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Prostate Cancer Screening
1
Murali Sundram
Consultant Urologist
Hospital KL
1st Malaysian Men’s Health Conference 2018
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TOPICS ON PROSTATE CANCER
• Epidemiology of Prostate cancer
• How to Screen
• Screening controversies
• Opportunistic screening
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EPIDEMIOLOGY OF PROSTATE CANCER
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Prostate Cancer in the West
• Most common male cancer in the West
• 2nd most common cause of cancer death
• Lifetime risk of :
Developing prostate cancer 30%
Dying from prostate cancer is 3%
• Commonly a slow growing disease in elderly men which
may not be harmful during his lifetime
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World wide Incidence of Prostate Cancer
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Prostate Cancer in Malaysia
Age Standardized Incidence rate (ASR) :12 per 100,000 population
Chinese > Indians >Malays
Men 60-70 > Men 50-60
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Age adjusted incidence rates of prostate
cancer in 6 Asian countries
Country % change incidence
from 1978-1982 to
1993-1997
Philippines 49.5
Singapore 118.2
Japan 110.4
China 38.7
India 10.8
Thailand 5.0
8European Journal of Cancer 2005
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Increasing incidence of prostate
cancer in Asia
• Westernization of Asian diets with loss of cultural protective factors.
• Better reporting of cases
• Increasing use of serum PSA
• Ageing population
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Projected growth of Asia’s Elderly Population > 65 yr. United Nation 2001
Region/
subregion
No people >65 yrs (1,000s)% Increase
2000-20502000 2025 2050
Asia 206822 456303 857040 314
East Asia 114729 244082 393802 243
Southeast
Asia24335 57836 128958 430 %
South Asia 67758 154385 334280 393
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Risk factors• Age > 50 yrs
• Ethnicity blacks > whites >asians
• Family history of prostate cancer. Ist degree relatives ( father, son , brother ) have X2 the risk
• Genetic predisposition to other cancers
Breast cancer or ovarian cancer
Hereditary colorectal cancer
• Environmental Factors
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Changes in Prostate Cancer Incidence
Rates for Asians Migrants to the US
12
1,8
14,9
China (Changai) USA (San Francisco)
5,1
16,5
Japan (Osaka) USA (San Francisco)
Eur Urol 1999;35 : 377-387
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Screening for Prostate Cancer
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Screening
• Finding cancer early before the
development of symptoms with the hope
that early detection leads to effective
treatment and reduces the risk of dying
from that particular cancer
• Digital rectal examination
• Serum PSA
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PSA (Prostate Specific Antigen)
• Produced by prostate gland
• Some PSA escapes from
the prostate into the blood
and we can detect this by a
PSA test
• Normal PSA level is 0-4
ng/ml
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Causes of raised PSA
Acute retention of urine
Infection
Bladder Stones
Ejaculation
Cycling
Urethral instrumentation
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PSA ( Prostate Specific Antigen)
• PSA provides a lead time of 6-7
years before clinical cancer
• Persistently raised PSA
4-10 , there is a 30% chance of cancer
> 10 , there is a 50% chance of cancer
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Transrectal Prostatic Biopsy
Complications
• Haematuria
• Haemospermia
• Urinary tract infection
• Sepsis ( & death)
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Multiparametric MRI of prostate
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Transperineal Prostate Biopsy
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Screening Debate
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Screening YES or NO ?
• Screening decreases death rate by 20% but
need to screen 1000men and treat 37 men to
save I life
? Cost effective
• Screening detects many cancers that will not
harm the patient in his life time but are still
treated
? Over diagnosis & Over treatment
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Patient Decision Aids
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How to screen
• Start at age of 50yrs ( 45 for men at risk)
• Screening interval of 2 years
• Stop at age of 70 yrs
• Do not screen men with poor health or life
expectancy < 10 yrs
• Baseline PSA at age of 40 yrs ?
• interpretation of PSA in men taking BPH
medication
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Health Screening
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Opportunistic Screening / Case Finding
• This refers to screening of Symptomatic
men and is recommended
• Patients > 50 yrs with voiding symptoms
should have a PSA as part of the
investigations
• Patients who are on certain types of BPH
medication should have the their PSA
adjusted
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Work up of patients with voiding symptoms
• Urinalysis
Urine Culture
• Renal function
• PSA
• KUB Ultra Sound
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SUMMARY
• Asia’s population is ageing rapidly
• Incidence of Prostate cancer in Asia appears to be
increasing
• Population screening of asyptomatic men is not
recommended
• Screening may be offered to well informed men in
the context of a shared decision making process
• Opportunistic screening of symptomatic men is
recommended
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THANK YOU
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Shared Decision Making
• Is a strategy for making a health care decision when there is more than one medically reasonable choice
• Joint decision making process between doctor and the patient
• Important that men receive BALANCED information to assist then in making an informed decision
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Does screening of Prostate Cancer lead
to better outcomes ?
• Does early diagnosis and treatment lead to decreased mortality ?
• No definite consensus
• Randomized trial neededScreening versus no screening
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European Randomized Study of Screening for
Prostate Cancer (ERSPC) NEJM March 2012
• Trial initiated in 1991
• 180,00 men aged 50-74 from 8 European countries
• Screened at 4 year interval and followed up for 11 years
• Results of this trial can be used to advise men on whether they want to be screened for prostate cancer
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PSA Testing
• Health Screening Programs for Asymptomatic patients
• Patients presenting with LUTS symptoms to the GP
This is NOT screening but Case finding
• Increased use of PSA testing by Primary Care
Physicians
Standard of care
Fear of litigation
Voss JD prostate cancer screening and
beliefs J Gen Inter Med 2001
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Screening detects more cancer
PSA SCREENING
96 cases of cancer
NO PSA SCREENING
60 cases of cancer
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Screening decreases mortality by 20 %
PSA SCREENING
4 patients died
NO PSA SCREENING
5 patients died
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Is Screening beneficial ?
