Navigating the Stream: Prostate Cancer and Early Detection Ifeanyi Ani, M.D. TPMG Urology Newport News
Understand epidemiology of prostate cancer Discuss PSA screening and PSA controversy Review tools available for assessing risks of prostate cancer Discuss treatment options for prostate cancer Review potential complications and management
52 y/o M initial presentation w/ hematospermia No famhx of prostate ca; No prior psa DRE abnormal PSA 6.79 (9/2015) PSA 7.2 (11/2015) Prostate Bx (12/1/15) Pathology-Gleason 8, 9 12/12 cores positive. Metastatic w/u-bone scan positive w/ sacral and pelvic bones. CT positive w/ b/l pelvic lymph nodes
At the time of diagnosis patient was 50 yrs old How many doctors would have done a DRE? How many doctors would have checked a psa? How many doctors would have followed the USPSTF recommendations?
U.S. Preventive Services Task Force (USPSTF) recommendation of a grade D for PSA (5/2012)
UPDATE
RRR of 21% and an ARR of death from PCa at 13 years 0.11 per 1,000 person-years or 1.28 per 1,000 men randomized One PCa death averted per 781 men invited for screening Number needed to detect to avoid 1 prostate cancer death-27
Mammography screening Number needed to invite for screening to prevent 1 breast cancer death of 1904 (CrI, 929 to 6378) with 11 to 20 years follow up
76 685 men, aged 55-74 years, were enrolled at 10 screening centers between November 1993 and July 2001 Randomization Intervention (organized screening of annual PSA testing for 6 years and annual DRE for 4 years; 38 340 men) Control (usual care, which sometimes included opportunistic screening; 38 345 men) arms. At 13 years cumulative incidence rates for prostate cancer in the intervention and control arms were 108.4 and 97.1 per 10 000 person-years Relative increase of 12% in the intervention arm (RR = 1.12, 95% CI = 1.07 to 1.17) Cumulative mortality rates from prostate cancer in the intervention and control arms were 3.7 and 3.4 deaths per 10 000 person-years non-statistically significant difference between the two arms (RR = 1.09, 95% CI = 0.87 to 1.36)
Screening decrease prostate cancer mortality Screening leads to overdiagnosis of prostate cancer by 40% Screening leads to overtreatment of prostate cancer Bottom Line: Need to minimize overdiagnosis and overtreatment
Difficult to distinguish between the two Aim to detect cancer before it becomes symptomatic or metastasize Early detection should factor in other factors such as risk level (Family history, Ethnicity, and tests)
Organization bodies (eg American Cancer Society, AUA, NCCN) have conflicting information of screening/early detection One important theme: Discus shared decision making with patient to make informed decision.
Index Patient 1: Age ±40 years recommends against PSA screening in men under age 40 years. Index Patient 2: Age 40-54 does not recommend routine screening in men between ages 40 to 54 years at average risk Index Patient 3: Age 55-69 strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening
Index Patient 4: Age 70+ Does not recommend routine PSA screening in men age 70+ years or any man with less than a 10 to 15 year life expectancy.
The prostate health index (PHI) measures the total PSA, free PSA, and [-2] proenzyme PSA. The NCCN guidelines include use of PHI as a secondary test option for men making decisions about an initial or repeat biopsy. 4K score uses a prediction model based on clinical variables (age, prior biopsy, digital rectal examination results) and laboratory measurements of total PSA, free PSA, intact PSA, and human kallikrein-related peptidase 2
Between November 2014 and April 2016, 212 biopsy-naïve patients with suspected PCa (PSA level 15 ng/ml and negative DRE results) were included in this randomized clinical trial Randomized into a prebiopsy mpmri group (arm A, n=107) or a standard biopsy (SB) group (arm B, n=105) Overall detection rate (DR) were higher in arm A versus arm B for PCa (50.5% vs 29.5%, respectively; p=0.002), clinically significant PCa (43.9% vs 18.1%, respectively; p<0.001) Targeted biopsy in arm A, SB in arm A, and SB in arm B, the overall DRs were significantly different for PCa (60.5% vs 19.2% vs 29.5%, respectively; p<0.001) Clinically significant PCa (56.8% vs 3.8% vs 18.1%, respectively; p<0.001)
Active Surveillance-a method of managing prostate cancer in which a man is closely monitored, but curative treatment is not initiated until the cancer has locally progressed (Increase psa, stage, or gleason score) Radical prostatectomy-removal of entire prostate, seminal vesicles, and vas deference.
Radiation Therapy-utilization of high energy radiation to treat prostate cancer. IMRT: Relying on computer softerware to determine the orientation, number, and intensity of radiation beams. Improves the precision of earlier EBRT. Proton Beam Radiation: Image guided radiation therapy using positively charged subatomic particles (proton) instead of photons (IMRT) to kill cancer cells. Brachytherapy (seeds): Placing radioactive seeds into the prostate. Cryotheraphy: Use of extreme cold and thaw cycles to treat prostate cancer.
Hormone treatment-a treatment for prostate cancer that has spread beyond the prostate. Slows the progression of cancer by preventing testosterone from acting on cancer cells but does not cure the cancer. Chemotherapy-A treatment for prostate cancer that progresses despite hormonal therapy. It can help to relieve pain and other symptoms of advanced Pca.
Incontinence Pelvic floor exercises Medication Corrected with surgery Impotence Medication Vacuum pump Corrected with surgery
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