Prostate Cancer Screening in Taiwan: a must

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1 Prostate Cancer Screening in Taiwan: a must 吳俊德基隆長庚醫院台灣醫學會 105 th

2 What is the PSA test? The blood level of PSA is often elevated in men with prostate cancer, and the PSA test was originally approved by the FDA in 1986 to monitor the progression of prostate cancer in men who had already been diagnosed with the disease. In 1994, the FDA approved the use of the PSA test in conjunction with a DRE test for prostate cancer diagnosis. 台灣醫學會 105 th NCCN website 2012

originally approved by the FDA in 1986 to monitor the progression of prostate cancer in men who had

4 Besides the PSA number itself, your doctor will consider a number of other factors to evaluate your PSA scores Your age The size of your prostate gland How quickly your PSA levels are changing Whether you're taking medications that affect PSA measurements, such as finasteride (Propecia, Proscar), dutasteride (Avodart) and even some herbal supplements Not ideal tumor marker 台灣醫學會 105 th NCCN website 2012

you're taking medications that affect PSA measurements, such as finasteride (Propecia, Proscar),

5 What's the advantage of a PSA test? Detecting certain types of prostate cancer early can be critical. Elevated PSA results may reveal prostate cancer that's likely to spread to other parts of your body (metastasize), or they may reveal a quick-growing cancer that's likely to cause other problems. Early treatment can help catch the cancer before it becomes life-threatening or causes serious symptoms. In some cases, identifying cancer early means you will need less aggressive treatment, reducing your risk of side effects such as erectile dysfunction and incontinence. If you are in a group of men at high risk of prostate cancer, you're even more likely to benefit from PSA testing. 台灣醫學會 105 th NCCN website 2012

other problems. Early treatment can help catch the cancer before it becomes life-threatening or causes serious symptoms.

6 Simple test, not-so-simple decision Pros of PSA screening PSA screening may help you detect prostate cancer early. Cancer is easier to treat and is more likely to be cured if it's diagnosed in the early stages of the disease. PSA testing can be done with a simple, widely available blood test. For some men, knowing is better than not knowing. Having the test can provide you with a certain amount of reassurance either that you probably don't have prostate cancer or that you do have it and can now have it treated. The number of deaths from prostate cancer has gone down since PSA testing became available. 台灣醫學會 105 th NCCN website 2012

PSA testing can be done with a simple, widely available blood test. For some men, knowing is better than not knowing.

8 E U R O P E A N U R O L O G Y 5 8 ( )

12 Conclusions of media reporting Only 23% of newsprint articles indicated that screening was a positive endeavour, whereas 31% were negative and the remainder were neutral (46%). Some 78% of UK articles indicated insufficient screening, whereas 57% in the USA and 80% in Canada reported screening as being excessive. Online media reflected USA reporting. The media influences public opinion and government policy and it is important that urological organizations are aware of the true impact. 台灣醫學會 105 th

Some 78% of UK articles indicated insufficient screening, whereas 57% in the USA and 80% in Canada reported screening as being

20 PSA screening for prostate cancer gets thumbs-down from federal panel The task force, which is comprised of 16 primary care physicians and public health experts with no financial interests in tests or treatments, issues screening and other preventive health recommendations that tend to be more conservative than those of medical societies -- composed mostly of specialists who treat diseases detected through screening -- or patient advocacy groups. In 2009, its expert panel came under a barrage of fire when it veered against nearly every American medical organization and stopped recommending routine mammograms for women in their 40s; the recommendation advised women to speak to their doctors about the risks and benefits before reaching an individual decision. The political fallout from that surprise downgrade led to specific language in the federal health care legislation last year mandating free coverage of mammograms in women age 40 and older and also led Congress to demand more transparency in the task force s decision-making. For PSA testing, the panel first issued draft recommendations last October and invited public comments, though the final language didn t change much from the draft. (PSA testing isn t one of the free preventive services required to be offered under the federal health law.) Daily Dose 21/may/2012

detected through screening -- or patient advocacy groups.

