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J. Jacques Carter, MD, MPH
Assistant Professor of Medicine
Department of Medicine
Harvard Medical School
Beth Israel Deaconess Medical
Center
Boston, Massachusetts
PHEN Medical Advisor
PROSTATE CANCER
The Screening Controversy
The Screening Controversy
Prostate Cancer
 Most
commonly diagnosed
visceral Cancer in men
 30% of all Cancers in men
 ~220K cases yearly
 ~30K deaths yearly
Lifetime risk of Developing CaP is
13-17% (~1 in 6)
Survival is multifactorial, especially the
extent of tumor at the time of diagnosis
 5-year survival with cancer confined to the
prostate (localized) or just regional is
spread is 100%
 Only 31.9% if diagnosed with distant
metastases

Possible Benefit of Screening?
A
screening program that could
identify asymptomatic men with
aggressive localized tumors might be
expected to reduce prostate cancer
morbidity and mortality
Why the Controversy???
Effectiveness of Treatment remains
uncertain
 No studies have yet proven a survival
benefit with screening
 Considerable Data showing potential
harms from aggressive treatments

Prostate Specific Antigen
Glycoprotein produced by prostate
epithelial cells
 May be elevated with Prostate Cancer
 Also elevated with BPH, prostatitis
 Other causes of elevation
 Value is lowered by some medications

Positive Predictive Value
A test performance statistic
 Refers to the PROPORTION of men with
an elevated PSA who really have prostate
cancer

The PPV value for a PSA greater than 4.0
is ~ 30 %
 For a PSA between 4.0 – 10.0, the PPV is
~ 25%
 This increases to 42 – 64 % for PSA’s
greater than 10.0

March 2009
Mortality Results from a Randomized
Prostate-Cancer Screening Trial
–N Eng J Med 2009; 360:1310-9
Report of the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer
Study Group
76K participants randomized to screening or control groups
Conclusion: No significant difference in mortality between the
two study groups
August 2009
Prostate Cancer Diagnosis and Treatment
After the Introduction of Prostate-Specific
Antigen Screening: 1986-2005
J Natl Cancer Inst 2009; 101:1-5



Drs. Welch (VA Outcomes Group & Dartmouth) and Albertsen
(UConn) looked at data from NCI’s SEER Program on prostate
cancer incidence beginning one year before PSA introduction.
Noted that an additional 1.3m men were diagnosed with CaP, with
1m undergoing definitive treatment
Reported a major increase incidence of younger men being
diagnosed, especially age 50-59, and under age 50.
Concluded that PSA screening resulted in more than 1m
ADDITIONAL men being diagnosed and treated . Most of this
excess incidence must represent overdiagnosis
Beth Israel
Deaconess Medical
Center
Boston
Massachusetts