Prostate Cancer Screening in Norway Dr Freddie Bray Cancer Registry of Norway, Oslo GEKID / EK NRW Symposium: The Role of Cancer Registries in Cancer Screening Programmes a European Perspective DGEpi Conference Münster, 16 September 2009
Auvinen et al, Int J Cancer 2002
Only two RCTs included.. high risk of bias in both trials, therefore insufficient evidence to either support or refute the routine use of screening for reducing prostate cancer mortality. Currently, no robust evidence from RCTs available regarding the impact of screening on quality of life, harms of screening, or its economic value. Results from two ongoing RCTs that will be available in several years are required to make evidence-based decisions regarding prostate cancer screening. Ilic et al, Cochrane Database Syst Rev 2006
Schröder et al, New Engl J Med 2009
Schröder et al, New Engl J Med 2009
Prostate Cancer Mortality Reduction by Prostate-Specific Antigen Based Screening Adjusted for Nonattendance and Contamination in the European Randomised Study of Screening for Prostate Cancer (ERSPC) Monique J. Roobol, Melissa Kerkhof, Fritz H. Schröder, Jack Cuzick, Peter Sasieni, Matti Hakama, Ulf Hakan Stenman, Stefano. Ciatto, Vera Nelen, Maciej Kwiatkowski, Marcos Lujan, Hans Lilja, Marco Zappa, Louis Denis l, Franz Recker, Antonio Berenguer, Mirja Ruutu, Paula Kujala, Chris H. Bangma, Gunnar Aus, Teuvo L.J. Tammela, Arnauld Villers, Xavier Rebillard, Sue M. Moss, Harry J. de Koning, Jonas Hugosson and Anssi Auvinen PSA screening reduces the risk of dying from prostate cancer by up to 31% in men actually screened. This benefit should be weighed against a degree of overdiagnosis and overtreatment inherent in prostate cancer screening. Roobol et al, Eur Urol. 2009
Schröder et al, New Engl J Med 2009
Curative treatment for early prostate cancer Hormonal therapy / radiotherapy for locally advanced disesase Chemotherapy for hormone refractory patients
Global mortality 2002 Ferlay et al, GLOBOCAN 2002
Kvale et al, JNCI 2009
Prostate cancer incidence and mortality 2001 a age-standardised rate using the World standard b rate ratio of age-standardised (World) rates using Denmark as the baseline d incidence:mortality ratio of age-standardised (World) using Denmark as the baseline
1997 1126 5251 806 201 52 3819 1068 9882 2625
+11.0% +2.0% +8.7% +1.4% +0.7% +4.7% -3.5% +1.0% +1.0% -1.9%
+14.8% +5.0% +3.9% -3.5% +1.6% +1.0% +1.5% -1.8% +1.1% -0.6%
+14.8% +5.0% +3.9% -3.5% +1.6% +1.0% +1.5% -1.8% +1.1% -0.6%
Based on a report from the Norwegian Centre for Health Technolgy Assessment (SMM), leaflets were distributed to GPs/urologists in March 2001: PSA should not be taken in asymptomatic men If the test is wanted, the physician is obliged to give information about the possible consequences 2000 2002
Parker et al, 2006
Parker et al, 2006
Treatment in the Nordic countries Treatment with a curative intent (and hormonal treatment) was used most extensively in Finland and Norway Jonsson et al. Int J Technol Assess Health Care 1995 Denmark has put the emphasis on initiating treatment only at a late stage, and radical prostatectomy was introduced around 1995 Borre M et al. Cancer 1997, Brasso K et al, Ugeskr Laeger 1998 However, before the mid-1990s radical treatment was infrequently used in all Nordic countries
Prostate cancer: what is going on? Mortality Artefact (e.g. attribution of cause of death) Earlier diagnosis (better awareness) Screening Treatment Changes in risk factors
Etzioni et al, CCC 2009 U.S. mortality trends 1980-2000: by 2000, models projected 45%-70% attributable to stage shift induced by PSA screening.
Ongoing research Screening - PLCO set to continue to 13 years ERSPC to report on quality of life, cost-effectiveness PSA monitoring developments Tilling et al, Eur Urol, 2009; Roobol et al, Eur Urol 2009; Vickers et al, Eur Urol 2009
Tilling et al, Eur Urol. 2009
Ongoing research Treatment (Wilt, JNCI, 2008) PIVOT (U.S., radical prostatectomy vs. watchful waiting, includes 3/4 PSA-detected) ProtecT (U.K., radiotherapy vs. radical prostatectomy vs. active surveillance, clinically-localised cancers) START (Canada, early interventions vs. active surveillance) Ongoing preventative trials (Thompson et al, J Urol 2009) Chemoprevention with Dutasteride (REDUCE)
National Prostate Cancer Programme (NPPC) Clinical Registry established. Collects infromaiton nationally on prostate cancer incidence, diagnostics, treatment Aims: provide an empirical base for scientific studies concerning prognostic factors and treatment outcomes evaluation of quality of cancer care.