M Ravanbod Medical oncologist Bushehr – 11/91

A 50 y/o white man comes for check up and wants to discuss about prostate cancer. Negative family history No lower urinary tract symptoms What would you advise?

Most frequent non-skin cancer Second leading cause of cancer death About 250,000 new cases anually About 34,000 deaths/yr After peaking in early 1990s about 30% decrease till 2007 After 2007 at diagnosis 80% confined to prostate,4% metastatic

Risk factors Older age Positive family history Black race Median age at diagnosis is 67.

In the US 90% detected by screening After introduction of PSA lifetime diagnosis doubled ;9% in 1985;16% in 2007 Great majority of men with a diagnosis of prostate cancer die from other causes Autopsy data suggests 30% of men>50y and 70% >70y have occult prostate cancer.

SEER registry data 90,000 prostate cancer Death risk from prostate cancer: 8% for well-diff. tumors 26% for poorly-diff. Death risk from other causes:60%

Screening The rationale for screening is that early detection and treatment of asymptomatic cancers could extend life, as compared with treatment at the time of clinical diagnosis.

Effective screening requires: - an accurate,reliable,easy to administer test that detects clinically important cancers at a preclinical stage. -availability of effective treatment that results in better outcomes when administered early.

For many years DRE was the primary screening test for prostate cancer In the late 1980s PSA widely adopted for screening. There was no evidence that testing reduced the risk of death from prostate cancer

False positive PSA BPH prostatitis Cystitis Ejaculation Perineal trauma Recent urinary tract instrumentation or surgery

False negative In prostate cancer prevention trial: -15% of men with normal DRE and PSA= 4 had prostate cancer - 9% in nl DRE and PSA< 1

Approaches to improve the diagnostic accuracy of PSA test Measuring PSA velocity Free & pr-bound PSA PSA density Use of cutoff values for age & race However,the clinical usefulness of these strategies remains unproved.

ERSPC trial 7 europian countries 182,160 men between 50-74y Prostate cancer 8.2% in screen group vs 4.8% in control group Mortality from prostate cancer was 20% lower in screen group, not for & y

PLCO trial In US, men between y PSA & DRE annually for 6 yrs 22% more cases detected in screen group Did not show any reduction in overall or prostate cancer mortality

US Preventive Services Task Force Recently issued a draft recommendation against PSA screening for asymptomatic men, regardless of their age,race or family history The Task Force concluded that the harms of screening outweigh the benefits.

conclusion Decision about prostate cancer screening should be based on the preferences of an informed patient.

ACS guidelines Shared decision making between patient and physician Age to begin: - average risk :50 (40 in AUA) - high risk (black or 1 st degree relative with prostate cancer) : (40 in AUA) Discontinuation of screening: life expectancy <10 yr

Screening tests: PSA, DRE(optional) Frequency : annual (every other yr if PSA<2.5) Criteria for biopsy:PSA>4.abnormal DRE. Individualize risk assessment if PSA = 2.5-4