Screening for Prostate Cancer
Christopher R. Williams, MD
Associate Professor, Division of Urology
Director, Urologic Oncology and Robotic Surgery
NO RELEVANT DISCLOSURES
How common is prostate cancer?
CA CANCER J CLIN 2017;67:7-30
Major Risk Factors
• Age
– Incidence rises rapidly after age 50
– Over 60% of new cases diagnosed in men over 65
• Family history
– 1st degree relative with cancer more than doubles
risk
• Brother > father
• Multiple relatives > single relative
• Multiple generations at early age > single generation at older
age
• Race
– African-American men are more than twice as
likely to die from prostate cancer than Caucasian
men
1. http://www.cancer.org/cancer/prostatecancer
2. Carter BS. J Urol 1993; 150: 797.
Prostate Cancer screening
• Most effective method for detection is combined
use of Prostate Specific Antigen (PSA) and Digital
Rectal Exam (DRE)
– ~15% of men with cancer have PSA <4
– PSA and DRE are complementary b/c they do not always
detect the same cancers
Thompson, NEJM, 2004
Serum PSA as a Screening Test
for Prostate Cancer
PSA accuracy in detecting cancer:
Sensitivity
Specificity
PPV
NPV
Overall accuracy
79%
59%
40%
89%
64%
(Catalona, NEJM, 1991)
Factors affecting PSA
• Age
– Age-adjusted PSA1
»
»
»
»
40 to 49 - 0.0 to 2.5
50 to 59 - 0.0 to 3.5
60 to 69 - 0.0 to 4.5
70 to 79 years - 0.0 to 6.5
• Prostate size:
– Percent free/total PSA 2
» 25% cutoff: 95% sensitivity & eliminates 20% of unnecessary biopsies
» < 15% Suspicious for cancer
» > 24% Suggests benign disease
» 15-24% Grey area
• Medications
– 5-alpha reductase inhibitors
– Oral Estrogen agents
– LHRH agonists and antagonists
1. Oesterling, JAMA 1993
2. Catalona, JAMA, 1998
2013 AUA PSA Screening
Guidelines
• PSA screening in men under age 40 years is not recommended.
• Routine screening in men between ages 40 to 54 years at
average risk is not recommended.
• Shared decision-making is recommended for men age 55 to 69
years that are considering PSA screening…
• Routine PSA screening is not recommended in men over age 70
or any man with less than a 10-15 year life expectancy.
• For men younger than age 55 years at higher risk (e.g. positive
family history or African American race), decisions regarding
prostate cancer screening should be individualized based on
personal preferences and an informed discussion regarding the
uncertainty of benefit and the associated harms of screening.
http://www.auanet.org/education/guidelines/prostate-cancer-detection
AUA after releasing its guidelines
PCP after reading AUA guidelines
2016 NCCN Screening
Guidelines
US Preventive Services Task
Force Considerations
• Reason for USPSTF investigation: Likely over-diagnosis and overtreatment of prostate cancer.
• In 2012 the USPSTF recommended against PSA screening on the
grounds that there is no net benefit and that the potential harms
outweigh the benefits. Grade D1
• The harms identified by USPSTF are overestimated and relate more
to treatment than screening.
• Not all prostate cancers require treatment. The patient is entitled to
know whether he has prostate cancer and be allowed to decide if he
desires treatment. A recommendation against screening deprives
him of that autonomy.
Moyer VA, Annals of internal medicine. 2012;157(2):120-34.
Transrectal Ultrasound-guided
Prostate Biopsy
Prostate biopsy complications
Infection
5-7%
Hospitalization
1-3%
Bleeding
Hematuria
Intervention
Rectal Bleeding
Intervention
Hematospermia
>4 weeks
50%
<1%
30%
2.5%
50%
30%
Other
LUTS (~1 mo)
Urinary Retention
ED (~1 mo)
6-25%
0.2 -2.6%
<1%
https://www.auanet.org/common/pdf/education/clinical-guidance/AUA-PNBWhite-Paper.pdf
Impact of the United States Preventive Services Task
Force 'D' recommendation on prostate cancer screening
and staging
Eapen, Renu S.; Herlemann, Annika; Washington, Samuel L. III;
Cooperberg, Matthew R.
Recent findings: Following the USPSTF recommendation, a substantial
decline in PSA screening was noted for all age groups. Similarly, overall
rates of prostate biopsy and prostate cancer incidence have significantly
decreased with a shift toward higher grade and stage disease upon
diagnosis. Concurrently, the incidence of metastatic prostate cancer has
significantly risen in the United States. These trends are concerning
particularly for the younger men with occult high-grade disease
who are expected to benefit the most from early detection and
definitive prostate cancer treatment.
Current Opinion in Urology: Post Author Corrections: February 17, 2017
doi: 10.1097/MOU.0000000000000383
2017 USPSTF Screening Update
• Men ages 55–69
•
The decision about whether to be screened for prostate cancer should be an individual one. The
USPSTF recommends that clinicians inform men ages 55 to 69 years about the potential benefits and
harms of prostate-specific antigen (PSA)–based screening for prostate cancer. Screening offers a
small potential benefit of reducing the chance of dying of prostate cancer. However, many men will
experience potential harms of screening, including false-positive results that require additional
workup, overdiagnosis and overtreatment, and treatment complications such as incontinence
and impotence. The USPSTF recommends individualized decision-making about screening for
prostate cancer after discussion with a clinician, so that each man has an opportunity to understand the
potential benefits and harms of screening and to incorporate his values and preferences into his
decision.
• Recommendation Grade C (Offer or provide this service for selected patients
depending on individual circumstances)
• Men age 70 and older
•
The USPSTF recommends against PSA-based
screening for prostate cancer in men age 70 years
and older.
• Recommendation Grade D
(Discourage the use of this service)
https://screeningforprostatecancer.org/#utm_
source=google&utm_medium=cpc&utm_cam
paign=recommendation&utm_term=branded&
utm_content=draft_uspstf
Summary
• Prostate cancer screening is worthwhile, as evidenced by
negative repercussions of the USPSTF recommendations
• Prostate cancer screening should include PSA and DRE
• The NCCN guidelines are more helpful for PCPs than the
AUA guidelines
• Serious prostate biopsy complications are very rare and
should not discourage screening
Thank You!