1. PSA (Prostate Specific Antigen) - what’s new
Tom Pickles
Professor, Radiation Oncology, UBC
Radiation Oncology Program, BC Cancer Agency
it is a couple of years since I last took apart and debate with drew. that time I got the Public vote. This time I think it is going to be more difficult for me to convince you. that is because he comes on with a wealth of scientific data to back his claims. but I have the arch nemesis, which is scientific skepticism. So lets ee how it pans out.

2. Summary Where PSA has established a useful role
Monitoring treatment outcomes
To predict treatment outcomes
Where the use is less clear
In population screening

3. PSA after treatment
Cured with surgery

4. PSA after treatment
Cured with seeds

5. PSA after treatment
PSA bounce

6. Improvements in outcome
2004
1994
p=0.013

7. PSA relapse
Brachy 95%
EBRT 75%
p=0.0008

8. PSA after treatment
Relapse

9. PSA after treatment
PSA relapse and risk of dying of prostate cancer

10. Predictive power of PSA
The PSA doubling time is the key.
D’Amico et al., Journal of the National Cancer Institute,
Vol. 95, No. 18, September 17, 2003

11. Now, where PSA is not so good
The Screening controversy

12. No PSA level free of cancer risk
Significant overlap
Holmström,BMJ 2009;339:b3537

13. PSA: No safe level
Thompson. JCO VOLUME 23 NUMBER 32 NOVEMBER

14. The underlying problem
PSA is not a great test!
Receiver Operating Characteristic Curve for PSA
Numbers on curve represent PSA cut points.
AUC=0.67
Hoffmaan, BMC Fam Pract. 2002; 3: 19.

15. Prostate cancer in Canada
Incidence
Canadian Cancer Society Stats 2014

16. Prostate cancer in Canada
Incidence
Canadian Cancer Society Stats 2014

17. PSA screening practices in Canada
~55% have had a PSA in the last 5 years
CCHS 2003

18. Screening trials: 3 proper ones
USA
most had PSA tests before
Patient randomized 50/50
family doc handled the results
Europe
few had PSA test before
control patients unaware of study
Urologist handled abnormal result UK
few had PSA test before
GP practices randomized
Patient counseled first

19. Screening trials: 3 proper onesUK
USA
Cumulative number of deaths
Study year of death
Europe

20. How many benefit? For every 1000 men screened
How many have an abnormal PSA?
How many have prostate cancer diagnosed?
How many will live longer as a result?

21. US Services Taskforce infographic http://www. cancer

22. US Services Taskforce infographic http://www. cancer

23. US Services Taskforce infographic http://www. cancer

24. US Services Taskforce infographic http://www. cancer

25. US Services Taskforce infographic http://www. cancer

26. Governmental recommendations
The USPSTF recommends discussing screening for prostate cancer.
2017: “Grade C” recommendation
Canadian Task Force on Preventive Health Care
2014: recommendations recommend against (Grade “D” recommendation)
NHS (UK)
Do it if patient wants
Australia
Do not offer

27. Prostate cancer in Canada
Incidence
Deaths
Canadian Cancer Society Stats 2014

28. Prostate cancer in Canada
Deaths down 45%
Since 1995
Canadian Cancer Society Stats 2014

29. New ways of screening Baseline test in mid 40’s
Then adapt screening intensity
E.g. PSA <0.5
check again at 50, if <1
Check again at 60, if <1 then stop
If PSA >1
Repeat annually to 50
If rising, consider biopsy

30. PSA testing at 45-50 yrs But beware of false positives
Risk of advanced cancer especially predicted
But beware of false positives
infection, ejaculation etc
Ulmert BMC Medicine 2008, 6:6

31. New tests
Not there yet
PCA3
ProPSA
PSA density
Free PSA
hK2