The Role of PCP in Prostate Cancer Screening Beaver Creek Ma< T. Rosenberg

Transcription

1 The Role of PCP in Prostate Cancer Screening Beaver Creek 2017 Ma< T. Rosenberg

2 A Look at the Historical Flow concern Office visit History DRE PSA Biopsy Specimen with pathologist

3 Too Many Unnecessary Procedures concern Office visit History DRE PSA Biopsy Specimen with pathologist This has been too subjec/ve

4 The PSA Dilemma What does the value mean? Why does an abnormal level not always result in Velocity? Density? 4.0? Why am I crea/ng unnecessary pa/ents? Age Changes?

5 PSA is an a Imperfect Test Serum PSA has a high false posi@ve rate Over 1 million prostate biopsies performed annually in the US 75% biopsies have low- grade indolent (Gleason 6) or no prostate cancer Serious complica@ons of biopsies include infec@on and hospitaliza@on

6 Prostate Cancer Screening: How We Got to the Dilemma Mass screening has small effect on CaP mortality PLCO: no benefit ERSPC: 20-30% RRR in subgroup (driven by 2 sites of 7) Significant risk of overdiagnosis Overdiagnosis drives overtreatment Overtreatment results in economic loss and side effects

7 Pa/ent Complica/ons Unnecessary Procedures Poor Consensus on PSA Values Recommenda/ons to NOT Screen

8 The End of PSA PSA

9 The End Result?

10 The Real (BAD) End Result!

11 Repeat PSA in 5 years Male Pa/ent 45 Years or Older With at Least a 10 Year Expectancy PSA <1.5 Screening PSA Consider Biopsy PSA 1.5 High Risk Further Inves/ga/o n by PCP or Urologist 4K, PHI,PCA3 SelectMDx Low Risk Rosenberg MT, Spring AD, Crawford ED. IJCP 2015

12 Using PSA as a predictor Risk of PCa (%) A single PSA measurement of > 1.6 ng/ml in men 45 to 49 years was associated with a 5.14% greater risk of dying of prostate cancer within 25 years of tes/ng Baseline PSA (ng/ml) Aus G, Damber JE, Khatami A, et al. Arch Intern Med 2005;165: Vickers AJ, Ulmert D, Sjoberg DD, et al. BMJ. 2013;346:f2023.

13 of PSA Levels 27% CONFIDENTIAL 13

14 Repeat PSA in 5 years We have accidently created a mess Male Pa/ent 45 Years or Older With at Least a 10 Year Expectancy PSA <1.5 Screening PSA Consider Biopsy PSA 1.5 High Risk Further Inves/ga/o n by PCP or Urologist 4K, PHI,PCA3 SelectMDx Low Risk Rosenberg MT, Spring AD, Crawford ED. IJCP 2015

15 Biomarkers No Consensus phi SelectMDx 4K Score What is high risk? Who to biopsy? Head to head studies? Cost PCA3

16 Lack of Consistency With Biopsies COST Poor Consensus on Biomarkers Primary Care is - Confused - Crea/ng pa/ent stress - Was/ng /me and money

17 The Future of Biomarkers? 4K phi PSA SelectMDx PCA3

18 The Requirements of New Guidelines Screen the right aggressive disease Standardize the process Develop consensus between the PCP and the Urologist Understanding that screening for all diseases is the within the specialty of primary care

19 The Right Is the healthy enough that I would treat an aggressive prostate cancer if they had it? NO - do nothing YES - DRE/PSA

20 Ini/al Screening Abnormal DRE PSA 1.5 ng/ml Refer to Urologist Biomarker

21 This is Not My First Rodeo If I see an high blood sugar I get an glycoslyated A1C If I see an abnormal TSH I get a thyroid series If I see abnormal liver func@on tests I get an ultrasound

22 This is Not My First Rodeo If I see an high blood sugar I get an glycoslyated A1C If I see an abnormal TSH I get a thyroid series If I see abnormal liver func@on tests I get an ultrasound Following a high PSA with a biomarker is no brainer

23 Ini/al Screening Abnormal DRE PSA 1.5 ng/ml Refer to Urologist Biomarker Ques/on 1: Is there a level of the PSA that should immediately prompt a Urology consult? If so, what is that level?

24 The Problem Now is that Biomarker is Not Consistent!

25 The PCP Needs Biomarker to Be Consistent!!! Ques/on 2: What level of a biomarker prompts a referral? Ques/on 3: Why would you NOT get a biopsy with a 4K of greater than 7.5%? Phi score of greater than 35? SelectMDx of greater than 10%? PCA3 of greater than 10%?

26 Why Develop a Consensus Amongst Urologists and PCPs Primary care order 90% of screening tests PCPs have dras@cally reduced screening for lack of guideline support PCPs want to do the right thing Clarity will make this easier The urologist must understand that the PCPs seek guidance from them

27 Repeat PSA in 5 years Male Pa/ent 45 Years or Older With at Least a 10 Year Expectancy PSA <1.5 Screening PSA Consider Biopsy PSA 1.5 High Risk PCP to evaluate further 4K, PHI,PCA3 SelectMDx Low Risk Rosenberg MT, Spring AD, Crawford ED. IJCP 2015, modified

28 Repeat PSA in 5 years Male Pa/ent 45 Years or Older With at Least a 10 Year Expectancy PSA <1.5 Screening PSA PSA 1.5 High Risk Refer Urologist for biopsy PCP to evaluate further 4K, PHI,PCA3 SelectMDx Low Risk Rosenberg MT, Spring AD, Crawford ED. IJCP 2015, modified

29 The Future We Must Embrace PCP screen only the who would benefit from if they have disease It is appropriate for the PCP to order the PSA and the biomarker The PCP should only refer the who are strong candidates for biopsy The only not geong a biopsy include Change of heart aper risk/benefit analysis by the Urologist They want an MRI Other?