Urological malignancies Men’s health January 2017

Mr.Jones, a 66 year old retired policeman, comes to see your tomorrow morning saying his wife has suggested he come to you for that blood test to see if he has prostate cancer. He has no urological symptoms. Do you: Send him to the nurse for a blood test Give him a leaflet/webpage balancing the risks and allow him to choose Give him a leaflet/webpage explaining why it is not an appropriate test to have

Previous correct answer: Send him to the nurse for a blood test Give him a leaflet/webpage balancing the risks and allow him to choose Give him a leaflet/webpage explaining why it is not an appropriate test to have

Current answer: Send him to the nurse for a blood test Give him a leaflet/webpage balancing the risks and allow him to choose Give him a leaflet/webpage explaining why it is not an appropriate test to have

BMJ 2013 PSA screening results in at most a small reduction in prostate cancer mortality, at a cost of considerable harm resulting from the dangers of over diagnosis and treatment related harms. For every 1000 men screened: 1 death from prostatic ca will be prevented 100 will receive a false +ve and need a prostate biopsy 100 will be diagnosed with ca, many receiving treatment, which may have never be needed European RCT Prostate Ca; US PLCOCANCER Trial.

BMJ 2014 So, what should we do when faced with a PSA request? ‘for most men doctors can recommend against routine PSA screening’ If screening is done (on patient request, after full discussion of potential risks and benefits), it should be targeted at men aged 55 to 69 without serious co-morbidities and the Swedish strategy (follow up screen 60yr olds with psa>2) of no further testing in men with a PSA found to be <1 (or even <2) is a potentially useful strategy for reducing over-diagnosis and risks of continued screening Doctors should strongly recommend against testing in men under 55 or over 70

Mike Evans Youtube: Deeper dive on PSA Screening Leaflet…

Prostate cancer Second commonest cancer in men (after lung cancer). 24% of all new male cancers Lifetime risk in UK = 1 in 10 (guidelines, July 2010) 37 000 men diagnosed with prostate cancer annually in UK. ( cf approx 10 000 for bladder cancer – both sexes). 10 000 men die of prostate cancer each year in UK. 10% of men with prostate cancer diagnosed in 50s Average age of diagnosis = 70-74 years old. Black : white ratio = 3 : 1 (lowest incidence in Asians).

Prostate Cancer (2) 30-40% of early onset cases ( diagnosed < 55yrs old) are caused by inherited susceptibility genes. No modifiable risk factors Risk factors = age, ethnicity and family history. Risk increases 2-3x if primary relative diagnosed. 4x if primary relative diagnosed less than 60 4x if more than 1 relative at any age. Estimated that 50% of men in their 50s have histological evidence of cancer in their prostate. Rising to 80% of men in their 80s. But only 1 in 26 men (3.8%) die from this disease (NICE guidelines on prostate cancer CG 58, 2008)

Prostate Cancer (3) Most men with prostate cancer are asymptomatic. Symptoms can be the same as BPH – freq of micturition and poor stream – occasionally haematuria. Back pain if skeletal mets. Prostate cancer are adenocarcinomas. Increased incidence in developed world but mortality rates are unchanged 5 year survival rate = 77% in UK. (2001-6). 90% for disease confined to prostate. 99% 5 year survival rate in USA !

Management of prostate cancer “Do not biopsy on the basis of PSA alone”. Other factors should be considered such as prostate vol and feel, age, ethnicity, FH and previous –ve biopsies. In men over 65y with low risk prostate cancer (PSA<10 and gleason <7), conservative management or ‘active surveillance’ offer high 10yr survival rates. (JAMA 2010) – this means deferring radical Rx until demonstrable progression. This is different to ‘watchful waiting’ where the disease has progressed (so not curative) and treatments such as hormone therapy are deferred until warranted by evidence of progression

NICE Prostate Cancer 2014 Treatment options: We should advise all patients that radical treatment and long term androgen deprivation therapy may result in loss of sexual function, including ejaculation Active surveillance Is recommended as an option: To men with low risk prostate cancer men with intermediate risk disease who do not wish to have radical treatment Part of this will increasingly be done in primary care, as part of shared care protocols (e.g. PSA measured every 3 months, DRE repeated every 6 for first year, then PSA every 6 months and DRE every 12 months) Radical treatment: Men will be offered a choice of : Surgery (robotic surgery recommended) Radical radiotherapy Hormonal androgen deprivation therapy A combination of radiotherapy and androgen deprivation therapy High dose brachytherapy (implantation of radioactive ‘seeds’ into the prostate to provide localised radiotherapy)

PSA testing PSA is not specific to cancer (can be raised in BPH and prostatitis) and can be normal in cancer. Low sensitivity ( 15% of prostate cancer patients have PSA below 4) Low specificity (2/3 men with PSA above 4 do not have cancer) PSA level threshold differs with age – above 3.0 for 50-59 yr olds and above 5.0 for 70 year old plus. Delay PSA if ejaculation within 48 hours, vigorous exercise within 48 hours and digital rectal exam within 1week. Delay PSA for at least 4 weeks after a proven treated UTI.

