Prostate Cancer Screening Bruce L. Houghton, MD Associate Professor of Medicine Division of General Medicine Department of Internal Medicine Creighton University School of Medicine
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What is a Prostate? Small gland (about 3 to 4 cm diameter) A little larger than a walnut Secretes a slightly alkaline fluid that combines with spermatozoa to create semen. The prostatic alkaline fluid prolongs the survival of the spermatozoa in the slightly acidotic vaginal tract
Prostate Prostate needs testosterone to function Diseases of the Prostate Prostatitis (inflammation and/or infection of the prostate) Benign Prostatic Hypertrophy (enlarged prostate) Prostate Cancer
Prostate Cancer Leading type of cancer for U.S. men 1 in every 6 U.S. men will develop invasive prostate cancer before he dies Second leading cause of cancer death in U.S. men Following Lung cancer 2007 218,890 new cases diagnosed 27,050 men died of prostate cancer
Prostate Cancer U.S. Men have 1 in 6 lifetime chance of getting prostate cancer But only 3% chance of dying of prostate cancer Autopsy series Detect Prostate Cancer in 1/3 of men younger than 80 years and 2/3 of men older than 80 Suggests that prostate cancer is slow growing and that men die of other causes before prostate cancer is evident
Prostate Cancer Incidence Age-Adjusted Incidence (new cases) of prostate cancer have increased over the last 50 years Peaked 1990s Mostly with increased early detection due to Prostate-specific antigen (PSA) testing in late 1980s Associated mostly with increased early detection
Prostate cancer: changes over time average annual age-adjusted incidence and mortality rates in the United States, 1973-2001 (2001 US standard) Source: SEER Program.
Prostate Cancer Risk Factors Increases with Age more common after age 50 years Increases with family history of prostate cancer African-American men at higher risk Both of developing prostate cancer and of dying from prostate cancer
Prostate Cancer Mortality Extent of tumor at time of diagnosis is especially important Localized (cancer only within gland) 75% 10-year survival rate Regional Extension 55% 10-year survival rate Metastases 15% 10-year survival rate
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Dan Fogelberg (expired age 56) http://www.stevelevine.com/fogelberg.jpg
Merv Griffin (expired age 82) http://asapblogs.typepad.com/photos/uncategorized/2007/08/12/merv_griffin_rumb.jpg
Robert De Niro (diagnosed 2003) http://www.celebritiesfans.com/showceleb.php?celebid=1162
Why push for screening? Most early prostate cancer is asymptomatic Symptoms of prostate cancer Sometimes similar to BPH symptoms Frequent urination, nocturnal urination, difficulty urinating Erectile dysfunction or painful ejaculation Advanced cancer can cause bone pain
Perfect Prostate Cancer Screening Test Identify asymptomatic men with aggressive tumors early when the tumor is localized Decrease mortality Decrease morbidity Urinary obstruction Prostate Cancer Metastatic bone pain
Prostate Cancer Screening Digital Rectal Examination (DRE) Prostate Specific Antigen Test (PSA)
BPH Cancer
Prostate Cancer Prevention? Vitamin E and Selenium Not enough evidence to recommend Finasteride (Proscar) Questionable Reduces risk of developing prostate cancer by about 25% However aggressive cancers were diagnosed more frequently in the first year in men who took finasteride than who did not
Digital Rectal Examination Physician examines the prostate with a gloved finger Detect enlargement of the prostate gland Asymmetry (enlarged lobe) Detect nodules (lumps)?normal consistency is similar to tip of your nose?
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How good is the DRE? Rarely done alone (PSA is often drawn as well) Ranges of Sensitivity for DRE alone 18 to 22% up to 55 to 68% in asymptomatic men
Prostate Specific Antigen (PSA) Glycoprotein produced by the prostate epithelial cells Elevated PSA can precede clinical disease by 5 to 10 years DRE has MINIMAL effect on PSA level and PSA CAN BE drawn following a rectal examination
What Will Elevate PSA? BPH Urinary retention Acute Prostatitis DRE 0.26 to 0.4 ng/ml Ejaculation Perineal trauma By up to 0.8 ng/ml Return to normal in 48 hours Procedures TURP Cystoscopy Prostate biopsy
Finasteride (Proscar) Dutasteride (Avodart) Treatments for BPH Will LOWER the PSA about 50% Double whatever level you get from a patient on Finasteride or Dutasteride
PSA Traditional cutoff level is 4 ng/ml Other Ranges (not recommended by FDA) 40 to 49 years 0 to 2.5 ng/ml 50 to 59 years 0 to 3.5 ng/ml 60 to 69 years 0 to 4.5 ng/ml 70 to 79 years 0 to 6.5 ng/ml
Other PSA Tests you may hear about PSA Velocity (measure PSA change over time) PSA Density Free PSA Complexed PSA
What is the Harm of Screening? Anxiety ( Labeling ) Unnecessary Prostate Biopsy If the PSA is elevated, most likely you will see a Urologist Risk of complication less than 1% Overdiagnosis Diagnosed and treated for disease that may have never caused significant problems Costs False Security
Prostate Cancer Treatments Surgery Radiation Treatment Hormonal Therapy
Other Resources www.patients.uptodate.com
What to Do? No convincing randomized controlled trials that show prostate cancer screening decreases morbidity or mortality from prostate cancer Cochrane Database Syst Rev. 2006 Jul 19;3:CD004720
Two Large Prostate Cancer Screening Trials Underway American Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial European Randomized Study of Screening for Prostate Cancer (ERSPC) Studies plan to pool their results Final data will not be available for years
What are Current Recommendations for Prostate Cancer Screening? American Urological Association American Cancer Society American Academy of Family Practice (AAFP) American College of Physicians Canadian Task Force on Preventative Health Care US Preventative Services Task Force (USPSTF)
American Urological Association Offer PSA Screening to men at age 50 years and who have an estimated life expectancy of 10 years or more Men with first degree relatives who have prostate cancer and African Americans may benefit from screening at an earlier age (usually in practice age 40)
American Cancer Society Both DRE and PSA be offered to men aged 50 an older and who have a life expectancy of 10 years or more
USPSTF, AAFP Insufficient evidence to recommend for or against routine screening with PSA or DRE
American College of Physicians Giving men information about the benefits and risks/harms of screening to help them make a decision based on personal preference
Canadian Task Force on Preventative Health Care Recommends against routine screening with PSA Insufficient evidence to make a recommendation on DRE
American College of Preventive Medicine (Feb 2008 statement) Concurs with USPSTF Insufficient evidence currently to recommend routine population screening with DRE or PSA. Am J Prev Med 2008; 34 (2)
Urologist Willet Whitmore is cure possible in those for whom it is necessary, and is cure necessary in those for whom it is possible? Urol Clin North Am 1990 Nov;17(4):689-97
So, What To Do? Speak with your physician Review the information on the website Decide what you want after weighing risks and benefits of screening
Questions/Comments?