21 PSA testing: new analysis tips balance in favor of informed decision-making Dr. Anthony D Amico, chief of genitourinary radiation oncology at Brigham and Women s Hospital, agreed. Most men will get positive gains from PSA screening but to make everyone a winner, doctors have to do more education. He d like to see a discussion not only about PSA screening itself but the specific steps that may follow an elevated reading such as a biopsy and the possible diagnosis of slow-growing cancers that might not need to be immediately treated. Daily Dose 08/16/2012

22 PSA screening for prostate cancer gets thumbs-down from federal panel It s hard to understand where they re coming from, said Dr. Anthony D Amico, chief of genitourinary radiation oncology at Brigham and Women s Hospital, in an interview. In an editorial he co-authored in the Annals of Internal Medicine journal, where the new recommendations were published, D Amico argued that the task force relied too heavily on data from a flawed study and failed to consider making separate recommendations for men in high-risk groups, such as those with a family history of prostate cancer and African Americans, who have a two to three times greater risk of dying of the cancer than white men. Daily Dose 21/may/2012

23 Govt. Panel Scuttles Prostate Cancer Testing Recommendations "PSA screening is the only test we have," said Dr. William Catalona, a professor of urology at Northwestern University. "The great majority of doctors who deal with prostate cancer patients believe that the task force underestimated the benefits and overestimated the harms. Perhaps it is because none of the Task Force members were urologists." ABC News 12/May/2012

24 Govt. Panel Scuttles Prostate Cancer Testing Recommendations "There is no mention of the dramatic decline in the number of men with advanced prostate cancer," said Dr. Patrick Walsh, professor of urology at Johns Hopkins University. "In 1990, 21 percent of men at diagnosis had metastatic prostate cancer to bone. Today it is 4 percent. This is clearly a dramatic effect of PSA testing. "[The new recommendations] fail to recognize that in the absence of PSA testing, a man will not know that he has the disease until he has symptoms, at which time the cancer is too far advanced to cure," Walsh said. ABC News 12/May/2012

25 Govt. Panel Scuttles Prostate Cancer Testing Recommendations And Dr. Gerald Andriole, chief of urology at Washington University School of Medicine, called the task force's recommendations "too draconian on categorically dismissing PSA." "In some respects we have not been using PSA as well as we could," Andriole said. "However, to post a headline that says 'No More PSA Testing' is throwing the baby out with the bathwater." ABC News 12/May/2012

26 New PSA Testing Recommendations Ignites Debate Again "It's a much more reasonable and balanced approach than the USPSTF," said Dr. Peter Scardino, chief of surgery at Memorial Sloan-Kettering Cancer Center in New York. "The idea that we stop recommending PSA screening altogether is not tenable." Scardino said some strong studies have found PSA testing led to a reduction in cancer-specific and overall mortality. Other studies, however, have found PSA testing to have no effect on the number of deaths. "I understand about the reasons the USPSTF was concerned -- they were disturbed by thefalse positive results and overdiagnosis and overtreatment," said Scardino. "It's very important for people to know that many low-risk prostate cancers do not need to be treated. They can be monitored with little risk. Prostate cancer is not uniformly lethal." ABC News 16/Jul/2012

27 Evidences from Taiwan

28 CK Chang J Urol Vol. 158, , November 1997

38 The increasing application of PSA testing was associated with a significant increase in clinical T1c disease and decrease in incidental carcinoma. There was also a significant trend towards less aggressive cancers. Despite the dramatic increase in the annual detection rate, tumours were not detected at an earlier stage. However, for patients treated with radical prostatectomy, there was a significant change to earlier stage disease and fewer dedifferentiated cancers. 台灣醫學會 105 th T.T Wu BJU International (2001), 87, 57-60

39 CH Chen UROLOGY 72 (6), 2008

41 YC Ou B J U I N T E R N A T I O N A L 1 0 8,

42 YJ Kuo & CC Pang Pathology International 2012; 62:

43 Population demographics and PSA distribution The median age of the 27,761 participants was 54.7 years. About two thirds were < 60 years of age. The median serum PSA value for the entire study cohort was 0.89 ngml1. A total of 3,442 (12.40%), 1,717 (6.18%) and 327 men (1.84%) had PSA levels >2.5, 4.0 and 10 ngml1 CH Chen Int. J. Cancer (2012) 台灣醫學會 105 th

44 After a median follow-up of 11 years in the core age group, the relative reduction in the risk of death from prostate cancer in the screening group was 21% (rate ratio,0.79; 95% confidence interval [CI], 0.68 to 0.91; P = 0.001), and 29% after adjustment for noncompliance. 台灣醫學會 105 th n engl j med 366;11 nejm.org march 15, 2012

45 n engl j med 367;7 nejm.org august 16, 2012

46 n engl j med 365;21 nejm.org 2018 november 24, 2011

47 Prostate cancer screen in Taiwan?! Yes Knowing gives options, even the option of doing nothing, that ignorance does not provide. 台灣醫學會 105 th

Cancer in Primary Care: Prostate Cancer Screening. How and How often? Should we and in which patients?

Cancer in Primary Care: Prostate Cancer Screening How and How often? Should we and in which patients? PLCO trial (Prostate, Lung, Colorectal and Ovarian) Results In the screening group, rates of compliance