Prostate Cancer Screening

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Murali Sundram

Consultant Urologist

Hospital KL

1st Malaysian Men’s Health Conference 2018

TOPICS ON PROSTATE CANCER

• Epidemiology of Prostate cancer

• How to Screen

• Screening controversies

• Opportunistic screening

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EPIDEMIOLOGY OF PROSTATE CANCER

Prostate Cancer in the West

• Most common male cancer in the West

• 2nd most common cause of cancer death

• Lifetime risk of :

Developing prostate cancer 30%

Dying from prostate cancer is 3%

• Commonly a slow growing disease in elderly men which

may not be harmful during his lifetime

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World wide Incidence of Prostate Cancer

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Prostate Cancer in Malaysia

Age Standardized Incidence rate (ASR) :12 per 100,000 population

Chinese > Indians >Malays

Men 60-70 > Men 50-60

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Age adjusted incidence rates of prostate

cancer in 6 Asian countries

Country % change incidence

from 1978-1982 to

1993-1997

Philippines 49.5

Singapore 118.2

Japan 110.4

China 38.7

India 10.8

Thailand 5.0

8European Journal of Cancer 2005

Increasing incidence of prostate

cancer in Asia

• Westernization of Asian diets with loss of cultural protective factors.

• Better reporting of cases

• Increasing use of serum PSA

• Ageing population

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Projected growth of Asia’s Elderly Population > 65 yr. United Nation 2001

Region/

subregion

No people >65 yrs (1,000s)% Increase

2000-20502000 2025 2050

Asia 206822 456303 857040 314

East Asia 114729 244082 393802 243

Southeast

Asia24335 57836 128958 430 %

South Asia 67758 154385 334280 393

Risk factors• Age > 50 yrs

• Ethnicity blacks > whites >asians

• Family history of prostate cancer. Ist degree relatives ( father, son , brother ) have X2 the risk

• Genetic predisposition to other cancers

Breast cancer or ovarian cancer

Hereditary colorectal cancer

• Environmental Factors

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Changes in Prostate Cancer Incidence

Rates for Asians Migrants to the US

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1,8

14,9

China (Changai) USA (San Francisco)

5,1

16,5

Japan (Osaka) USA (San Francisco)

Eur Urol 1999;35 : 377-387

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Screening for Prostate Cancer

Screening

• Finding cancer early before the

development of symptoms with the hope

that early detection leads to effective

treatment and reduces the risk of dying

from that particular cancer

• Digital rectal examination

• Serum PSA

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PSA (Prostate Specific Antigen)

• Produced by prostate gland

• Some PSA escapes from

the prostate into the blood

and we can detect this by a

PSA test

• Normal PSA level is 0-4

ng/ml

Causes of raised PSA

Acute retention of urine

Infection

Bladder Stones

Ejaculation

Cycling

Urethral instrumentation

PSA ( Prostate Specific Antigen)

• PSA provides a lead time of 6-7

years before clinical cancer

• Persistently raised PSA

4-10 , there is a 30% chance of cancer

> 10 , there is a 50% chance of cancer

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Transrectal Prostatic Biopsy

Complications

• Haematuria

• Haemospermia

• Urinary tract infection

• Sepsis ( & death)

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Multiparametric MRI of prostate

Transperineal Prostate Biopsy

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Screening Debate

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Screening YES or NO ?

• Screening decreases death rate by 20% but

need to screen 1000men and treat 37 men to

save I life

? Cost effective

• Screening detects many cancers that will not

harm the patient in his life time but are still

treated

? Over diagnosis & Over treatment

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Patient Decision Aids

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How to screen

• Start at age of 50yrs ( 45 for men at risk)

• Screening interval of 2 years

• Stop at age of 70 yrs

• Do not screen men with poor health or life

expectancy < 10 yrs

• Baseline PSA at age of 40 yrs ?

• interpretation of PSA in men taking BPH

medication

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Health Screening

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Opportunistic Screening / Case Finding

• This refers to screening of Symptomatic

men and is recommended

• Patients > 50 yrs with voiding symptoms

should have a PSA as part of the

investigations

• Patients who are on certain types of BPH

medication should have the their PSA

adjusted

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Work up of patients with voiding symptoms

• Urinalysis

Urine Culture

• Renal function

• PSA

• KUB Ultra Sound

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SUMMARY

• Asia’s population is ageing rapidly

• Incidence of Prostate cancer in Asia appears to be

increasing

• Population screening of asyptomatic men is not

recommended

• Screening may be offered to well informed men in

the context of a shared decision making process

• Opportunistic screening of symptomatic men is

recommended

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THANK YOU

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Shared Decision Making

• Is a strategy for making a health care decision when there is more than one medically reasonable choice

• Joint decision making process between doctor and the patient

• Important that men receive BALANCED information to assist then in making an informed decision

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Does screening of Prostate Cancer lead

to better outcomes ?

• Does early diagnosis and treatment lead to decreased mortality ?

• No definite consensus

• Randomized trial neededScreening versus no screening

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European Randomized Study of Screening for

Prostate Cancer (ERSPC) NEJM March 2012

• Trial initiated in 1991

• 180,00 men aged 50-74 from 8 European countries

• Screened at 4 year interval and followed up for 11 years

• Results of this trial can be used to advise men on whether they want to be screened for prostate cancer

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PSA Testing

• Health Screening Programs for Asymptomatic patients

• Patients presenting with LUTS symptoms to the GP

This is NOT screening but Case finding

• Increased use of PSA testing by Primary Care

Physicians

Standard of care

Fear of litigation

Voss JD prostate cancer screening and

beliefs J Gen Inter Med 2001

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Screening detects more cancer

PSA SCREENING

96 cases of cancer

NO PSA SCREENING

60 cases of cancer

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Screening decreases mortality by 20 %

PSA SCREENING

4 patients died

NO PSA SCREENING

5 patients died

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Is Screening beneficial ?

