1. Prostate Cancer Screening – Where We Stand now
Thomas W. Jarrett, MD
Professor and Chairman of Urology

2. Background
Chairman of Urology at GW University – an urban hospital serving DC and its surroundings
DC has the highest incidence of prostate cancer and the second highest death rate in the country

4. African Americans
60% more likely to develop the disease
> 1 in 5
Higher death rate
More aggressive disease at an earlier age
Recommendations against screening are highly likely to adversely affect population this high risk population
NCI

5. Disclosure
I was diagnosed with prostate cancer as a result of PSA screening at age 46
This was due to screening starting at age 40 because I am in the HIGH RISK group as my father and grandfather had the disease

6. Prostate Cancer Most genetic of all non skin cancers
Second highest cause of cancer death in men
The cancer that is most likely to become more relevant with the increasing life expectancy of our population

7. Lecture Outline Trends in death rates from prostate cancer
Affect of extended life expectancy
Recommendations of USPSTF based on screening studies
Relevance to African American Men

8. Death Rates from Prostate Cancer Falling Dramatically
Mortality from prostate cancer has decreased substantially (SEER data)
4% average per year
More rapid than any other cancer
Less than 10% present with metastatic disease
Etzioni R, et al
Cancer Causes Control, 2008

9. Age-adjusted death rate in US MenLL
Lung
Age-adjusted death rate in US Men
Prostate
Colon

10. The Number of Deaths From Prostate Cancer Could Dramatically Increase
The age at diagnosis for prostate cancer is higher than for any other cancer.

11. The Number of Deaths From Prostate Cancer Will Increase
The age at diagnosis for prostate cancer is higher than for any other cancer.
Although the death rate from prostate cancer (deaths per 100,000 men adjusted for age) is falling, if there are more older men in the population then there will be more total deaths.

12. 83 years
79 years
67 years

14. From 1997 to 2007, the death rate from CVD declined 27.8%
Estimated another 20% decrease in
Almost 50% decrease in death rates from cardiovascular disease

16. 2007 Death Rates
CVD
300.3 for males
211.6 for females.
Cancer
217.5 for males
151.3 for females
If CVD death rates continue to drop at current rates, cancer will overcome CVD as the major cause of death in years

17. Cause of Death in Men Younger Than 85
Cause C

18. Prostate Cancer

21. How Did We Get Where We Are Now?

22. Michelle Obama highlights preventive screening coverage health law July 2010

23. United States Preventative Services Task Force (USPSTF)

24. Healthy men don’t need PSA testing for prostate cancer panel says
Government task force discourages routine testing for prostate cancer
Front page

25. Prostate cancer discriminates: Understanding the unique and urgent needs of black men
Root DC

26. U.S. Preventive Services Task Force (USPSTF) 2012
Government task force discourages routine testing for prostate cancer
Healthy men don’t need PSA testing for prostate cancer, panel says
Recommended against prostate cancer screening even in high risk populations where there was little or no data to draw conclusions

27. U.S. Preventive Services Task Force (USPSTF) 2012
Criticism of prostate cancer screening programs
Adverse effects of treatment
Large number of patients needed to screen (NNS) and treat (NNT) to save a life
Claim that decrease in prostate cancer death rates not related to PSA screening

28. Conclusions of USPSTF
Based largely on European study followed out to 9 years and published in 2009
Short follow up in terms of prostate cancer
very few men of African descent in trial
Ignored 2012 study (published after recommendations had been decided) that showed increasing benefit of those who were followed out 11 years or greater

29. USPSTF Recommendations
Lumped AA and high risk men into recommendations without any data to support the actions

30. ESRPC Trial – Actual Follow-up
Relative Risk Reduction of 21%, p=0.001

31. Prostate cancer mortality I Intention to screen analysis, FU 11 and ≥12 years
21% decrease in relative risk of death from prostate cancer
29% decrease in relative risk of death if non-compliance factored in
38% reduction in cancer deaths in those followed at 11 and 12 years out
42% decrease in the number of men who present with advanced disease
Thus patient spared the agonizing consequences of spread to bone and other organs
Courtesy of Fritz Schroeder

32. Nelson-Aalen curves overall
Nelson-Aalen cumulative hazard estimates of M+ PCa.
Risk ratio 0.688, relative reduction in S arm 31.2%, P < 0.001

33. The Good of USPSTF Not all prostate cancer kills
Men with limited life expectancy are unlikely to benefit from screening
Many prostate cancers do not kill
Concept of not treating all men especially those with low risk disease

34. Prostate Cancer in African American Men
No great studies in America concentrating on the prostate cancer specifically in AA men
Outside studies strongly suggest that prostate cancer in AA men
More aggressive
Earlier in life
Higher death rate

35. Prostate Cancer in African American Men
BUT the studies we have strongly suggest that compared to other populations
60% more likely to develop the disease
Higher death rate
More aggressive disease at an earlier age
How could task force make such recommendations without any data
Racial and Ethnic
Differences in
Advanced-Stage Prostate
Cancer: the Prostate Cancer
Outcomes Study

36. Prostate Cancer in African American Men
Absence of screening eliminates the chance for early diagnosis
More deaths from disease
More patients presenting with advanced/painful disease

37. Problem
Take home message from media to most men is that screening is not desirable
Most detrimental is perception in African American men that screening is not needed without any basis for conclusions

38. Impact of Recommendations

39. GW - Prostate cancer screening program 2008-9
Joint effort of GW Cancer Center, GW Hosp, GW MFA, Urologic Surgeons of Washington
1800 screenings in 14 months
63 cancer diagnoses
>50% African American
No patient denied treatment
High profile screenings at
Redskins stadium
NBC Health Fair Expo
Weekly screening in GW MFA

40. GW Prostate cancer screening program 2012-13
86 men screened

41. Each September the NFL ignores Prostate Cancer Awareness Month
Each September the NFL ignores Prostate Cancer Awareness Month. Never has the NFL had their teams display blue ribbons or other items depicting a campaign to raise awareness and funding for the second most deadly cancer affecting men. 1 in 6 men will be afflicted with this dreaded disease. This means an average of 10 men on each NFL team will have to deal with this illness sometime in their lives and many will die from it.

43. Breast and Prostate Cancer
Why are two such similar diseases treated so differently
Studies show that PSA screening is equally as good as breast cancer screening?
The women’s groups had successfully persuaded the nation to realize that the advice was a mistake

44. Alternative Approach
Eliminating screening eliminates the chances for early diagnosis

45. Alternative Approach
Rather than halting efforts at halting PSA screening
Prostate cancer diagnosis must be uncoupled from prostate cancer intervention
More expectant management
Most serious side effects are from treatment, not diagnosis of prostate cancer

46. Research Identify those with prostate cancer at risk for progression
Imaging
Genetic testing
Better risk categorization

47. Summary Prostate Cancer Screening
As life expectancy increases, it is quite possible that many more men will live long enough to succumb to prostate cancer
Men at high risk (first degree relative, African American) still should be screened starting at age 40
Studies looking specifically at high risk men needed to draw conclusions

48. “We need to make better use of the test, not ban it”
Michael Milliken