PSA testing No consensus on best treatment for early stage prostate cancer. Natural progression of disease poorly understood – it is not possible to predict which tumours are aggressive. 1 in 5 clinically significant prostate cancers are missed at biopsy.

PSA testing PSA test is said to be “unreliable” – it picks up innocuous tumours and subjects participants to unnecessary anxiety and treatments – that cause impotence, incontinence and ejaculatory problems. The PSA test in the US is a “hugely expensive public health disaster” – it cannot separate the turtle from the rabbit. Those with a PSA <1.0 were very unlikely to develop clinically relevant disease (mets, death)

scrotal swellings Most testicular tumours can be diagnosed as non-tender swellings of the body of the testis. Usually seminomas or teratomas and more common in 20-40s age group. Epididymal cysts are translucent, more common in over 40s and can be palpated as being isolated from the testis. Refer for urgent USS if diagnosis is unclear, such as when a hydrocoel is present. Remember acute swelling and pain in a 10-25 yr old male is testicular torsion until proven otherwise.

scrotal swellings (2) Rare – 8 cases / 100 000 population. 96% five year survival rate (even if metastasised) Painless, solid unilat mass but testicle can be enlarged and scrotal pain in 20% of cases. Also backache in 11% (para-aortic nodes) and gynaecomastia in 7% cases Suspect testicular cancer if lump in testis, doubtful epididymo-orchitis or orchitis not resolving after 3w. Do not do tumour markers – 2ww referral.

Haematuria - macroscopic Macroscopic (visible) haematuria in an adult is an urgent ( 2 week rule) referral to urology. Usually benign if under 50 and often due to UTIs – exclude this initially. 80% of cases of bladder cancer present as macroscopic haematuria. 25% of patients with visible haematuria had an underlying pathology. ( ? Referrals to a haematuria clinic). A bladder cancer can bleed intermittently so refer after one episode of visible bleeding. Anybody over 50 with a UTI and assoc bleeding should be rechecked for haematuria after treatment.

Haematuria-non-visible Microscopic haematuria (NVH) is a common problem in primary care and can be persistent in 2.5% of the population. Urine dipstick is the standard test for NVH – not urine microscopy (standardisation problems). 1+ blood is significant – exclude transient causes such as UTI, running (wait 3/7) and post-intercourse. In an asymptomatic person, NVH is defined as 2 out of 3 positive samples at an interval of 2-3 weeks. 15% of primary care referrals to a haematuria clinic had an identifiable cause (5% = cancer).

Decision algorithm for the investigation of non-visible haematuria and the referral criteria adopted by the British Association of Urological Surgeons and the Renal Association. Decision algorithm for the investigation of non-visible haematuria and the referral criteria adopted by the British Association of Urological Surgeons and the Renal Association. GFR, glomerular filtration rate; PCR, protein:creatinine ratio; ACR, albumin:creatinine ratio Kelly J D et al. BMJ 2009;338:bmj.a3021 ©2009 by British Medical Journal Publishing Group

Bladder Cancer Mostly TCCs – often multifocal in the bladder. 70% are superficial. Uncommon below 50 – commonest incidence at 65 yrs old. ( M:F ratio = 3:1 ) 90% present as macroscopic haematuria. 5-10% as microscopic haematuria. Common in industrialised countries and no single causative factor. Associations are smoking (2x risk), Schistosomiasis (WW) and occupational exposures, esp textiles and printing.

Be clear on cancer campaign If you notice blood in your pee, even if it’s ‘just the once’, tell your doctor. Relates to kidney and bladder cancer. 16, 600 people diagnosed annually each year and 7,500 deaths. Increased risk of renal carcinoma in dialysis patients. Increased risk of bladder cancer in manufacturing jobs – mainly rubber, dyes, textiles and plastics. Bladder cancer is 4x more common than renal cancer.

2 week rule referrals Macroscopic haematuria Persistent microscopic haematuria in > 40 yr olds. Testicular swelling High PSA (>20) with clinically malignant prostate. Elevated age specific PSA (with life expectancy above 10 yrs).

References Testicular and bladder cancers BMJ learning (website) BMJ 24/1/09 NVH in primary care JD Kelly The renal association (website) GP notebook (website) NICE cancer referral guidelines (2005) SIGN guidelines 124, 2011

References (2) Prostate cancer and PSA screening PSA screening for prostate cancer BMJ2014;348:g2559 Prostate cancer screening, BMJ2013; 346;f325

Link to GP curriculum 10.2 men’s health 3.5 evidence based practice 4.1 management in primary care 11 sexual health 5 healthy people (screening) 15.X rest of GP.