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

Transcription

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

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6 PLCO trial (Prostate, Lung, Colorectal and Ovarian) Results In the screening group, rates of compliance were 85% for PSA testing and 86% for digital rectal examination. Rates of screening in the control group increased from 40% in the first year to 52% in the sixth year for PSA testing. After 7 years of follow-up, the incidence of death per 10,000 person-years was 2.0 (50 deaths) in the screening group and 1.7 (44 deaths) in the control group. The data at 10 years were 67% complete and consistent with these overall findings.

7 ERSPC European Randomized Study of Screening for Prostate Cancer Largest randomized trial with 182,000 men from seven European countries At 11 years: 214 prostate ca deaths in the screening group 326 prostate cancer deaths in the control group (with 20% contamination in the control group) 20% decrease in prostate cancer deaths 29% decrease if adjusted for overall screening 1 death from prostate ca prevented per 1000 randomized patients

8 The USPSTF recommends against prostate-specific antigen (PSA) based screening for prostate cancer (grade D recommendation). A grade D recommendation means that the USPSTF has concluded that there is at least moderate certainty that the harms of doing the intervention equal or outweigh the benefits in the target population, whereas a grade C recommendation means that the USPSTF has concluded that there is at least moderate certainty that the overall net benefit of the service is small.

9 Screening for Prostate Cancer: USPSTF Recommendations Statement The U.S. PLCO and ERSPC Trials were primarily used because they had the largest populations and were of the highest quality The U.S. trial did not demonstrate any reduction of prostate cancer mortality. The European trial found a reduction in prostate cancer deaths of approximately 1 death per 1000 men screened in a subgroup aged 55 to 69 years

10 Screening for Prostate Cancer: USPSTF Recommendations Statement Mortality from prostate cancer peaked between 1991 and roughly the same time when PSA Screening became available, and began to decline after that Although this positive trend may be related to increased screening, other factors, including new treatment approaches, could also account for some or all of the observed decline in mortality

11 Screening for Prostate Cancer: USPSTF Recommendations Statement Comment on PIVOT Trial: Randomized 731 men ages 75 or younger, PSA levels less than 50, and clinically localized prostate cancer to: radical prostatectomy versus watchful waiting Treated patients with a PSA greater than 10 had an absolute risk reduction of prostate-specific and all-cause mortality of 7.2% and 13.2% respectively.

12 Guideline Statement 1: The Panel recommends against PSA screening in men under age 40 years. Guideline Statement 2: The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk. For men younger than age 55 years at higher risk (e.g. positive family history or African American race), decisions regarding prostate cancer screening should be individualized.

13 Guideline Statement 3: 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.

14 Guideline Statement 4: To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. Guideline Statement 5: The Panel does not recommend routine PSA screening in men age 70+ years or any man with less than a 10 to 15 year life expectancy. Some men age 70+ years who are in excellent health may benefit from prostate cancer screening.

15 Some men with high risk aggressive prostate cancer with a life expectancy of less than a decade may benefit from the diagnosis and treatment of their disease, such as patients with a PSA of at least 10 ng/ml. Thus, the goal should be to identify these men while avoiding associated overdiagnosis and overtreatment

16 Natl Cancer Inst Aug 20;100(16): Radical prostatectomy versus watchful waiting in localized prostate cancer: the Scandinavian prostate cancer group-4 randomized trial. METHODS: From October 1, 1989, through February 28, 1999, 695 men with clinically localized prostate cancer were randomly assigned to radical prostatectomy (n = 347) or watchful waiting (n = 348). RESULTS: At 12 years, 12.5% of the surgery group and 17.9% of the watchful waiting group had died of prostate cancer At 12 years, 19.3% of men in the surgery group and 26% of men in the watchful waiting group had been diagnosed with distant metastases (difference = 6.7% ; P =.006).

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