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Prostate Cancer Screening Bruce L. Houghton, MD Associate Professor of Medicine Division of General Medicine Department of Internal Medicine Creighton University School of Medicine http://en.wikipedia.org/wiki/Image:Prostatelead.jpg http://upload.wikimedia.org/wikipedia/commons/3/35/Male_anatomy.png What is a Prostate? • Small gland (about 3 to 4 cm diameter) • A little larger than a walnut • Secretes a slightly alkaline fluid that combines with spermatozoa to create semen. • The prostatic alkaline fluid prolongs the survival of the spermatozoa in the slightly acidotic vaginal tract Prostate • Prostate needs testosterone to function • Diseases of the Prostate – Prostatitis (inflammation and/or infection of the prostate) – Benign Prostatic Hypertrophy (enlarged prostate) – Prostate Cancer Prostate Cancer • Leading type of cancer for U.S. men • 1 in every 6 U.S. men will develop invasive prostate cancer before he dies • Second leading cause of cancer death in U.S. men – Following Lung cancer • 2007 – 218,890 new cases diagnosed – 27,050 men died of prostate cancer Prostate Cancer • U.S. Men have 1 in 6 lifetime chance of getting prostate cancer – But only 3% chance of dying of prostate cancer • Autopsy series – Detect Prostate Cancer in 1/3 of men younger than 80 years and 2/3 of men older than 80 • Suggests that prostate cancer is slow growing and that men die of other causes before prostate cancer is evident Prostate Cancer Incidence • Age-Adjusted Incidence (new cases) of prostate cancer have increased over the last 50 years • Peaked 1990s – Mostly with increased early detection due to Prostate-specific antigen (PSA) testing in late 1980s • Associated mostly with increased early detection Prostate cancer: changes over time average annual age-adjusted incidence and mortality rates in the United States, 1973 - 2001 (2001 US standard) Source: SEER Program. Prostate Cancer Risk Factors • Increases with Age – more common after age 50 years • Increases with family history of prostate cancer • African-American men at higher risk – Both of developing prostate cancer and of dying from prostate cancer Prostate Cancer Mortality • Extent of tumor at time of diagnosis is especially important • Localized (cancer only within gland) – 75% 10-year survival rate • Regional Extension – 55% 10-year survival rate • Metastases – 15% 10-year survival rate http://nymag.com/daily/intel/31_giuliani_lg.jpg Dan Fogelberg (expired age 56) http://www.stevelevine.com/fogelberg.jpg Merv Griffin (expired age 82) http://asapblogs.typepad.com/photos/uncategorized/2007/08/12/merv_griffin_rumb.jpg Robert De Niro (diagnosed 2003) http://www.celebritiesfans.com/showCELEB.php?celebID=1162 Why push for screening? • Most early prostate cancer is asymptomatic • Symptoms of prostate cancer – Sometimes similar to BPH symptoms • Frequent urination, nocturnal urination, difficulty urinating – Erectile dysfunction or painful ejaculation – Advanced cancer can cause bone pain “Perfect” Prostate Cancer Screening Test • Identify asymptomatic men with aggressive tumors early when the tumor is localized – Decrease mortality – Decrease morbidity • Urinary obstruction • Prostate Cancer Metastatic bone pain Prostate Cancer Screening • Digital Rectal Examination (DRE) • Prostate Specific Antigen Test (PSA) • BPH Cancer Prostate Cancer Prevention? • Vitamin E and Selenium – Not enough evidence to recommend • Finasteride (Proscar) – Questionable – Reduces risk of developing prostate cancer by about 25% – However aggressive cancers were diagnosed more frequently in the first year in men who took finasteride than who did not Digital Rectal Examination • Physician examines the prostate with a gloved finger • Detect enlargement of the prostate gland • Asymmetry (enlarged lobe) • Detect nodules (lumps) • ?Normal consistency is similar to tip of your nose? http://www.abbottdiagnostics.com/Your_Health/Cancer-Oncology/images/cancer_prostate_04.jpg http://www.hubbywishlist.com/images/fletch.jpg How good is the DRE? • Rarely done alone (PSA is often drawn as well) • Ranges of Sensitivity for DRE alone – 18 to 22% up to 55 to 68% in asymptomatic men Prostate Specific Antigen (PSA) • Glycoprotein produced by the prostate epithelial cells • Elevated PSA can precede clinical disease by 5 to 10 years • DRE has MINIMAL effect on PSA level and PSA CAN BE drawn following a rectal examination What Will Elevate PSA? • • • • BPH Urinary retention Acute Prostatitis DRE – 0.26 to 0.4 ng/ml • Ejaculation • Perineal trauma – By up to 0.8 ng/ml – Return to normal in 48 hours • Procedures – TURP – Cystoscopy – Prostate biopsy Finasteride (Proscar) Dutasteride (Avodart) • Treatments for BPH • Will LOWER the PSA about 50% • ‘Double’ whatever level you get from a patient on Finasteride or Dutasteride PSA • Traditional cutoff level is 4 ng/ml • Other Ranges (not recommended by FDA) – 40 to 49 years — 0 to 2.5 ng/mL – 50 to 59 years — 0 to 3.5 ng/mL – 60 to 69 years — 0 to 4.5 ng/mL – 70 to 79 years — 0 to 6.5 ng/mL Other PSA Tests you may hear about • PSA Velocity (measure PSA change over time) • PSA Density • Free PSA • Complexed PSA What is the Harm of Screening? • Anxiety (‘Labeling’) • Unnecessary Prostate Biopsy – If the PSA is elevated, most likely you will see a Urologist – Risk of complication less than 1% • Overdiagnosis – Diagnosed and treated for disease that may have never caused significant problems • Costs • False Security Prostate Cancer Treatments • Surgery • Radiation Treatment • Hormonal Therapy Other Resources • www.patients.uptodate.com What to Do? • No convincing randomized controlled trials that show prostate cancer screening decreases morbidity or mortality from prostate cancer – Cochrane Database Syst Rev. 2006 Jul 19;3:CD004720 Two Large Prostate Cancer Screening Trials Underway • American Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial • European Randomized Study of Screening for Prostate Cancer (ERSPC) • Studies plan to pool their results • Final data will not be available for years What are Current Recommendations for Prostate Cancer Screening? • • • • • American Urological Association American Cancer Society American Academy of Family Practice (AAFP) American College of Physicians Canadian Task Force on Preventative Health Care • US Preventative Services Task Force (USPSTF) American Urological Association • Offer PSA Screening to men at age 50 years and who have an estimated life expectancy of 10 years or more • Men with first degree relatives who have prostate cancer and African Americans may benefit from screening at an earlier age (usually in practice age 40) American Cancer Society • Both DRE and PSA be offered to men aged 50 an older and who have a life expectancy of 10 years or more USPSTF, AAFP • Insufficient evidence to recommend for or against routine screening with PSA or DRE American College of Physicians • Giving men information about the benefits and risks/harms of screening to help them make a decision based on personal preference Canadian Task Force on Preventative Health Care • Recommends against routine screening with PSA • Insufficient evidence to make a recommendation on DRE American College of Preventive Medicine (Feb 2008 statement) • Concurs with USPSTF • Insufficient evidence currently to recommend routine population screening with DRE or PSA. • Am J Prev Med 2008; 34 (2) Urologist Willet Whitmore • is cure possible in those for whom it is necessary, and is cure necessary in those for whom it is possible? • Urol Clin North Am 1990 Nov;17(4):689-97 So, What To Do? • Speak with your physician • Review the information on the website • Decide what you want after weighing risks and benefits of screening Questions/Comments?