• Screening reduced mortality from prostate cancer

(relative risk reduction of 20%)

• But to prevent I death from prostate cancer you need to screen 1000 men over 10 years and treat 37 cancers

• Unanswered Questions

Is it cost effective ?

Does benefits outweigh the harm ?

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American Guidelines prostate cancer screening 2013

Recommended

• PSA screening in men 55-69yr who are well informed and wish to be screened

• Screening interval of 2 years

• Shared decision making

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American Guidelines prostate cancer screening 2013

Not recommended

• < 40 yrs

40-54 with average risk of

prostate cancer

>70 yrs

< 10 yr life expectancy

• In the scenario where shared-decision making is not routine practice

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Prostate Cancer in Malaysia

• NO national screening program for prostate cancer

• Nation wide prostate awareness campaigns

(1998, 1999, 2001, 2003, 2005, 2007)

• Private health screening

• Case finding when patient presents with symptoms of BPH to the primary care physician

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Prevention of Prostate Cancer

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Dietary Advise

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Anything which is heart healthy is also prostate healthy

Fibre, vegetables and fruit √ red meat ×

Selenium & Vit C cancer prevention trial

(SELECT)

• 35,000 men were randomized to receive

selenium, vit E, combination or placebo

• Follow-up was 7-12 years

• No reduction in the risk of prostate cancer with

selenium

• Men who took vit E 400IU/day had a 17%

increase in the risk of prostate cancer

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Obesity (BMI>25)

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Difficulty in detecting

prostate cancer in

obese men

In Men with prostate cancer obesity is linked

to more ggressive cancer

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• Increased risk of

recurrence after

treatment

• Increased risk of

death

Chemoprevention with 5-ARIs

• 5ARIs ( finasteride/dutesteride)

• Reduce the overall risk of prostate cancer

• May increase the risk for high grade cancer

• Chemoprevention is an off label indication

• Cause a 50% reduction in PSA value which

may give patients a false sense of security

that could delay a diagnosis of cancer

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DIAGNOSTIC WORKUP

Symptoms

1. Asymptomatic with raised PSA

2. Urinary symptoms

(LUTS)

3. Symptoms related to spread of

the cancer

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Mr Warren, 70 yr old male schoolteacher

• Chief Complaint of LUTS

( Lower Urinary Tract symptoms )

• Main concerns

Do I have a prostate problem ?

Do I have cancer ?

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Causes of LUTS (Lower urinary tract

symptoms)

Bladder

Cancer, Stones,

Cystitis, TB

Functional disorders

Neurogenic Bladder

Prostate

BPH, cancer

prostatitis

Urethra

Stones, strictures

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NEUROGENIC BLADDER

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Bladder

Continence center

Brain

Stroke,

Parkinsons

Tumour

Meningitis

MS

Spinal cord

Trauma,

Metastatsis

TB

Peripheral

nerves

DM

surgery

Diagnostic workupHISTORY

• Voiding history

Voiding diary

Haematuria ?

• Diseases of the genitourinary tract

• Neurological disease

DMCurrent medications

• Sexual function

Time interval Urine Passed

Mid-night – 1.00

220 ml1.00 – 2.00

2.00 – 3.00

3.00 – 4.00 200 ml

4.00 – 5.00

5.00 – 6.00

225 ml6.00 – 7.00

7.00 – 8.00

8.00 – 9.00 150 ml

9.00 – 10.00

10.00 – 11.00

11.00 – 12.00 200 ml

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Diagnostic workup

Physical Examination

• Palpable Bladder/Kidneys

• Genitalia

• Neurological examination of the LL

• DRE ( Digital rectal Examination)

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Physical Exam

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Neurological Exination

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KUB

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Ultrasound

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• All Tests were within normal ranges

PSA 2.5ng/ml

• In men > 50yrs with LUTS and a negative workup the most common diagnosis is BPH

• Medical management of BPH was commenced.

@ blocker was the first line therapy

Later 5 @ reductase inhibitor was added (proscar/dutesteride)

• Advised to repeat his PSA in a year

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• A year later he had a repeat PSA

PSA increased to 3.5 ng/ml

Prostate was normal on DRE

• What would you advise ?

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• He is on a 5@ reductase inhibitor

which will decreases PSA by half

• His real PSA is 3.5 X 2 = 7 ng/ml

• Reevaluate the patient and repeat the PSA

• Repeat PSA was still > 4, recommend he see

a urologist for a prostatic biopsy

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Histopathological Report

• Adenocarcinoma of the

Prostate

• Grade 7

• What does that mean ?

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Grading of Prostate Cancers

Grade 4-6

LOW GRADE CANCERSGrade 7-10

HIGH GRADE CANCERS

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More likely to die WITH the

cancerMore likely to die BECAUSE of

the cancer

Staging

Local staging

• Rectal Examination

• MRI of the prostate

Metastatic staging

• Bone Scan

• CT /US Abdomen

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Counseling

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Prostate Cancer Screening

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Murali Sundram

Consultant Urologist

Hospital KL

1st Malaysian Men’s Health Conference 2018