Prostates & Pissing in the Wind

1. Prostates & Pissing in the Wind

2. The Laytons Jack July 18, 1950 – August 22, 2011 Bob December 25, 1925 – May 9, 2002

3. In the news…

4. On the streets…

5. Disclosure I have a prostate

6. Why I care… 1:7 & 1:27

7. Medical Education For some reason they forgot the prostate…

8. “Prostate cancer is the most common nonskin cancer and the second leading cause of cancer death in men in the United States.”

9. Current Screening +/- PSA

10. DRE Sensitivity 27% Specificity 33% PPV 18%

11. PSA Sensitivity 35% Specificity 75% PPV 28%

12. Combined Sensitivity 38% Specificity 92% PPV 56%

13. Screen Positive • Positive DRE – enlarged, irregular, nodular • Elevated PSA – multiple readings recommended • Investigational: • Increasing PSA velocity • PSA density • Free PSA : Total PSA

14. Biopsy Pain Hematuria Hemospermia Infection Emotional stress

15. Biopsy Matrix Chance >55 yo biopsy positive = 25%

16. Questions • What is a biologically significant PCa?

17. Assumption • Prostate-specific antigen screening presupposes that most asymptomatic prostate cancer cases will ultimately become symptomatic cases that lead to poor health outcomes.

18. So what? • No good evidence to suggest improved morbidity or mortality outcomes. • For any cancer-screening program to be effective, there must be curative therapies. • Evidence of curative benefit only exists for radical prostatectomy • 17 men needed to be treated to save one life from PCa (this study was in the pre-PSA era) • 10 year follow up showed overall survival was not different but PCa mortality and risk of metastases were reduced by radical prostatectomy.

19. USPSTF 2008 Statement • Men Younger than Age 75 Years • No recommendation (Grade I: Insufficient Evidence) • Therefore, the balance of harms and benefits cannot be determined. • Men Age 75 Years or Older • Do not screen (Grade D) • For men age 75 years or older and for those whose life expectancy is 10 years or fewer, the incremental benefit from treatment of prostate cancer detected by screening is small to none. Therefore, harms outweigh benefits.

20. Recent Research • Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial • The European Randomized Study of Screening in Prostate Cancer (ERSPC)

21. By the numbers • PLCO trial randomized 76,693 men aged 55 to 74 years to annual PSA screening for 6 years (and concomitant digital rectal examination for 4 years) or to usual care. After 7 years (complete followup), a nonstatistically significant trend toward increased prostate cancer mortality was seen in the screened arm (rate ratio [RR], 1.14 [95% CI, 0.75–1.70]) compared with men in the control arm. Similar findings were observed after 10 years. • The ERSPC trial randomized 182,000 men aged 50 to 74 years from seven European countries, after a median followup of 9 years, there was no statistically significant difference in prostate cancer mortality for all enrolled men (RR, 0.85 [95% CI, 0.73 to 1.00]). • In a prespecified subgroup analysis limited to men aged 55 to 69 years, a statistically significant reduction in prostate cancer deaths was seen (RR, 0.80 [95% CI, 0.65–0.98]). • Subgroup analyses demonstrated a nonsignificant trend toward increased prostate cancer mortality in screened men aged 50 to 54 and 70 to 74 years. • The observed difference in prostate cancer mortality for the subgroup of men aged 55 to 69 years first emerged at approximately 9 years (the median length of followup for the trial); thus, the effect size may change (increase or disappear) with further followup.

22. USPSTF 2011 DRAFTStatement • The U.S. Preventive Services Task Force (USPSTF) recommends against prostate-specific antigen (PSA)-based screening for prostate cancer. This is a grade D recommendation. • This recommendation applies to men in the U.S. population that do not have symptoms that are highly suspicious for prostate cancer, regardless of age, race, or family history. The Task Force did not evaluate the use of the PSA test as part of a diagnostic strategy in men with symptoms that are highly suspicious for prostate cancer. This recommendation also does not consider the use of the PSA test for surveillance after diagnosis and/or treatment of prostate cancer.

23. Homo sapiens non urinat in ventum.-Man should not piss into the wind. Paul B. Jones PGY1

24. References • Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation StatementDRAFT. http://www.uspreventiveservicestaskforce.org/draftrec3.htm • Screening for Prostate Cancer, Topic Page. October 2011. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsprca.htm • Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2008;149:185-191. • Lin K., Lipsitz, R., Miller T., & Janakiraman, S. Benefits and Harms of Prostate-Specific Antigen Screening for Prostate Cancer: An Evidence Update for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149:192-199. • Izawa, J.I. Klotz J. Siemens, D.R.Kassouf W. So, A. Jordan, J. Chetner M. and Iansavichene A.E. Prostate Cancer Screening: Canadian Guidelines 2011. The Canadian Urological Association. • Ilic D, O’Connor D, Green S, Wilt TJ. Screening for prostate cancer. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004720. DOI: 10.1002/14651858.CD004720.pub2.

25. Simple • Unexpected • Concrete • Credible • Emotional • Stories