• Screening reduced mortality from prostate cancer
(relative risk reduction of 20%)
• But to prevent I death from prostate cancer you need to screen 1000 men over 10 years and treat 37 cancers
• Unanswered Questions
Is it cost effective ?
Does benefits outweigh the harm ?
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American Guidelines prostate cancer screening 2013
Recommended
• PSA screening in men 55-69yr who are well informed and wish to be screened
• Screening interval of 2 years
• Shared decision making
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American Guidelines prostate cancer screening 2013
Not recommended
• < 40 yrs
40-54 with average risk of
prostate cancer
>70 yrs
< 10 yr life expectancy
• In the scenario where shared-decision making is not routine practice
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Prostate Cancer in Malaysia
• NO national screening program for prostate cancer
• Nation wide prostate awareness campaigns
(1998, 1999, 2001, 2003, 2005, 2007)
• Private health screening
• Case finding when patient presents with symptoms of BPH to the primary care physician
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Prevention of Prostate Cancer
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Dietary Advise
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Anything which is heart healthy is also prostate healthy
Fibre, vegetables and fruit √ red meat ×
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Selenium & Vit C cancer prevention trial
(SELECT)
• 35,000 men were randomized to receive
selenium, vit E, combination or placebo
• Follow-up was 7-12 years
• No reduction in the risk of prostate cancer with
selenium
• Men who took vit E 400IU/day had a 17%
increase in the risk of prostate cancer
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Obesity (BMI>25)
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Difficulty in detecting
prostate cancer in
obese men
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In Men with prostate cancer obesity is linked
to more ggressive cancer
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• Increased risk of
recurrence after
treatment
• Increased risk of
death
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Chemoprevention with 5-ARIs
• 5ARIs ( finasteride/dutesteride)
• Reduce the overall risk of prostate cancer
• May increase the risk for high grade cancer
• Chemoprevention is an off label indication
• Cause a 50% reduction in PSA value which
may give patients a false sense of security
that could delay a diagnosis of cancer
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DIAGNOSTIC WORKUP
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Symptoms
1. Asymptomatic with raised PSA
2. Urinary symptoms
(LUTS)
3. Symptoms related to spread of
the cancer
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Mr Warren, 70 yr old male schoolteacher
• Chief Complaint of LUTS
( Lower Urinary Tract symptoms )
• Main concerns
Do I have a prostate problem ?
Do I have cancer ?
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Causes of LUTS (Lower urinary tract
symptoms)
Bladder
Cancer, Stones,
Cystitis, TB
Functional disorders
Neurogenic Bladder
Prostate
BPH, cancer
prostatitis
Urethra
Stones, strictures
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NEUROGENIC BLADDER
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Bladder
Continence center
Brain
Stroke,
Parkinsons
Tumour
Meningitis
MS
Spinal cord
Trauma,
Metastatsis
TB
Peripheral
nerves
DM
surgery
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Diagnostic workupHISTORY
• Voiding history
Voiding diary
Haematuria ?
• Diseases of the genitourinary tract
• Neurological disease
DMCurrent medications
• Sexual function
Time interval Urine Passed
Mid-night – 1.00
220 ml1.00 – 2.00
2.00 – 3.00
3.00 – 4.00 200 ml
4.00 – 5.00
5.00 – 6.00
225 ml6.00 – 7.00
7.00 – 8.00
8.00 – 9.00 150 ml
9.00 – 10.00
10.00 – 11.00
11.00 – 12.00 200 ml
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Diagnostic workup
Physical Examination
• Palpable Bladder/Kidneys
• Genitalia
• Neurological examination of the LL
• DRE ( Digital rectal Examination)
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Physical Exam
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Neurological Exination
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KUB
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Ultrasound
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• All Tests were within normal ranges
PSA 2.5ng/ml
• In men > 50yrs with LUTS and a negative workup the most common diagnosis is BPH
• Medical management of BPH was commenced.
@ blocker was the first line therapy
Later 5 @ reductase inhibitor was added (proscar/dutesteride)
• Advised to repeat his PSA in a year
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• A year later he had a repeat PSA
PSA increased to 3.5 ng/ml
Prostate was normal on DRE
• What would you advise ?
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3
• He is on a 5@ reductase inhibitor
which will decreases PSA by half
• His real PSA is 3.5 X 2 = 7 ng/ml
• Reevaluate the patient and repeat the PSA
• Repeat PSA was still > 4, recommend he see
a urologist for a prostatic biopsy
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Histopathological Report
• Adenocarcinoma of the
Prostate
• Grade 7
• What does that mean ?
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Grading of Prostate Cancers
Grade 4-6
LOW GRADE CANCERSGrade 7-10
HIGH GRADE CANCERS
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More likely to die WITH the
cancerMore likely to die BECAUSE of
the cancer
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Staging
Local staging
• Rectal Examination
• MRI of the prostate
Metastatic staging
• Bone Scan
• CT /US Abdomen
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Counseling
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Prostate Cancer Screening
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Murali Sundram
Consultant Urologist
Hospital KL
1st Malaysian Men’s Health Conference 2018