PROSTATE CANCER SCREENING PROSTATE CANCER SCREENING

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1 3:45 4:45pm Screening Guidelines for Men's Health SPEAKER Radha Rao, MD Presenter Disclosure Information The following relationships exist related to this presentation: Radha Rao, MD: No financial relationships to disclose. Off-Label/Investigational Discussion In accordance with pmicme policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations. LEARNING OBJECTIVES PROSTATE, LUNG & COLON CANCER SCREENING Radha Rao M.D Assistant Professor of Medicine Michael E. Debakey V.A Medical Center Baylor College of Medicine Discuss current updates in screening guidelines for Prostate Cancer Lung Cancer Colon Cancer Justify the merits for and frequency of cancer screening on a patient to patient basis Implement Shared Decision Making in screening Prostate Cancer in 2014 in the US Diagnosis : 233,000 Deaths: 30,000 Higher risk: Older Age, AA men, and family history (FH) in 1st degree relatives receiving a diagnosis early in life JAMA Oncol. Feb 19, 2015 Lifetime Prostate Cancer Risk < 55 yrs yrs 75+ yrs 2% 70% 28% Guidelines Being Compared American Cancer Society (ACS) American Urological Association (AUA) U.S. Preventive Services Task Force (USPSTF). 2012

2 Areas of Agreement 1. PSA-based prostate cancer screening should not occur in the absence of an informed, shared decision-making process 2. Decision to initiate or continue PSA screening should reflect an explicit understanding of the possible benefits and harms, as well as patients' preferences and values. AUA Strongly recommends psa with shared decision-making for men ages 55 to 69 years Grade B 2 years or more preferred over annual screening -Grade C AUA Explicitly recommends against PSA screening in men under age 40 years- Grade C in average-risk men aged 40 to 54- Grade C men aged > 70 with < 10 to 15 year life expectancy- Grade C ACS recommends that men begin receiving screening information according to risk level : PSA +/- DRE Age 40 ( high risk -those with FH in multiple family members < 65 yrs.) Age 45 (intermediate risk- African American men and FH in a 1 st degree relative < 65 yrs) Age 50 (average risk) Base rescreening intervals on the results of the initial PSA test. ACS psa >2.5 - yearly psa <2.5 -Q2yrs psa >4.0 biopsy psa( ) individualize USPSTF Recommends a discussion between patient and physician about harms and benefits of screening In contrast to ACS and AUA, explicitly advises physicians to recommend against PSA-based screening for prostate cancer- Grade D

3 Guidelines being compared USPSTF 2014 American College of Chest Physicians(Grade 2B)2013 American Cancer Society 2013 After the publication of National Lung screening trial (NSLT) in 2011 the above recommended low dose CT screening for the high risk yr old group. The USPSTF on Dec. 31, 2013, recommends annual screening for lung cancer with Low Dose CT (LDCT)(Grade B ) in adults aged 55 to 80 years 30 pack-year smoking history and currently smoke quit less than 15 years Screening should be discontinued not smoked for 15 years Limited life expectancy All organizations recommend shared decision making with the patient and extensive discussion on benefits, harms of low dose CT HARMS False positives. In the NLST, 25% had positive results 95% of those did not receive a diagnosis of cancer Radiation exposure Incidental findings and over diagnosis Anxiety Cost NEJM 2011; 365: ;August AAFP : Insufficient evidence to recommend for or against screening for lung cancer with low-dose CT Hard to replicate in communities European studies showed no benefits Guidelines being compared ACS 2008 ACP statement 2012 ACG 2009 USPSTF 2010 USPSTF relied on modeling 80% mortality from lung cancer is still going to occur.

4 Colorectal cancer (CRC) is the third leading cause of death in the US Colorectal cancer incidence has been decreasing in the United States by 2% 3% per year over the past 15 years The lifetime risk for Colorectal cancer in men and women in the United States is approximately 6% USPSTF 2010 Recommends screening with FOBT,sigmoidoscopy or colonoscopy in yr olds -Grade A yrs- individualize Grade C >85 yrs -Do not screen Grade D ACG 2009 AA begin screening at 45 yrs CT colonography replaces DCBE FIT replaces FOBT Average risk for Colorectal cancer is 6% Intermediate risk: First-degree relative with CRC >60yrs, risk is 2 fold (12%) High risk: 2 first-degree relatives or a single first-degree relative with CRC <60 yrs, risk is 3- to 4-fold (18-24%) Hereditary nonpolyposis CRC & Familial adenomatous polyposis screening, genetic counseling and testing Second- and third-degree relatives with CRC -risk is small In the Clinic ;Annals of Internal Medicine 6 May 2014 Average risk :colonoscopy at 50 yrs, repeat every 10 yrs Intermediate risk : colonoscopy at age 40 yrs,repeat every 10 yrs High risk : colonoscopy at 40 yrs, or 10 yrs before the youngest 1 st degree relative, repeat every 5 yrs. HISTORY OF COLONOSCOPY Dr. William Wolff, and Dr. Hiromi Shinya, pioneered the development of the colonoscope in 1969 In the Clinic ;Annals of Internal Medicine 6 May 2014

5 CONCLUSION Prostate Cancer: High risk- I recommend :Screen <10 yr LE I recommend :Do not screen Average risk- Shared decision making Lung Cancer: I offer Low dose CT in 55 yrs to 80 yr smokers,discuss harms and benefits, let patient choose Colon Cancer: I follow ACP guidance statement