Transcript Prostate cancer Screening in 2013

Prostate Cancer Screening in
2013: Reports of its Death Are
Greatly Exaggerated
Norm D. Smith, M.D.
Associate Professor
Co-Director
Urologic Oncology
University of Chicago
United States Preventive
Services Task Force (USPSTF)
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USPSTF Warns Against Blood Test For
Prostate Cancer
ABC World News - “An earthquake today in
the debate over men and prostate cancer”
New York Times "PSA does not save lives,
but results in needless medical procedures
that have left tens of thousands of men
impotent, incontinent or both”
United States Preventive
Services Task Force (USPSTF)
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Los Angeles Times -16-member panel
determined whether widespread PSA testing
saves enough lives to justify the
considerable medical fallout
HealthDay - the task force studied "five trials,
the two largest done in Europe and in the
United States... found no reduction in deaths
due to prostate cancer among men of all
ages in the study who underwent PSA
testing”
United States Preventive
Services Task Force (USPSTF)
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New York Times - Aetna and Kaiser
Permanente said it was unclear whether they
would continue paying for the test… United
Healthcare and WellPoint said they would
continue coverage
GQ Medicare "is required under a 2008 law to
cover the PSA test annually for beneficiaries
50 years old and older. Presumably it would
take an act of Congress to undo that
coverage requirement. Medicaid coverage of
the PSA test is a state by state decision."
United States Preventive
Services Task Force (USPSTF)
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No Urologists
Grade D recommendation against PSAbased screening for prostate cancer
“moderate or high certainty that the
service has no net benefit… harms
outweigh the benefits”
Discourage PSA screening
Prostate Cancer Screening
Studies - 2009
Prostate Test Found to
Save Few Lives
(New York Times, March 2009)
Last week, two major studies from the
United States and Europe found that
P.S.A. testing — the annual blood test
used to screen men for prostate cancer —
saves few if any lives, while exposing
patients to aggressive and unnecessary
treatments that can leave them impotent
and incontinent
Prostate-Specific Antigen
Best Practice Statement:
2009 Update
(American Urological Association)
http://www.auanet.org/content/guidelines-andquality-care/clinical-guidelines/mainreports/psa09.pdf
PSA Biopsy Thresholds
(4.0 versus 2.5 ng/ml)
Results Age < 60
1
 0.9
sensitivity
0.8
 1.4
 0.9
 2.6
 1.4
adjusted for bias
0.6
0.4
 2.6
unadjusted
 4.1
 4.1
0.2
 6.1
.69  .86
p = 0.0001
 6.1
0
0
0.2
0.4
0.6
1-specificity
0.8
1
Results Age > 60
1
 1.1
sensitivity
0.8
 2.1
 1.1
 2.1
0.6
adjusted for bias
 4.1
unadjusted
 4.1
0.4
 6.1
 6.1
0.2
.62  .72
p = 0.008
 10.1
 10.1
0
0
0.2
0.4
0.6
1-specificity
0.8
1
Probability of No PSA Progression
T1c Patients with RRP by PSA at
Diagnosis ( PSA Follow-up Study)
1.0
2.6-4.0
4.1-6.0
6.1-9.9
> 10
.9
.8
.7
.6
.5
.4
PSA correlates with 10-year progressionfree survival rates
.3
.2
.1
0.0
0
20
40
60
80
Number of Months
100
120
Freedland SJ. J Urol 174: 1276-81, 2005
Age to Start PSA Screening
Baltimore Longitudinal Study
on Aging
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Median PSA level:
Age 40-49 = 0.6 ng/ml
Age 50-59 = 0.7 ng/ml
3-fold higher risk of prostate cancer within
10-25 years if PSA > median for age group
Fang et al. Urology, 58: 411, 2001.
Age- Specific Median PSA
Age Group
40s
Median PSA
(ng/ml)
0.7
50s
0.9
60s
1.3
70s
1.7
If baseline PSA is > median for age group, the risk of cancer
is 12- to 22-fold higher
Odds Ratio of Subsequent
Prostate Cancer Diagnosis
Variable
OR
95% CI
Any baseline PSA >0.7 ng/mL for men 40–
49 yr
30.9
4.2–229.4
Baseline PSA between 0.7 and 2.5 ng/mL
for men 40–49 yr
14.6
1.9–113.7
Any baseline PSA >0.9 ng/mL for men 50–
59 yr
13.2
9.9–17.4
Baseline PSA between 0.9 and 2.5 ng/mL
for men 50–59 yr
7.6
5.7–10.2
Suspicious vs. negative DRE
4.9
3.9–6.1
Age in 50s vs. 40s
2.3
1.6–3.5
African-American heritage
1.2
0.9–1.5
Family history
1.06
1.02–1.11
Loeb S, Roehl KA, Antenor JA, Catalona WJ, Suarez BK, Nadler RB. Baseline prostate-specific antigen compared with median
prostate-specific antigen for age group as predictor of prostate cancer in men younger than 60 years old. Urology.
2006;67(2):316-20.
PSA Kinetic Parameters
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PSA Velocity
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absolute change in PSA per year
Independent of baseline PSA value
Better for diagnosis
PSA Doubling Time
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Time it takes PSA value to double
A function of baseline PSA (the higher the
baseline, the longer it takes to double)
Not as useful for diagnosis
PSA Velocity in PSA Study
Cancer
Non-Cancer
Biopsy
No Biopsy
Median
PSAV
(ng/ml/yr)
0.8
0.1
0.1
P<0.0001
PSA Velocity for Detecting LifeThreatening PCa when Still Curable
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For men with a consistent PSAV of >0.35
ng/ml/year, there is more than a 5-fold
increased risk of PCa death in next 2-3
decades
Recommended to begin PSA testing at
age 40 to acquire reliable PSAV data
Carter HB et al JNCI 2006;98:1521-7
Multivariate analysis to predict prostate cancer
detection
OR
(95% CI)
p-value
PSAV > 0.4
6.06 (5.19-7.08)
<0.0001
Total PSA (per
unit)
1.08 (1.05-1.10)
<0.0001
Age (per year)
1.04 (1.03-1.05)
<0.0001
AA vs Caucasian
1.57 (1.19-2.07)
0.002
Family history
1.25 (1.03-1.52)
0.02
AUC=0.80
American Cancer Society, Cancer Facts & Figures 2005
Example of National Mortality Rate Trends
Denmark
Example of WHO Global
Mortality Rate Trends
“The trends in prostate cancer mortality rates in
examined countries suggest that PSA screening
may be effective in reducing mortality from
prostate cancer.”
Pattern A: Prostate Cancer Mortality Lower than before PSA Era
Pattern B: Prostate Cancer Mortality Decreasing but Still Higher
than Before PSA Era
Pattern C: Prostate Cancer Rate Still Increasing Constantly
(18 of 38 Countries Examined)
Take Home Messages
for PSA Screening
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Initial PSA screening at age 40
If PSA higher than median for age,
annual screening at minimum (perhaps
6 months)
Annual PSA screening at 40 for AfricanAmericans and men with family history
Biopsy threshold 2.5 in men < 60
Consider biopsy for PSA velocity > 0.35
PSA screening likely saves lives