Prostate Cancer Screening

Bruce L. Houghton, MDAssociate Professor of Medicine

Division of General MedicineDepartment of Internal Medicine

Creighton University School of Medicine

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What is a Prostate?

• Small gland (about 3 to 4 cm diameter)• A little larger than a walnut• Secretes a slightly alkaline fluid that

combines with spermatozoa to create semen.

• The prostatic alkaline fluid prolongs the survival of the spermatozoa in the slightly acidotic vaginal tract

Prostate

• Prostate needs testosterone to function• Diseases of the Prostate

– Prostatitis (inflammation and/or infection of the prostate)

– Benign Prostatic Hypertrophy (enlarged prostate)

– Prostate Cancer

Prostate Cancer

• Leading type of cancer for U.S. men• 1 in every 6 U.S. men will develop invasive

prostate cancer before he dies• Second leading cause of cancer death in

U.S. men– Following Lung cancer

• 2007– 218,890 new cases diagnosed– 27,050 men died of prostate cancer

Prostate Cancer

• U.S. Men have 1 in 6 lifetime chance of getting prostate cancer– But only 3% chance of dying of prostate cancer

• Autopsy series– Detect Prostate Cancer in 1/3 of men younger than

80 years and 2/3 of men older than 80• Suggests that prostate cancer is slow growing

and that men die of other causes before prostate cancer is evident

Prostate Cancer Incidence

• Age-Adjusted Incidence (new cases) of prostate cancer have increased over the last 50 years

• Peaked 1990s– Mostly with increased early detection due to

Prostate-specific antigen (PSA) testing in late 1980s

• Associated mostly with increased early detection

Prostate cancer: changes over time average annual age-adjusted incidence and mortality rates in the United States, 1973 - 2001 (2001 US standard)

Source: SEER Program.

Prostate Cancer Risk Factors

• Increases with Age– more common after age 50 years

• Increases with family history of prostate cancer

• African-American men at higher risk– Both of developing prostate cancer and of

dying from prostate cancer

Prostate Cancer Mortality

• Extent of tumor at time of diagnosis is especially important

• Localized (cancer only within gland)– 75% 10-year survival rate

• Regional Extension– 55% 10-year survival rate

• Metastases– 15% 10-year survival rate

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Dan Fogelberg (expired age 56)

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Merv Griffin (expired age 82)

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Robert De Niro (diagnosed 2003)

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Why push for screening?

• Most early prostate cancer is asymptomatic

• Symptoms of prostate cancer– Sometimes similar to BPH symptoms

• Frequent urination, nocturnal urination, difficulty urinating

– Erectile dysfunction or painful ejaculation– Advanced cancer can cause bone pain

“Perfect” Prostate Cancer Screening Test

• Identify asymptomatic men with aggressive tumors early when the tumor is localized – Decrease mortality– Decrease morbidity

• Urinary obstruction• Prostate Cancer Metastatic bone pain

Prostate Cancer Screening

• Digital Rectal Examination (DRE)• Prostate Specific Antigen Test (PSA)

• BPH Cancer

Prostate Cancer Prevention?

• Vitamin E and Selenium– Not enough evidence to recommend

• Finasteride (Proscar)– Questionable – Reduces risk of developing prostate cancer

by about 25%– However aggressive cancers were diagnosed

more frequently in the first year in men who took finasteride than who did not

Digital Rectal Examination

• Physician examines the prostate with a gloved finger

• Detect enlargement of the prostate gland• Asymmetry (enlarged lobe)• Detect nodules (lumps)• ?Normal consistency is similar to tip of

your nose?

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How good is the DRE?

• Rarely done alone (PSA is often drawn as well)

• Ranges of Sensitivity for DRE alone – 18 to 22% up to 55 to 68% in asymptomatic

men

Prostate Specific Antigen (PSA)

• Glycoprotein produced by the prostate epithelial cells

• Elevated PSA can precede clinical disease by 5 to 10 years

• DRE has MINIMAL effect on PSA level and PSA CAN BE drawn following a rectal examination

What Will Elevate PSA?• BPH• Urinary retention• Acute Prostatitis• DRE

– 0.26 to 0.4 ng/ml• Ejaculation• Perineal trauma

– By up to 0.8 ng/ml– Return to normal in 48

hours

• Procedures– TURP– Cystoscopy– Prostate biopsy

Finasteride (Proscar)Dutasteride (Avodart)

• Treatments for BPH• Will LOWER the PSA about 50%• ‘Double’ whatever level you get from a

patient on Finasteride or Dutasteride

PSA

• Traditional cutoff level is 4 ng/ml• Other Ranges (not recommended by FDA)

– 40 to 49 years — 0 to 2.5 ng/mL– 50 to 59 years — 0 to 3.5 ng/mL– 60 to 69 years — 0 to 4.5 ng/mL– 70 to 79 years — 0 to 6.5 ng/mL

Other PSA Tests you may hear about

• PSA Velocity (measure PSA change over time)

• PSA Density• Free PSA• Complexed PSA

What is the Harm of Screening?• Anxiety (‘Labeling’)• Unnecessary Prostate Biopsy

– If the PSA is elevated, most likely you will see a Urologist

– Risk of complication less than 1%• Overdiagnosis

– Diagnosed and treated for disease that may have never caused significant problems

• Costs• False Security

Prostate Cancer Treatments

• Surgery• Radiation Treatment• Hormonal Therapy

Other Resources

• www.patients.uptodate.com

What to Do?

• No convincing randomized controlled trials that show prostate cancer screening decreases morbidity or mortality from prostate cancer– Cochrane Database Syst Rev. 2006 Jul

19;3:CD004720

Two Large Prostate Cancer Screening Trials Underway

• American Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial

• European Randomized Study of Screening for Prostate Cancer (ERSPC)

• Studies plan to pool their results• Final data will not be available for years

What are Current Recommendations for Prostate

Cancer Screening?• American Urological Association• American Cancer Society• American Academy of Family Practice (AAFP)• American College of Physicians• Canadian Task Force on Preventative Health

Care• US Preventative Services Task Force (USPSTF)

American Urological Association

• Offer PSA Screening to men at age 50 years and who have an estimated life expectancy of 10 years or more

• Men with first degree relatives who have prostate cancer and African Americans may benefit from screening at an earlier age (usually in practice age 40)

American Cancer Society

• Both DRE and PSA be offered to men aged 50 an older and who have a life expectancy of 10 years or more

USPSTF, AAFP

• Insufficient evidence to recommend for or against routine screening with PSA or DRE

American College of Physicians

• Giving men information about the benefits and risks/harms of screening to help them make a decision based on personal preference

Canadian Task Force on Preventative Health Care

• Recommends against routine screening with PSA

• Insufficient evidence to make a recommendation on DRE

American College of Preventive Medicine (Feb 2008 statement)

• Concurs with USPSTF• Insufficient evidence currently to

recommend routine population screening with DRE or PSA.

• Am J Prev Med 2008; 34 (2)

Urologist Willet Whitmore

• is cure possible in those for whom it is necessary, and is cure necessary in those for whom it is possible?

• Urol Clin North Am 1990 Nov;17(4):689-97

So, What To Do?

• Speak with your physician• Review the information on the website• Decide what you want after weighing risks

and benefits of screening

Questions/Comments?