Prostate Cancer Screening: Phantom menace to society. Folusho Ogunfiditimi, DM, MPH, PA-C Vattikuti Urology Institute Henry Ford Health System
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1 Prostate Cancer Screening: Phantom menace to society Folusho Ogunfiditimi, DM, MPH, PA-C Vattikuti Urology Institute Henry Ford Health System
2 Objectives USPTF Recommendations on PSA testing Justification for the recommendations Journal club: Evidence Pros and Cons to screening What is PSA The Politics of Screening Where do we go from here Discuss AUA guidelines
3 Urologist v. World
4 USPSTF Recommendation Goal of USPSTF is to separate the science of screening from the politics of screening- theoretically Mammography Guidelines of 2009 Stop screening for women below 50years Screening should be every 2 years for women above 50yrs Prostate Cancer guidelines have been in place since 2009 but not released till Oct The Cancer Letter Oct. 2011
5 USPSTF Recommendation Downgrade PSA screening rating from I to D. I = Inconclusive, - insufficient evidence (Current status) D = No Benefit for screening men below 75- Mod- high evidence that service has no net benefit USPSTF represents a pillar of evidence based medicine in the US Government Level 1 Evidence - 5 RCTs Quebec Trial-2004, ERSPC Trial-2009, PLCO 2009, Goteborg Trial (Sweden, 2010), Norrkoping (Sweden, 2011-Update) The Cancer Letter Oct. 2011
6 6 Initial Reaction
7 Risk Reduction of CaP Mortality Quebec (2004) 64%reduction ERSPC (2009) 20%reduction PLCO (2009) No reduction Goteborg (2010) 44% reduction Norrkoping (2011) No reduction 7
8 Summary of Trials Screening trial Age range Median follow-up, Years (Time Period) Method of screening PSA threshold Cumulative CaP incidence: screened vs control CaP deaths/total screened vs control Risk of death from prostate cancer Quebec (2004) [5] ( ) PSA + DRE ± TRUS (annual) <3.0 not provided 10/7 348 vs 74/ Relative risk = 0.36 (CI ) i.e. 64% reduction in CaP mortality ERSPC (2009) [6] ( ) PSA ± DRE ± TRUS (4-yearly in 6 of 7 centres) < % vs 4.8% 214/ vs 326/ Rate ratio = 0.80 (CI ) i.e. 20% reduction in CaP mortality PLCO (2009) [7] ( ) PSA (yearly for 6 years) + DRE (yearly for 4 years) < % vs 6.1% 50/ vs 44/ (at 7 years) Rate ratio = 1.11 (CI ) i.e. no reduction in CaP mortality Göteborg study (2010) [8] ( ) PSA (every 2 years) < % vs 8.2% 44/9 952 vs 78/9 952 Relative risk = 0.56 (CI, ) i.e. 44% reduction in CaP mortality Norrkoping (2011) [9] ( ) DRE for first round; PSA + DRE after (3-yearly) < % vs 3.9% 30/1 494 vs 130/7 532 Risk ratio = 1.16 (CI ) i.e. no reduction in CaP mortality Ghani, K, et. BJU 2011
9 Critique Quebec (2004) Old Study, Old data, low compliance ERSPC (2009) Gold Standard, but only 20% reduction in 7 years, PLCO (2009) US study, poor screening interval (5-6yrs), controls were contaminated by unlimited amount of prescreening (44%) and higher PSA cut off. Goteborg (2010) younger patients, lower PSA threshold, shorter screening trial, low number of participants Norrkoping (2011) Longest follow, significant under screening and drop out rate. Change in screening protocol from DRE to PSA screening, 2/3 rd did not get a second PSA screening. 9 Ghani, K,et. BJU 2011
10 What is the PSA Test PSA Perfect Serum Assay PSA= Prostate Specific Antigen (No cancer in the definition Good Specificity to Prostate Tissue Poor Sensitivity to Prostate Cancer The best non perfect serum tumor marker for prostate cancer Its cheap Mammograms for Brest CT scans for Kidneys, MRIs etc.
11 Other Prostate Cancer Screening Options Ultrasensitive PSA [redefined PSA assay] % Free PSA [% free <20, suspect CaP] PSA Velocity [>0.75 rise in PSA annually] PSA Density [PSA/Prostate ml. High ratio =? CaP] Alkaline Phosphatase [only present with advanced CaP]
12 Economics about PSA Screening NNS and NNT (ratio to mortality) ERSPC=1410 NNS, 48 NNT Gothburg =293 NNS, 12 NNT PSA based screening results in earlier diagnosis of CaP Politics, Prostate Cancer and Your Health Cost and Funding Impact of Health Care Reform Mammography Congressional Influences
13 Screened Unscreened NNS= No Cancer NNS= Cancer NNS= No Cancer NNS= Cancer No treat No treat NNT = Treat NNT= Treat Mortality
14 14 CONFIDENTIAL
15
16 Prostate-cancer screening--what the U.S. Preventive Services Task Force left out. 3 points that influence PSA Screening Office based decision not based on evidence based medicine No such things as clear evidenced based medicine 2 large trials are conflicting at best Can informed consent truly be informed if there is no concrete Data to support Variability in PSA level Management in urology and PC practices The influence of ABX on PSA no data to support Multiple screenings to asses degree of variability for everyone, or for individuals Impact of Health Policy and Cost on Health Care Practices and decision making ERSPC = 5.2m spent to prevent 1 death from CaP Impact of Health Disparities Should we segregate screening 16 o Brett AS, Ablin RJ. N Engl J Med Nov 24;365(21):
17 AUA Guidelines Prostate cancer is the most common noncutaneous cancer in men in the US, and the second leading cause of male cancer death (28,660 in 2008) CaP is heterogeneous - autopsy studies= 1/3 men >50ys has CaP, with 80% limited in size and grade and, clinically insignificant. The lifetime risk of prostate cancer death = 3%. All clinicians should discuss the benefits and harms associated with CaP with Patients Decision to screen should be based on individual patient preferences. o AUA
18 18 CONFIDENTIAL
19 Summary 19 PSA = Over detection : Yes Overreaction = Overtreatment: Yes Alternate Options = Little to none Consider all factors influencing Cap Screening What to do Improved Counseling on screening and treatment options Earlier detection is better than late cure Research for better test, Improve on existing treatment options including active surveillance
20 20?
21 It boils down to this...i just turned 40 and I m getting my PSA test and MORE on Monday.
22 22 Questions and answers
23 References The Cancer Letter Special Issue. Oct. 7, Vol. 37 No. 37 Ghani, K., Trinh, Q-D., Menon, M. The Phantom Menace of Prostate Cancer Screening. BJUI. Nov Brett AS, Ablin RJ. Prostate-cancer screening--what the U.S. Preventive Services Task Force left out. N Engl J Med Nov 24;365(21): ndex.html 23 CONFIDENTIAL
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