Title: Carcinoma of Prostate: issues of screening 2005
1Carcinoma of Prostate issues of screening 2005
- David R. Rudy, MD,MPH
- Professor in Chair, Family and Preventive
Medicine - Chicago Medical School/ RFUMS
- Preventive Medicine MTD 601
2Relative significance of Prostate Ca
- Tumor Incidence Cause specific
mortality - Lung 172,570 163,510
MF 5545 - CRC 145,290 56,290
- Breast 212,930 40,870
- Prostate 232,090 30,350 Jemal
A, Tiwari RC, Murry T, Ward E , Samuels A,
TiwariRC, Ghafoor A, Feuer EJ, Thun M Cancer
Statistics, 2005. CA Cancer J. for Clin 2005
55(1) 10-30
3Case mortality prostate Ca
- Prostate Ca deaths/US 2002 30,350 incidence/
US 232,090 13 compare to 21 1998
4Ca Prostate burden of suffering 1(epidemiology,
incidence)
- Most common cancer in males (and pop.) second
cause cancer death (men) after lung - Incidence 147.6/100,000/yr males),
1000/100,000/yr by age 80 28,900 deaths - 189,000 new expected US 2002spurious increase
due to increased screening during the 1980s (lead
time bias) Jemal A, et al Cancer Statistics,
2002. CA - Cancer Journ Clin. 2002 52(1) 23-45
5Ca Prostate burden of suffering 2(mortality)
- 15.7 /100,000/year mortality (1998)
- Case mortality increased nearly 20 from 1976
(22.1) to 1994 (26.0), possibly due to
increasing life expectancy. - Cause of mortality in 3.6 (i.e. lifetime risk of
dying of Ca prostate, comparable to breast Ca
deaths for women)
6Ca Prostate burden of suffering 3(geography,
ethnicity)
- African-Americans lifetime death risk is 66
higher in African Americans than white Americans
(4.5 vs 3.6), though lifetime incidence is only
mildly higher than in whites (18.8 vs 18.5)
7Ca Prostate
- Pathophysiology multicentric carcinoma of
varying aggressiveness increasingly incident and
prevalent decreasingly aggressive with age. - Causation incidence directly related to
testosterone production. 2ndy causes may
include inadequate vegetables/fruit, vitamins D,
A also obesity.
8Ca Prostate presentation (how discovered) (1)
- Prostatism (symptoms of obstruction), (Causes of
prostatism BPH, prostatitis, Ca) - or finding a (stony hard palpable) nodule on DRE
50 have metastases - asymmetrical DRE finding 50 have Ca
- bone metastases
- or screened w/ elevated PSA.
9CA prostate presentation 1A
- If PSA 4ng/mL once, 66 are organ confined
nearly 75 if screened by serial determinations
for rate of rise, i.e. latter more sensitive
i.e., going from 1 ng/mL/yr.
10Prostatism
- the syndrome of urinary obstruction of varying
degrees - Nocturia, urgency, hesitancy, decreased size of
stream susceptibility to acute retention - Causes BPH, prostatitis, carcinoma
11Ca Prostate presentation (2)staging
- A non-palpable (always confined to one
lobe) - B palpable, confined to capsule
- C penetration of capsule, to seminal vesicles
or bladder - D lymph node involvement
D1 without distant mets D2 distant
mets, e.g. bone, lung
12Ca Prostate presentation (3)Work-up
- PSA height correlates roughly with stage (see
Table III - 6) - IVP to r/o involvement of ureters, kidneys
- Cystoscopy to r/o bladder (contiguous) involvement
13Ca Prostate presentation (4)Work-up
- Chest XR to r/o lung (i.e. distant) metastases
- Staging exploration lymphadenectomy (as many as
2/3 of cases initially diagnosed as stages A,B
may become C or D after lymph exploration)
14Therapeutic approaches prostate Ca
- Prostatectomy
- Irradiation
- Hormone (orchiectomy/estrogen)
15Ca prostate treatment 1Organ confined
- Patient
Radical prostatectomy - Patient / 70 y.o., life expectancy Radiotherapy. Prognosis same as surgery for
the first 10 years - Patients / 70 y.o. with decreased life
expectancy or w/ small, low grade cancer
Watchful waiting (Naitoh J et al
AFP 1998 571131-39)
16Survival Ca Prostate
- 78 overall survival Journal CA, 43(1) (only
1/380 with histologic dx Ca prostate will die of
it) - Stage A 87
- Stage B (5-10 of total) 81
- Stage C 65
- Stage D 30 CA 1993 43(2)
17Ca Prostate prevalence in different settings
- 1 in a primary care practice
- 23 in a urologists practice
- 33 of men over the age of 50 50 in 70 y.o. 70
by 80 y.o. (autopsy studies, i.e. indolent)
(Guide to Clinical Preventive Services, 1989)
18Ca Prostate burden of suffering 6(geography,
ethnicity)
- -much less frequent in Asians.
