PROSTATE CANCER. The Basics of Screening and Decision Making

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2 I, Lee Jackson, do NOT have a financial interest/arrangement with one or more organizagons that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentagon.

3 Why we screen Who we screen When to screen How to invesggate risk for prostate cancer What are the management strategies

4 Why do we screen? PCa is the most common non- cutaneous cancer in men PCa is the second most common cause of cancer death in men Localized PCa is asymptomagc Symptoms are produced by advanced disease and metastases

5 Why do we screen? Management opgons for late stage disease are limited. To reduce PCa mortality we must diagnose early stage disease. We must look for it. We must screen.

6 PSA Screening PSA is a prostate specific protein It is NOT cancer specific Interpret PSA in the context of other risk factors to esgmate a man s risk for PCa. Family History/African American ethnicity

7 PSA Screening: The Controversy 1986: PSA is introduced as a serum tumor marker. 1989: The USPSTF recommends against the use of serum tumor markers 2008: USPSTF recommends against the use of PSA screening for men over 75 years old

8 PSA Screening: The Controversy 2012: The USPSTF recommends against PSA screening for men of all ages This led to a reduced number of screening in all age groups. Reduced number of biopsies

9 PSA Screening: The Controversy Results in a smaller percentage of men diagnosed with localized disease and an increased percentage of men diagnosed with advanced disease. JAMA Oncol. 2016

10 PSA Screening: The Controversy Re- evaluagon of the original screening studies concluded that PSA screening reduced PCa mortality by 32%. Ann Internal Med US age adjusted PCa mortality decreased by 53% during the PSA era. Cancer J Clin.2017

11 PSA Screening: The Controversy Clear that PSA screening was directly related to decreased PCa mortality 2017: USPSTF Drab in April changes the recommendagon to allow PSA screening in men age as a shared medical decision

12 PSA Screening : WHO Who should we screen? When should we screen?

13 PSA Screening: WHO The strongest predictor of a life threatening PCa is a baseline PSA in a man s 40s. J Clin Oncol.2016 Urology, 2006 Median PSA age is 0.7

14 PSA Screening: WHO If baseline PSA < 1/average risk for PCa, begin screening at age 50. If baseline PSA > 1 or increased risk for PCa, the begin annual or biennial screening at 40. This is not a biopsy threshold.

15 PSA Screening: WHEN The AUA guidelines recommend screening for men at average risk at age 55 69, biennially. For men at increased risk, screen ages NCCN guidelines recommend biopsy threshold PSA >3.

16 EvaluaGng an elevated PSA: HOW TRUS guided biopsy / over diagnosis and missed diagnosis. mpmri / reader dependent with variable negagve predicgve value. May be paired with TRUS biopsy

17 EvaluaGng an elevated PSA: HOW mpmri decreased over diagnosis of trivial PCa and avoided biopsy in 27% Increased the diagnosis of clinically significant prostate cancer Lancet; 2017

18 Decision : WHAT What do we do once we have a diagnosis? What are the management strategies? What are our goals? What do we take into consideragon when making a management decision?

19 EsGmate risk of PCa progression in the context of a man s life Gme and select a management strategy Prevent PCa progression and metastases Prevent PCa mortality Minimize adverse QoL issues

20 EsGmaGng Risk of Progression Gleason Score/histologic pajerns 3-5, sum of 6-10 Grade Groups 1-5 StraGfy men into risk categories based on Gleason score or Grade group and PSA

21 Categories of Risk of Progression Very low and low risk/grade group 1, PSA < 10 Favorable intermediate risk/grade group 1 and PSA >10 or Grade group 2/PSA < 10 Unfavorable intermediate risk/grade group 3 High risk/ Grade group 4 and 5 or PSA > 20

22 Management Strategies for Risk Categories AUA & NCCN guidelines recommend AcGve Surveillance for very low & low risk PCa Confirmatory biopsy or MRI PSA surveillance at 3-6 month intervals Annual or biennial biopsy surveillance MRI surveillance with or without biopsy

23 Management Strategies for Risk Categories AUA guidelines recommend Favorable and unfavorable intermediate risk should be offered definigve treatment Surgery or radiagon with androgen deprivagon treatment

24 Management Strategies for Risk Categories High risk oben requires mulgmodal therapy AUA guidelines recommend RadiaGon with months of androgen deprivagon Surgery with adjuvant or early salvage radiagon and ADT for adverse pathology

25 Quality of Life Issues and Management Strategies All management strategies, including AcGve Surveillance are associated with potengal adverse quality of life issues Urinary, bowel and sexual dysfuncgon

26 Quality of Life Urinary and Sexual dysfuncgon more common with surgery than radiagon Bowel dysfuncgon seen with radiagon. Rarely seen with surgery. Urinary and Sexual dysfuncgon also seen with AcGve Surveillance due to aging

27 Quality of Life: Urinary InconGnence Prevalence of urinary incongnence in men over 60 years of age was 18.9% Jurol.1986 Similar study, the prevalence was 15% J American Geriatric Soc. 1990

28 Quality of Life: ErecGle DysfuncGon. ErecGle funcgon is a complex interacgon between psychologic, neurologic, endocrine, hormonal and vascular systems that is vulnerable to compromise by common comorbidiges and age

29 Quality of Life: ErecGle DysfuncGon Mass. Male Aging Study found age to be the strongest variable related to erecgle funcgon More important than CV disease, HTN, diabetes, tobacco use and medicagon. The relagonship was linear. 40% of 40yr old men to 70% of 70yr olds. Jurol.1994

30 Summary We screen for prostate cancer because early stage disease is asymptomagc PSA screening is directly related to decreased prostate cancer mortality Prostate cancer risk of progression is variable Prostate cancer progresses slowly

31 Summary Select management strategy most likely to prevent PCa progression during a man s life expectancy AcGve Surveillance, Surgery, RadiaGon and ADT All management strategies will affect QoL