Prostate Cancer

• One of the commonest causes of death in the Western World

• USA 2005– 232,090 new cases– 30,350 deaths

• Lifetime risk of disease 16.6%• Lifetime risk of death 3.4%

Prostate Cancer

• BAUS Cancer Registry 2004– 14,858 new cases

• >70% well / mod differentiated• 66% T1/T2

• CUH – 150+ new diagnosis per year.

Deaths related to age

Epidemiology

• Dietary factors– Increased risk with

increased fat– Phytoestrogens reduce

risk– Selenium, lycopenes are

protective

• No definite evidence for formal recommendations

PSA

• Useful in detection, staging and monitoring of prostate cancer

• Prostate specific but not cancer specific• Other causes of elevated PSA

– BOH, urinary retention, catheter– Prostatitis– Urological intervention– Sexual activity

Diagnosis and Staging

• DRE• PSA• TRUS and biopsy• MRI• Bone Scan• Partins Tables (PSA,

DRE, Biopsy data)

PSA 34KDa

TRUS and Biopsy

Multi parametric MRI

Multi parametric MRI

Multi parametric MRI

Multi parametric MRI

MRI Fusion biopsies - TP

Does PSA Testing Influence the Natural History of Prostate Cancer

Summary

• RCT data does not support routine screening• Screening aids earlier diagnosis and detect cancer at

earlier stage• Screening does not have a significant impact on

mortality• Cost: testing, over treatment, adverse effects, QoL• Therefore discussion at individual level for PSA

testing

PSA

• Confused?

– I am!!

The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188

• 1. For men aged 50-69 years, level 1 evidence shows that psa testing reduces the incidence of metastatic prostate cancer and prostate cancer specific mortality rates.

– Population screening not recommended but well informed men should be fully counselled about the positive and negative aspects of psa testing.

The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188

• 2. Prostate cancer diagnosis must be uncoupled from prostate cancer intervention

– Screening allows diagnosis of high risk cases within the window of curability

– Many with low risk disease do not need aggressive treatment

– Active surveillance protocols need to be standardised and validated

The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188

• 3. PSA testing should not be considered on its own, but rather as part of a multivariable approach to early prostate cancer detection

– Consider:• Age, ethnicity, FHx, PMHx, DRE findings• F:T, PCA3, biomarkers

The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188

• 4. Baseline PSA testing for men in their 40s is useful for predicting the future risk of prostate cancer and its aggressive forms

– Median psa for men 40-49yr = 0.5-0.7ng/ml– The higher above median the greater risk of later

developing life-threatening disease– Baseline psa test in 40s has value for risk

stratification

The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188

5. Older men in good health with a > 10 year life expectancy should not be denied PSA testing based on their age.

– Men should be assessed on an individual basis rather than applying an arbitrary chronological age prohibiting testing.

The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188

Summary:

•There is no right answer•Individual based shared decision making process.•Increase in AS•“treatment or non-treatment decisions can be made once cancer is found, but not knowing about it in the first place surely burns bridges”

CUH – Urology, ahead of the field

• Early OPD• Same day MRI• Full counselling• Move towards targeted

biopsies• Individual based shared

decision making process