- Japanese men have less Ca prostate but
Japanese-American mens rates approximate those
of other American men.
19Pathophysiology 1
- Carcinoma of prostate produces increased serum
PSA (normal upper limit 4.0 ng/mL, rising
normally with age or size of gland as in BPH - PSA elevation is lacking in 20 of cases (but
less if rate if rise or proportion of bound PSA
are considered)
20Pathophysiolgy 2
- Ca exists in proportion to proportion of BOUND
PSA. - Corollary PSA in carcinoma of prostate occurs in
lesser proportion as FREE form (unbound). - a cutoff of sensitivity, 18 specificity (avoid bx in 18
- Cutoff of allows 95 sensitivity, 20 specificity
Cataloña J.A.M.A. 1997 277 1452-55
21Dx 3 PSA sens. ( 4.0 ng/mL)by stage of
prostate cancer
- Stage A
38.0 - Stage B
52.2 - Stage C
68.4 - Stage D
79.9
from USN
Hosp Great Lakes Lab 1997
(Table III - 6, Syllabus
22Ca prostate screening/diagnosis 1 PSA
- PSA elevation ( 4ng/mL) is /80 sensitive for
prostate cancer, and 90 specific . - Thus, with average risk there are many false
positives - Thus, PSA not an ideal screen test
23Ca prostate diagnosis 2 PSA
- Normal PSA defined according to age group. (See
Table III-7) - 40-49 years 0.0-2.5 ng/mL (median 0.7)
- 50-59 years 0.0-3.5 ng/mL (median 1.0)
- 60-69 years 0.0-4.5 ng/mL (median 1.4)
- 70-79 years 0.0-6.5 ng/mL (median 2.0)
(Oesterling et al J.A.M.A. 1993 270 860-64) - Another criterion rise PSA 0.7 ng/mL/yr
24Ca prostate Dx
- Percent of free PSA
- Free PSA
- Free PSA 25 cuts risk to 8
- Free PSA measurement is most useful when total
PSA 4 -10 ng/mL Cataloña et al Patient Care
1998 Sept 30 58-83
25Ca prostate diagnosis 4Spurious causes of PSA
elevation
- cystoscopy, prostate biopsy, prostate massage,
prostatitis, urethral instrumentation - large volume of gland as in BPH
26Criteria for screenability satisfied?
- 1. Condition has significant effect on life (yes)
- 2. Treatment available (sort of)
- 3. Asymptomatic period of diagnoseability (yes)
- 4. Treatment in asymptomatic yields result
superior to delaying until symptoms appear
(maybe) - 5. Tests of reasonable cost- sensitivity and
specificity appropriate for population risk (not
perfect) - 6. Incidence sufficient to justify cost (yes)
27Screening recommendations for prostate Ca,
conservative view
- ACS (June 6, 1997) and NCI annual DRE from the
age of 50 if life expectancy of at least 10
years) - at 45 years of age for those at high risk ( 2
1st degree relatives with prostate cancer,
African-American). - Urological association same except start at 40
y.o.
28Ca prostate Screening, liberal (aggressive) view
- PSA screening annually recommended when
1. male 50 y.o., 2. 40 y.o. African American male
3. male 35 y.o. if 1st degree F.H. Ca
prostate x 3 at early ages - If 2.5-
- If 4 -10, obtain free PSA if 25, biopsy
29Ca prostate Dx 5 Indications for Biopsy
- Abnormal DRE
- Elevated PSA 4
- PSA for age (e.g. 2.5 for 3.5 for
- Percent of free PSA
- Rate of rise with age 0.7/yr)
30Ca prostate Dx 5 A Other Indications for Biopsy
- PSA 4 -10 ng/mL with free PSA
- PSA 10 ng/mL!
Cataloña et al Patient Care 1998 Sept 30 58-83
31Ca prostate definitive diagnosis
- Transrectal ultrasonic study
- Transurethral resection biopsy
- Transrectal biopsy
32Therapy of Ca Prostate 1 stages A or B
- Patient
Radical prostatectomy - Patient / 70 y.o., life exp 10 years or
Radiotherapy. Prognosis same as surgery for
the first 10 years - Patients / 70 y.o. with decr. life expectancy
or w/ small, low grade cancer
Watchful waiting
33Therapy of Ca Prostate 2 Stages C or D
- Testosterone deprivation i.e., orchiectomy,
estrogen therapy - Irradiation of prostate (49)
- or of pelvic nodes f/b prostate (45.5)
34Complications of Radical Prostatectomy 1
Impotence
- 40-50 years 0
- 51-60 years 45
- 61-70 years 57
- 70 years 100
35Complications of Radical Prostatectomy 2
Incontinence
- None 81.5
- Mild (one pad/d) 14
- Moderate (multiple pads) 3
- Severe (total) 1.5