Prostate Cancer: Screening Update Middlesex Hospital Cancer Center Comprehensive Prostate Cancer Program

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1 Prostate Cancer: Screening Update Middlesex Hospital Cancer Center Comprehensive Prostate Cancer Program Edward G. Myer, M.D. Middlesex Urology, P.C. October 15, 2015

2 Middlesex Hospital Cancer Center Comprehensive Prostate Cancer Program

3 The Question: How do we distinguish clinically significant from indolent prostate cancers?

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5 Haas GP, Delongchamps N, Brawley OW, Wang CY, delarosa G. The Worldwide Epidemiology of Prostate Cancer: Perspectives from Autopsy Studies. Can J Urol 2008;15(1):

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7 Screening: the goal has changed How do we identify clinically significant prostate cancers early enough to have a meaningful intervention? Catalona WJ, Smith MD, Ratliff TL, et al. Measurement of prostate specific antigen in serum as a screening test for prostate cancer. NEJM 1991;324(17):

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9 Screening Recommendations U.S. Preventative Services Task Force American Cancer Society National Comprehensive Cancer Network Centers for Disease Control and Prevention American College of Preventative Medicine Institute for Clinical Systems Improvement American Medical Association American Urological Association European Association of Urology Memorial Sloane-Kettering Cancer Center Mayo Clinic

10 USPSTF The USPSTF recommends against prostatespecific antigen (PSA)-based screening for prostate cancer (grade D recommendation). Moyer VA, on behalf of the USPSTF. Screening for prostate cancer: U.S. Preventative Services Task Force Recommendation Statement. Ann Int Med 2012;157(2):

11 USPSTF Andriole GL, Crawford ED, Grubb RL, et al. Mortality results from a randomized prostate cancer screening trial. NEJM 2009;360: Schroder FH Hugosson J, Roobol MJ, et al. Screening and prostate cancer mortality in a randomized European study. NEJM 2009; 360:

12 AUA For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man's values and preferences. (Standard; Evidence Strength Grade B) NNS 1410 NNT 48 Carter HB, Albertsen PC, Barry MJ, et al. Early detection of prostate cancer: AUA Guideline. Schroder FH Hugosson J, Roobol MJ, et al. Screening and prostate cancer mortality in a randomized European study. N Engl J Med. 2009;360:

13 Goteburg Trial Control 77 Screening 44 NNS 293 NNT 12 Hugosson J, Carlsson S, Aus G, et al. Mortality results from the Goteburg Randomized Prostate Cancer Screening Trial. Lancet Oncol 2010;11(8):

14 Since 2012?

15 ERSPC, revisited NNS 781 NNT 27 Schroder FH Hugosson J, Roobol MJ, et al. The European Randomized Study of Screening for Prostate Cancer Prostate cancer mortality at 13 years of follow up. Lancet 2014;384:

16 Screening since 2012 Kim SP, Karnes RJ, Nguyen PL, et al. A national survey of radiation oncologists and urologists on recommendations of prostatespecific antigen screening for prostate cancer. BJU Int May;113(5b):E

17 Screening since 2012 Aslani A, Minnillo BJ, Johnson B, et al. The impact of recent screening recommendations on prostate cancer screening in a large health care system. J Urol 2014;191(6):

18 Screening since 2012 Cohn JA, Wang CE, Lakeman JC, et al. Primary care physician PSA screening practices before and after the final USPSTF recommendation. Urologic Oncology 2014;32:23-41.

19 Screening since 2012 Drazer MW, Huo D, Eggener SE. National Prostate Cancer Screening Rates After the 2012 US Preventive Services Task Force Recommendation Discouraging Prostate-Specific Antigen-Based Screening. J Clin Oncol. 2015;33(22):

20 Screening since 2012 Li J, Berkowitz Z, Hall IJ. Decrease in Prostate Cancer Testing Following the US Preventive Services Task Force (USPSTF) Recommendations. J Am Board Fam Med Jul-Aug;28(4):491-3.

21 Screening since 2012 Perez T, Danzig MR, Ghandour RA, et al. Impact of the 2012 USPSTF statement on prostate-specific antigen screening: analysis of urologic and primary care practices. Urology 2015;85(1):85-91.

22 Screening since 2012 Bhindi B, Mamdani M, Kulkarni GS, et al. Impact of the U.S. Preventative Services Task Force recommendations against prostate specific antigen screening on prostate biopsy and cancer detection rates. J Urol 2015;193:

23 Screening since 2012 Bhindi B, Mamdani M, Kulkarni GS, et al. Impact of the U.S. Preventative Services Task Force recommendations against prostate specific antigen screening on prostate biopsy and cancer detection rates. J Urol 2015;193:

24 Screening since 2012 Banerji JS, Wolff EM, Massman JD III et al: Prostate needle biopsy outcomes in the era of the U.S. Preventive Services Task Force recommendations against PSA based screening. J Urol

25 Screening since % decrease in incident diagnoses of prostate cancer in the year following the USPSTF recommendation Diagnoses of low, intermediate, and high risk localized disease all showed significant decreases. The incidence of non-localized disease was unchanged. Barocas, D.A., Mallin, K., Graves, A.J. et al. The effect of the U. S. Preventive Services Task Force grade D recommendation against screening for prostate cancer on incident prostate cancer diagnoses in the United States. J Urol. 2015; In Press

26 On Beyond PSA Free PSA: Blood test, its level best defined for total PSA levels between 4 and 10, it gives percent likelihood of finding prostate cancer with biopsy. Prostate Health Index (PHI) (Beckman Coulter): Blood test, used for total PSA levels between 2 and 10, it measures 3 forms of PSA (total, free, and pro2psa), and it gives percent likelihood of finding prostate cancer with biopsy. PCA3 (Metamark and Hologic): Performed post-dre, measures total PSA, free PSA, intact PSA, and hk2 in urine, indicates the likelihood of finding prostate cancer with biopsy. 4Kscore (OPKO lab): Blood test of total PSA, free PSA, intact PSA, and hk2, predicts risk of high grade tumor on biopsy and 20 year risk of distant metastases. MiPS (University of Michigan Deparment of Pathology and Hologic): Performed post-dre, measures serum total PSA and urinet2:erg and PCA3, gives the probability of finding prostate cancer on biopsy and of finding histologically aggressive prostate cancer.

27 Conclusions PSA-based screening has resulted in an overdiagnosis and overtreatment of prostate cancer In its current form, screening affords a marginal short term benefit Long term benefits may be more pronounced The men who derive the greatest benefit from screening fall between 50 and 69 Newer tests improve diagnosis, but await long term CSS data