer: Sensitivity 79% Specificity 59% PPV 40% NPV 89% Overall accuracy 64% (Catalona, NEJM, 1991)

Factors affecting PSA Age Prostate size: Medications Age-adjusted PSA1 40 to 49 - 0.0 to 2.5 50 to 59 - 0.0 to 3.5 60 to 69 - 0.0 to 4.5 70 to 79 years - 0.0 to 6.5 Prostate size: Percent free/total PSA 2 25% cutoff: 95% sensitivity & eliminates 20% of unnecessary biopsies < 15% Suspicious for cancer > 24% Suggests benign disease 15-24% Grey area Medications 5-alpha reductase inhibitors Oral Estrogen agents LHRH agonists and antagonists 1. Oesterling, JAMA 1993 2. Catalona, JAMA, 1998

2013 AUA PSA Screening Guidelines PSA screening in men under age 40 years is not recommended. Routine screening in men between ages 40 to 54 years at average risk is not recommended. Shared decision-making is recommended for men age 55 to 69 years that are considering PSA screening… Routine PSA screening is not recommended in men over age 70 or any man with less than a 10-15 year life expectancy. For men younger than age 55 years at higher risk (e.g. positive family history or African American race), decisions regarding prostate cancer screening should be individualized based on personal preferences and an informed discussion regarding the uncertainty of benefit and the associated harms of screening. http://www.auanet.org/education/guidelines/prostate-cancer-detection

AUA after releasing its guidelines

PCP after reading AUA guidelines

2016 NCCN Screening Guidelines

US Preventive Services Task Force Considerations Reason for USPSTF investigation: Likely over-diagnosis and over-treatment of prostate cancer. In 2012 the USPSTF recommended against PSA screening on the grounds that there is no net benefit and that the potential harms outweigh the benefits. Grade D1 The harms identified by USPSTF are overestimated and relate more to treatment than screening. Not all prostate cancers require treatment. The patient is entitled to know whether he has prostate cancer and be allowed to decide if he desires treatment. A recommendation against screening deprives him of that autonomy. Moyer VA, Annals of internal medicine. 2012;157(2):120-34.

Transrectal Ultrasound-guided Prostate Biopsy

Prostate biopsy complications Infection 5-7% Hospitalization 1-3% Bleeding Hematuria 50% Intervention <1% Rectal Bleeding 30% Intervention 2.5% Hematospermia 50% >4 weeks 30% Other LUTS (~1 mo) 6-25% Urinary Retention 0.2 -2.6% ED (~1 mo) <1% https://www.auanet.org/common/pdf/education/clinical-guidance/AUA-PNB-White-Paper.pdf

Impact of the United States Preventive Services Task Force 'D' recommendation on prostate cancer screening and staging Eapen, Renu S.; Herlemann, Annika; Washington, Samuel L. III; Cooperberg, Matthew R. Recent findings: Following the USPSTF recommendation, a substantial decline in PSA screening was noted for all age groups. Similarly, overall rates of prostate biopsy and prostate cancer incidence have significantly decreased with a shift toward higher grade and stage disease upon diagnosis. Concurrently, the incidence of metastatic prostate cancer has significantly risen in the United States. These trends are concerning particularly for the younger men with occult high-grade disease who are expected to benefit the most from early detection and definitive prostate cancer treatment. Current Opinion in Urology: Post Author Corrections: February 17, 2017 doi: 10.1097/MOU.0000000000000383

2017 USPSTF Screening Update Men ages 55–69 The decision about whether to be screened for prostate cancer should be an individual one. The USPSTF recommends that clinicians inform men ages 55 to 69 years about the potential benefits and harms of prostate-specific antigen (PSA)–based screening for prostate cancer. Screening offers a small potential benefit of reducing the chance of dying of prostate cancer. However, many men will experience potential harms of screening, including false-positive results that require additional workup, overdiagnosis and overtreatment, and treatment complications such as incontinence and impotence. The USPSTF recommends individualized decision-making about screening for prostate cancer after discussion with a clinician, so that each man has an opportunity to understand the potential benefits and harms of screening and to incorporate his values and preferences into his decision. Recommendation Grade C (Offer or provide this service for selected patients depending on individual circumstances) Men age 70 and older The USPSTF recommends against PSA-based screening for prostate cancer in men age 70 years and older. Recommendation Grade D (Discourage the use of this service) https://screeningforprostatecancer.org/#utm_source=google&utm_medium=cpc&utm_campaign=recommendation&utm_term=branded&utm_content=draft_uspstf

Summary Prostate cancer screening is worthwhile, as evidenced by negative repercussions of the USPSTF recommendations Prostate cancer screening should include PSA and DRE The NCCN guidelines are more helpful for PCPs than the AUA guidelines Serious prostate biopsy complications are very rare and should not discourage screening

Thank You! Prostate Cancer Testing & Treatment Options [Patient Education]