Transcript Prostate cancer * Who needs screening?

Prostate cancer – Who needs
screening?
Professor Frank Chinegwundoh MBE
Consultant Urological Surgeon Barts
Health NHS Trust
Definition of screening
• Screening is a process of identifying apparently
healthy people who may be at increased risk of a
disease or condition.
• They can be offered information, further tests
and appropriate treatment to reduce their risk
and/or any complications arising from the disease
or condition
• www.screening.nhs.uk/screening#fileid7942 accessed
28.6.15
UK screening programmes
UK National Screening Committee
(UKNSC)
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Programme appraisal criteria
Criteria for appraising the viability, effectiveness and appropriateness of a screening programme
The Condition
• 1. The condition should be an important health problem
• 2. The epidemiology and natural history of the condition,
including development from latent to declared disease,
should be adequately understood and there should be a
detectable risk factor, disease marker, latent period or early
symptomatic stage.
• 3. All the cost-effective primary prevention interventions
should have been implemented as far as practicable.
• 4. If the carriers of a mutation are identified as a result of
screening the natural history of people with this status should
be understood, including the psychological implications.
Criteria for screening programme
continued
• The Test
• 5. There should be a simple, safe, precise and validated screening test.
6. The distribution of test values in the target population should be known
and a suitable cut-off level defined and agreed.
7. The test should be acceptable to the population.
8. There should be an agreed policy on the further diagnostic investigation
of individuals with a positive test result and on the choices available to
those individuals.
– Wilson JMG, Jungner G. Principles and practice of screening for disease. Public
Health Paper Number 34. Geneva: WHO, 1968.
Criteria for screening programme cont.
• The Treatment
• 10. There should be an effective treatment or intervention
for patients identified through early detection, with
evidence of early treatment leading to better outcomes
than late treatment.
11. There should be agreed evidence based policies
covering which individuals should be offered treatment and
the appropriate treatment to be offered.
12. Clinical management of the condition and patient
outcomes should be optimised in all health care providers
prior to participation in a screening programme.
Criteria for screening programme cont.
• The Screening Programme
13. There should be evidence from high quality Randomised Controlled Trials that
the screening programme is effective in reducing mortality or morbidity.
14. There should be evidence that the complete screening programme (test,
diagnostic procedures, treatment/ intervention) is clinically, socially and ethically
acceptable to health professionals and the public.
15. The benefit from the screening programme should outweigh the physical and
psychological harm (caused by the test, diagnostic procedures and treatment).
16. The opportunity cost of the screening programme (including testing, diagnosis
and treatment, administration, training and quality assurance) should be
economically balanced in relation to expenditure on medical care as a whole (ie.
value for money). Assessment against this criteria should have regard to evidence
from cost benefit and/or cost effectiveness analyses and have regard to the
effective use of available resource.
http://www.screening.nhs.uk/criteria#fileid9287
accessed 28.6.15
Review of evidence
Prostate cancer is an important health
issue
Increase of prostate cancer over time
Natural history
Risk factors for prostate cancer –
ethnicity, age, FH
Age
Family history
Additional risk factors for prostate
cancer
• Weight - Risk of
advanced prostate
cancer
by 9% for every 5kg/m2
& 15-20 % risk of dying
Height - 7%
Risk of dying from ca p per 6cm
increase in height
Other potential risk factors
Risk calculators
UKNSC screening criteria 8
• There should be an
agreed policy on the
further diagnostic Ix of
individuals with a +ve
test result
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TRUS Bx
mpMRI
Transperineal Bx
Fusion targeted Bx
TRUS biopsy
UKNSC screening criteria 10
• The Treatment
• there should be agreed
evidence based policies
covering which
individuals should be
offered treatment and
the appropriate
treatment to be offered
UKNSC criteria 13 evidence base from
randomised clinical trials of reduction
in mortality or morbidity
Update on European randomised
screening study 2014
European screening study
• In The Lancet, Fritz Schroder and colleagues3
now report 13-year mortality data from the
ERSPC study. At 9 years, screening appeared to
reduce prostate cancer mortality by 15% (rate
ratio 0·85, 95% CI 0·70–1·03); this reduction
was 22% at 11 years (0·78, 0·66–0·91) and
21% at 13 years (0·79, 0·69–0·91).
ESPRC 2014 update
• In men aged 55-69 years, the relative mortality
reduction remained similar at 21%; the absolute
reduction increased from 0.9 to 1.28 fewer
deaths/1000 men screened. This translates into much
improved figures needing to be invited for screening
and diagnosed, at 781 and 27 (1410 and 48 in 2009).
• overall mortality does not differ between the arms of
the study. The main downside of PSA-driven screening
remains the diagnosis of non-life-threatening cancers
(overdiagnosis) by screening, at a frequency of about
40%
UKNSC position on screening for
prostate cancer June 2015
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The UK NSC recommendation on Prostate cancer screening/PSA testing in men over the age of 50
(currently in consultation)
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This recommendation is currently being reviewed as part of the UK NSC's regular review cycle of all
policies.
The review process began in Jan 2014 and is estimated to be completed by Nov 2015.
» Download the expert review for Prostate Cancer (PDF document, 1016KB)
The UK NSC welcomes comments and feedback on the expert review during the consultation
period that lasts from 03/06/2015 until 04/09/2015. Please send comments to Adrian Byrtus by email using this feedback form.
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• Recommendation: Systematic population screening
programme not recommended
• The UK NSC does not recommend universal screening of men
for prostate cancer.
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PSA (prostate specific antigen) testing can, however, be performed on request. Information is
provided on the risks and benefits by the Prostate Cancer Risk Management Programme.
UKNSC –why not to screen population
• The UK NSC does not recommend universal screening of men for prostate
cancer because:
• The test for prostate cancer is not effective enough and
does not identify a large proportion of men who in fact
have prostate cancer.
• A positive test will lead in most cases to a biopsy, which
often does not give a definitive answer and leads to anxiety
and to further investigations.
• Current research indicates for every 100,000 men at age 50
offered screening, 748 would end up being treated. The
men accepting screening would have their lives extended
on average by a day – while 274 men would be made
impotent, 25 incontinent and 17 would have rectal
problems as a result of the treatment.
Overtreatment can be reduced
• Outcome Following Active Surveillance of Men with Screendetected Prostate Cancer. Results from the Göteborg Randomised
Population-based Prostate Cancer Screening Trial
• By: Rebecka Arnsrud Godtmana , Erik Holmbergb, Ali Khatamia,
Johan Strannea and Jonas Hugossona
• European Urology, Volume 63 Issue 1, January 2013, Pages 101-107
• Published online: 01 January 2013
• Conclusion results indicate that overtreatment—one of the major
potential drawbacks of PSA screening—can be reduced, as a large
proportion of screen-detected PCa can be managed safely with AS.
Men with very low- and low-risk PCa constituted more than half of
all screen-detected PCa, and for these men, AS appears to be an
attractive alternative, especially in men >65 yr of age.
How to screen high risk groups
• Ethnicity
• Family history
• By GP
• National invitation
An American perspective