Mercy s Cancer Program 2014 Update

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1 Mercy s Cancer Program 2014 Update Mercy Hospital & Medical Center is accredited Academic Comprehensive Cancer Program by the American College of Surgeon s Commission on Cancer. This study is directed by the Mercy s Cancer Committee related to Standard 4.6: Assessment of Evaluation and Treatment Planning. Prostate Cancer patients initially diagnosed at Mercy are compared to their national counterparts, reviewing and analyzing incidence, screening and detection, demographics, stage at presentation, initial course of treatment and survival. Incidence: Prostate cancer remains the most common non-skin cancer in men. The American Cancer Society estimates that 233,000 1 new prostate cancers will be diagnosed in the U.S. in 2014, accounting for 27% of the total estimated new male cancers. The incidence of prostate cancer at Mercy mirrors the American Cancer Society s National statistics, however Mercy s incidence may be a little lower due to changes in the screening process and some of the unfavorable publicity PSA testing has received in the last two years. Nationally, the overall number of prostate biopsies has dropped by 15% over the last 2 years. 1 Cancer Facts & Figures pg 19 Age at Diagnosis: As with any cancer, early detection of prostate cancer is the key to better survival. Prostate cancer is much more common as a man ages, increasing with every decade of a man s lifetime. This begins primarily at the 5th decade which is about the time PSA and digital rectal exam screening should begin. Current best practice is to screen African Americans at age 45, Caucasians and other ethnicities at age 50, and individuals with a family history at age 40. Screening involves PSA and digital rectal exam. Most recommend stopping screening at age 75, however this can be controversial. Below are the official American Urology Association guidelines for prostate cancer screening in response to the United States Preventative Task Force s recommendations on prostate cancer screening.

2 Screening and Detection: The American Urology Association (AUA) recognizes that the interpretation of an asymptomatic patient s PSA level is a nuanced exercise that must be tailored to the patient in question. Therefore, the AUA no longer recommends one single PSA threshold for biopsy. Although previous thresholds such as 2.5 and 4.0 ng/ml have been used in the past, the AUA now recommends that the decision to biopsy should take into account the patient s digital rectal exam results, age, ethnicity, comorbidities, and prior biopsy history in addition to their serum PSA level. In order to increase the efficacy of serum PSA interpretation, a number of performance variables are used clinically. These include age-adjusted PSA, density, velocity, and the free-to-complexed PSA ratio. a. Age Adjusted PSA: Since PSA normally rises with age, age-adjusted thresholds have been described. Benign growth of the prostate that normally occurs with age is the most common cause of PSA elevation. Roughly 70% of patients with an elevated PSA level between 4 and 10 will have a negative prostate biopsy. Conversely, there is no level of PSA at which you can guarantee a patient that they do not have cancer. Moreover, the absolute PSA level does not predict whether or not prostate cancer is harmful. b. PSA Density: Another strategy used to improve the results of PSA screening is the calculation of PSA density by measuring prostate volume and dividing the absolute PSA level by the prostate volume (in ml). Prostate volume measurements can be obtained by either trans rectal ultrasound or MRI. By these criteria, a PSA density threshold of 0.15 or greater is an indication for prostate biopsy. c. PSA Velocity: Since prostate cancer presumably grows faster than normal prostate, PSA velocity (or change in PSA levels over time) is another strategy to detect prostate cancers in men with "normal" PSA levels. PSA values fluctuate significantly over time due to physiological variation, thus PSA velocity is best determined using at least 3 measurements obtained over a 2-year period. The threshold value for PSA velocity is dependent on the total PSA. The threshold is 0.35 ng/ml/year for PSA values < 4 ng/ml and 0.75 ng/ml/year for patients with total PSA values >4 ng/ml. d. Free-Complexed PSA: PSA exists in the serum in two forms, free and complexed to protease inhibitors. Patients with prostate cancer tend to have a higher percentage of PSA complexed to protease inhibitors and thus the percentage of free PSA within the serum is used to add information to the total PSA in patients with PSA levels between 4 and 10 and help determine the degree of suspicion for biopsy. Although there again is no agreement on the best threshold value for free PSA, values above 25% reliably predict the absence of clinically significant prostate cancer. Race/Ethnicity: African Americans in particular seem to have a higher death rate from prostate cancer, earlier onset of the disease, a higher incidence, more aggressive disease, and a higher stage at presentation. The graph shown above reinforces this race disparity, and reflects Mercy s population being a higher mix of African Americans. The Urology Department at Mercy Hospital has made a considerable grass roots community outreach for education and free screenings to help diagnose this diverse group at an earlier, more treatable stage. Outreach activities are held primarily through church and community groups.

3 Stage at Diagnosis: We are pleased to share Mercy s stage at diagnosis mirrors the National Cancer Data Base statistics. This is particularly important since we serve higher number of African Americans that commonly present at a later stage. Early stage diagnosis is important for cure and is at risk as a result of the National Health Institute s push to reduce screening efforts. This push is not currently supported by the American Urological Association. In addition there are many new genetic markers now being used to help predict the aggressiveness of the cancers, similar to breast cancer, that will help to define better treatment protocols for patients. Treatment: The treatment for prostate cancer is highly variable and is treated with robotic surgery, radiation, hormonal therapy, chemo therapy, active surveillance, as well as combinations of all of these treatments. These treatment protocols are highly individualized to each patient and take into account a number of variables including stage at diagnosis, grade, co-morbidities and age. Overall Mercy is in line with the National Cancer Data Base statistics on the treatment of prostate cancer, but changes are anticipated as new and exciting treatments have been exploding on the scene in the last two years. New hormone, immune and radiopharmaceutical therapies are all involved primarily in treatment of higher stage disease, but as these modalities are found to be more effective, these evolving therapies will most likely be incorporated into the treatment plan of earlier disease stages.

4 Survival: The Survival of men with prostate cancer at Mercy is compared here to the NCDB data. As can be seen, the five year survival of patients treated at Mercy is 9% lower than national statistics. This difference in survival statistics is likely to be explained by Mercy s high risk patient cohort who, as seen in prior graphs, are more likely to be African American who experience earlier onset of the disease, a higher rate of incidence, and more aggressive disease. Survival: Although these graphs do not reflect the national survival trend, there is a trend now that survival is improving. With genetic markers and new treatment protocols, an overall improvement in survival is expected in the next few years. Prostate cancer is 20 years behind breast cancer treatments, protocols, tissue sparing procedures, and survival, but has shown a significant increase in the last two years.

5 Cohort of Patients at Mercy: These 3 graphs below reinforce that we are serving a local population with a much lower income then the ACS statistics. It is commendable that Mercy is able to treat this cohort of patients as effectively as other cohorts with the barriers of access to care, racial disparity, and high percentage of at-risk African American patients. Mercy provides academic level treatments and services that are evidence based and can be compared to any hospital in quality and availability. In summary, prostate cancer is reaching a new high in the development of new genetic markers, immune therapies, and other exciting new treatments. Offering access to an academic level, full continuum of cancer care to an underserved and high-risk population, Mercy provides a holistic approach to care which includes nutritional support, psychological support, patient navigation, and social services. Mercy hosts a very active US2 Prostate Support group that has met monthly at Mercy for the last 20 years. Screening needs to be continued in this especially high-risk population, and our grass-roots community outreach will continue. Prostate cancer is seeing rapid and exceptional progress in care, as seen previously in breast cancer care, which has led to focal tissue sparing surgery, treatment protocols based on genetic and tissue markers, and a plethora of new treatments to treat all stages of the disease. John Cudecki, MD Cancer Committee Chairman Daniel Vicencio, MD Cancer Liaison Physician