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Prostate cancer – Who needs screening? Professor Frank Chinegwundoh MBE Consultant Urological Surgeon Barts Health NHS Trust Definition of screening • Screening is a process of identifying apparently healthy people who may be at increased risk of a disease or condition. • They can be offered information, further tests and appropriate treatment to reduce their risk and/or any complications arising from the disease or condition • www.screening.nhs.uk/screening#fileid7942 accessed 28.6.15 UK screening programmes UK National Screening Committee (UKNSC) • • • Programme appraisal criteria Criteria for appraising the viability, effectiveness and appropriateness of a screening programme The Condition • 1. The condition should be an important health problem • 2. The epidemiology and natural history of the condition, including development from latent to declared disease, should be adequately understood and there should be a detectable risk factor, disease marker, latent period or early symptomatic stage. • 3. All the cost-effective primary prevention interventions should have been implemented as far as practicable. • 4. If the carriers of a mutation are identified as a result of screening the natural history of people with this status should be understood, including the psychological implications. Criteria for screening programme continued • The Test • 5. There should be a simple, safe, precise and validated screening test. 6. The distribution of test values in the target population should be known and a suitable cut-off level defined and agreed. 7. The test should be acceptable to the population. 8. There should be an agreed policy on the further diagnostic investigation of individuals with a positive test result and on the choices available to those individuals. – Wilson JMG, Jungner G. Principles and practice of screening for disease. Public Health Paper Number 34. Geneva: WHO, 1968. Criteria for screening programme cont. • The Treatment • 10. There should be an effective treatment or intervention for patients identified through early detection, with evidence of early treatment leading to better outcomes than late treatment. 11. There should be agreed evidence based policies covering which individuals should be offered treatment and the appropriate treatment to be offered. 12. Clinical management of the condition and patient outcomes should be optimised in all health care providers prior to participation in a screening programme. Criteria for screening programme cont. • The Screening Programme 13. There should be evidence from high quality Randomised Controlled Trials that the screening programme is effective in reducing mortality or morbidity. 14. There should be evidence that the complete screening programme (test, diagnostic procedures, treatment/ intervention) is clinically, socially and ethically acceptable to health professionals and the public. 15. The benefit from the screening programme should outweigh the physical and psychological harm (caused by the test, diagnostic procedures and treatment). 16. The opportunity cost of the screening programme (including testing, diagnosis and treatment, administration, training and quality assurance) should be economically balanced in relation to expenditure on medical care as a whole (ie. value for money). Assessment against this criteria should have regard to evidence from cost benefit and/or cost effectiveness analyses and have regard to the effective use of available resource. http://www.screening.nhs.uk/criteria#fileid9287 accessed 28.6.15 Review of evidence Prostate cancer is an important health issue Increase of prostate cancer over time Natural history Risk factors for prostate cancer – ethnicity, age, FH Age Family history Additional risk factors for prostate cancer • Weight - Risk of advanced prostate cancer by 9% for every 5kg/m2 & 15-20 % risk of dying Height - 7% Risk of dying from ca p per 6cm increase in height Other potential risk factors Risk calculators UKNSC screening criteria 8 • There should be an agreed policy on the further diagnostic Ix of individuals with a +ve test result • • • • TRUS Bx mpMRI Transperineal Bx Fusion targeted Bx TRUS biopsy UKNSC screening criteria 10 • The Treatment • there should be agreed evidence based policies covering which individuals should be offered treatment and the appropriate treatment to be offered UKNSC criteria 13 evidence base from randomised clinical trials of reduction in mortality or morbidity Update on European randomised screening study 2014 European screening study • In The Lancet, Fritz Schroder and colleagues3 now report 13-year mortality data from the ERSPC study. At 9 years, screening appeared to reduce prostate cancer mortality by 15% (rate ratio 0·85, 95% CI 0·70–1·03); this reduction was 22% at 11 years (0·78, 0·66–0·91) and 21% at 13 years (0·79, 0·69–0·91). ESPRC 2014 update • In men aged 55-69 years, the relative mortality reduction remained similar at 21%; the absolute reduction increased from 0.9 to 1.28 fewer deaths/1000 men screened. This translates into much improved figures needing to be invited for screening and diagnosed, at 781 and 27 (1410 and 48 in 2009). • overall mortality does not differ between the arms of the study. The main downside of PSA-driven screening remains the diagnosis of non-life-threatening cancers (overdiagnosis) by screening, at a frequency of about 40% UKNSC position on screening for prostate cancer June 2015 • The UK NSC recommendation on Prostate cancer screening/PSA testing in men over the age of 50 (currently in consultation) • This recommendation is currently being reviewed as part of the UK NSC's regular review cycle of all policies. The review process began in Jan 2014 and is estimated to be completed by Nov 2015. » Download the expert review for Prostate Cancer (PDF document, 1016KB) The UK NSC welcomes comments and feedback on the expert review during the consultation period that lasts from 03/06/2015 until 04/09/2015. Please send comments to Adrian Byrtus by email using this feedback form. • • • • Recommendation: Systematic population screening programme not recommended • The UK NSC does not recommend universal screening of men for prostate cancer. • PSA (prostate specific antigen) testing can, however, be performed on request. Information is provided on the risks and benefits by the Prostate Cancer Risk Management Programme. UKNSC –why not to screen population • The UK NSC does not recommend universal screening of men for prostate cancer because: • The test for prostate cancer is not effective enough and does not identify a large proportion of men who in fact have prostate cancer. • A positive test will lead in most cases to a biopsy, which often does not give a definitive answer and leads to anxiety and to further investigations. • Current research indicates for every 100,000 men at age 50 offered screening, 748 would end up being treated. The men accepting screening would have their lives extended on average by a day – while 274 men would be made impotent, 25 incontinent and 17 would have rectal problems as a result of the treatment. Overtreatment can be reduced • Outcome Following Active Surveillance of Men with Screendetected Prostate Cancer. Results from the Göteborg Randomised Population-based Prostate Cancer Screening Trial • By: Rebecka Arnsrud Godtmana , Erik Holmbergb, Ali Khatamia, Johan Strannea and Jonas Hugossona • European Urology, Volume 63 Issue 1, January 2013, Pages 101-107 • Published online: 01 January 2013 • Conclusion results indicate that overtreatment—one of the major potential drawbacks of PSA screening—can be reduced, as a large proportion of screen-detected PCa can be managed safely with AS. Men with very low- and low-risk PCa constituted more than half of all screen-detected PCa, and for these men, AS appears to be an attractive alternative, especially in men >65 yr of age. How to screen high risk groups • Ethnicity • Family history • By GP • National invitation An American perspective