Prostate cancer. Christopher Eden. The Royal Surrey County Hospital, Guildford & The Hampshire Clinic, Old Basing.

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1 Prostate cancer Christopher Eden The Royal Surrey County Hospital, Guildford & The Hampshire Clinic, Old Basing.

2 Screening

3 Screening men for PCa (prostate cancer) using PSA (Prostate Specific Antigen blood test) saves lives.

4 European Randomised study of Screening for Prostate Cancer (ERSPC) 182,000 men randomised to screening or not. PSA tests every 2-4 years. Biopsy if PSA 3.0 ng/ml. Median Follow Up = 11 years. 29% reduction in PCa deaths in screened arm.

5 Swedish subset of ERSPC (Göteborg study). 20,000 patients randomized to screening or no screening. Mean Follow Up = 14 years. 42% reduction of rate of metastasis (spread of a cancer from one organ or part to another not directly connected with it) 44% reduction in Prostate Cancer-related deaths in screened patients.

6 Effect of screening on cancer mortality/10 5 men in USA FDA approves PSA for screening

7 NNT (Number Needed to Treat) 1 Breast cancer 18 1 Colon cancer 29 2 Cervical cancer 10 3 Prostate cancer 12 (48 in 2009) 1 Richardson A. J Med Screen 2001;8: Roetzheim R. Ann Fam Med 2004;2: Hugosson J et al. Lancet Oncology 2010;11:

8 Overtreatment

9 Individualized estimation of benefit from surgery from the Scandinavian Prostate Cancer Group Randomized trial (Eur Urol 2012; 62: ) After adjustment for competing risks:- It is hard to justify surgery in patients with Gleason score 6, pt1 or >70 years. Conversely surgery seems unequivocally of benefit if Gleason score 7, T 2. Note: Staging is the process of determining how far the cancer has spread. T stands for Tumour; T1 means the cancer can t be felt or seen on scans, and can only be seen under a microscope; T2 means the cancer can be felt or seen on scans, but is still contained inside the prostate; T>2 indicates locally advanced prostate cancer. Staging is crucial; it plays a central role in deciding which form of treatment is best.

10 Active surveillance

11 N = 450. Median FU = 6.8 years. Treatment in 30% (50% failed). Overall Survival = 78.6% Cause Specific Survival = 97.2% Risk of non-pca death was 18.6x higher

12

13 Surgeon volume predicts patient outcome Benoit RM et al. Complications after radical retropubic prostatectomy in the Medicare population. Urology 2000;56: Klein EA et al. Surgeon experience is strongly associated with biochemical recurrence after radical prostatectomy for all preoperative risk categories. J Urol 2008; 179: Savage C. J., Vickers A. J. Low annual caseloads of United States surgeons conducting radical prostatectomy. J Urol 2009; 182:

14 UK surgical caseload (British Association of Urological Surgeons complex operations database)

15 Most surgeons will take 8 years to overcome the steepest part of the learning curve.

16 Problems Recognised by USPSTF (USA), CTFPHC (Canada) & NICE (UK). PLCO study, Concerns re. overtreatment & side-effects.

17 Problems Recognised by USPSTF (USA), CTFPHC (Canada) & NICE (UK). PLCO study, Concerns re. overtreatment & side-effects. Cost.

18 The cost is balanced against benefit UK population = 60 million = 3.8 million men yrs. If screening uptake = 80% and biopsy rate = 23% (Rotterdam) then 756,600 men would be biopsied. Expected rate of detection (USA): 8.7% 17% 2.8x increase in surgery & 2.2x increase in DXT.

19 Resource implications screening. referral. imaging, biopsy. follow-up. re-imaging, re-biopsy, treatment. follow-up.

20 Resource implications screening. referral. imaging, biopsy. follow-up. re-imaging, re-biopsy, treatment. follow-up.?

21

22 any PCa palpable PCa advanced PCa

23 .baseline PSA measurements at a young age are stronger predictors of prostate cancer risk than race and family history.

24 Effect of USPSTF recommendations in 2012

25 Effect of USPSTF recommendations in % per year.

26 Cancer screening in the UK in Prostate cancer risk management programme. aim is to ensure that men who are concerned about the risk of prostate cancer receive clear and balanced information about the advantages and disadvantages of the PSA test and treatment for prostate cancer.

27 The future PSA at age 45. Risk-adapted screening thereafter. Better diagnostics. Low-risk: active surveillance unless genomic classifiers (Prolaris, Decipher) predict more aggressive tumour behaviour. Intermediate & high-risk: concentration of resources in cancer centres.

28 Prostate cancer Christopher Eden The Royal Surrey County Hospital, Guildford & The Hampshire Clinic, Old Basing.

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