Prostate Cancer Screening: Current

Understanding and Management

Adeep Thumar MD

June 11, 2015

 What is the Prostate
1. Size and shape of walnut on
average
2. Function is the release of fluid
to protect and nourish sperm
3. As men age prostate gets
bigger and some patients will
experience lower urinary tract
symptoms
4. As men age likelihood of
prostate cancer is higher
1. 22-55% by age 50-60
2. 48-90% by age over 80

Campbell’s Urology 2012

 Prostate Cancer Incidence

• 5th most common worldwide cancer

• 2nd most common cancer in men

• 11.7% of new cancers, due to screening

19% of cancers detected in the united
states in comparison to 5.3% in developing
countries
 Prostate cancer and race

Campbell’s Urology 2012

• African Americans have incidence 1.6 times

white Americans
• Death rates 2.4 times greater than white
Americans
 What is PSA
• Prostate Specific Antigen:
 Protein

 Secreted in high concentrations into seminal fluid

 Bound and unbound forms

 Levels in blood can vary by age, prostate volume, and race

 It is influenced by androgen

 Prostate disease- bph, prostatitis, prostate manipulation, urinary

tract infection and prostate cancer can all elevate psa
 What is Screening
• The Examination of a group to separate well persons from those who
have an undiagnosed pathologic condition or who are at high risk.

• Benefits of diagnosis at earlier stage of disease to increase better

survival and reduce morbidity.
 Since the beginning of PSA
• From 1993 to 2008 after the onset of widespread
PSA testing, the mortality rate from prostate cancer
declined by 40%( Surveillance, Epidemiology, and End Results [SEER] Program),

• 75% reduction in the proportion of advanced-stage

disease at diagnosis.

• Compared to United Kingdom screening is only

performed in 10% of people
 Prostate cancer deaths only decreased by 12% in UK
 2 big trials in 1990s
• ESPRC- 20% reduction in mortality in screened population
over 9 years.
 However to prevent one prostate cancer death- 1410 people
need to be screened and 48 people need to be treated

• PLCO trial- Showed no difference in mortality between

screened and unscreened population.
 Highly controversial trial- contamination of patients

• Bottom line over-treatment risk is high

 Interpretation of PSA
• Only way to confirm diagnosis is by tissue from prostate biopsy

• Triggers for biopsy:

 Abnormal digital rectal exam

 Traditionally 4 ng/ml was used but 25% of prostate cancers were detected below 4

 Now a baseline can be established and reconfirmed depending on age

 Rapidly rising psa (psa velocity), elevated psa in comparison to prostate size (psa
density) are markers
– PSA density >0.15 for pts with psa between total values of 4 and 10
– PSA velocity- >0.75 ng/ml/year for psa 4-10. Some say even lower threshold for lower psa.
– % free psa- cancer pts have lower free psa as psa is complexed
What is a biopsy
 What is biopsy
• Traditionally performed by transrectal ultrasound

• Performed in office

• Tolerated well

• Main risk is infection which is reduced by antibiotics

• Other risks of bleeding, blood in urine, trouble urinating

 Risk of hospitalization across the board is low at 4%
 Plus and Minus of Biopsy
• Only 26% biopsy will return with cancer diagnosis

• May return with low grade low volume cancer.

• If did not use screening picks up cancers 5-7 years prior

to it becoming symptomatic.
 Adjunct Markers and Tests
• Alternative blood tests
 PCA3
 Prostate Health Index
 4k score

• Prostate MRI
 May be useful in patients for repeat biopsies
 May be useful in patients on surveillance
 No standardization in interpretation at this time
 Guidelines- US Preventative Task Force
• 2012- Panel gave PSA screening grade D
• Recommends against Prostate Cancer Screening in general population

• They do not have recommendation for people of certain ethnicity known for
higher incidence of prostate cancer

• No recommendation for use of psa screening for positive family history

• Prior recommendation was there was insufficient data for general population
but definitely no benefit for individuals over age of 75.

• Same task force in 2009 that recommended against mammography screening for
breast cancer which was later rescinded

• Conclusions were made based on large trial data that had contamination.
 Guidelines- American Cancer Society

• Age 50 and above for average risk

• Age 45 for men at high risk
• Age 40 for men at even higher risk

• Men screened every 2 years below PSA 2.5

• Men screened annually for PSA > 2.5

 Guidelines- National Comprehensive Cancer Network

• Thorough history including family history, previous psa, previous

exams and biopsy

• Start discussion risks and benefits for screening

• Age 45-49: obtain baseline psa

 If > 1 obtain repeat test 1-2 years
 If < 1 obtain repeat testing at age 50

• Age 50-70 or >70 in specific healthy population

 1-2 year testing. Trigger for biopsy is abnormal digital rectal exam
or psa >3
 Guidelines- American Urological Association
• The Panel recommends against PSA screening in men under age 40
years.

• The Panel does not recommend routine screening in men between

ages 40 to 54 years at average risk.
– This does not include increased risk population such has family history and African Americans

• For men ages 55-69 Recommendation to screen after discussion of

weighing benefits of prostate cancer mortality of 1 man for 1000
screened

• Possible to screen PSA every 2 years instead of 1

• No screening in population above 70 unless 10 to 15 year life

expectancy
 Summary
• Societies against screening
 US Preventative Task Force

• Societies for screening

 American Cancer Society
 National Comprehensive Cancer Network
 American Urological Association
 Conclusions
• In accordance with the American Urological Association

 1. PSA screening does yield survival benefit

 2. PSA screening picks up cancers 5-7 years

prior to symptomatic disease

 3. PSA screening may represent over

diagnosis in 25% of people
 Bottom Line
 Each individual is different once the risks of screening
are explained and results are individually tailored
• If diagnosis is confirmed, treatment is also custom planned

 Guidelines are tools in recommending plan and are not

certainly rigid for each individual.

 Certainly overtreatment of prostate cancer but if

aggressive cancers are caught early, early treatment
can be curative rather than palliative
 References
• Campbell, Meredith F., Wein, Alan J.Kavoussi, Louis R. (Eds.) (2007)
Campbell-Walsh urology /editor-in-chief, Alan J. Wein ; editors, Louis
R. Kavoussi ... [et al.]Philadelphia : W.B. Saunders,
• www.auanet.org
• www.nccn.org
• www.cancer.org
• www.uspreventitivetaskforce.org