J Jacques Carter MD MPH Assistant Professor of

J. Jacques Carter, MD, MPH Assistant Professor of Medicine Department of Medicine Harvard Medical School Beth Israel Deaconess Medical Center Boston, Massachusetts PHEN Medical Advisor

PROSTATE CANCER The Screening Controversy

Prostate Cancer n Most commonly diagnosed visceral Cancer in men n 30% of all Cancers in men n ~220 K cases yearly n ~30 K deaths yearly

Lifetime risk of Developing Ca. P is 13 -17% (~1 in 6) Survival is multifactorial, especially the extent of tumor at the time of diagnosis n 5 -year survival with cancer confined to the prostate (localized) or just regional is spread is 100% n Only 31. 9% if diagnosed with distant metastases n

Possible Benefit of Screening? n. A screening program that could identify asymptomatic men with aggressive localized tumors might be expected to reduce prostate cancer morbidity and mortality

Why the Controversy? ? ? Effectiveness of Treatment remains uncertain n No studies have yet proven a survival benefit with screening n Considerable Data showing potential harms from aggressive treatments n

Prostate Specific Antigen Glycoprotein produced by prostate epithelial cells n May be elevated with Prostate Cancer n Also elevated with BPH, prostatitis n Other causes of elevation n Value is lowered by some medications n

Positive Predictive Value A test performance statistic n Refers to the PROPORTION of men with an elevated PSA who really have prostate cancer n

The PPV value for a PSA greater than 4. 0 is ~ 30 % n For a PSA between 4. 0 – 10. 0, the PPV is ~ 25% n This increases to 42 – 64 % for PSA’s greater than 10. 0 n

March 2009 Mortality Results from a Randomized Prostate-Cancer Screening Trial –N Eng J Med 2009; 360: 1310 -9 Report of the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Study Group 76 K participants randomized to screening or control groups Conclusion: No significant difference in mortality between the two study groups

August 2009 Prostate Cancer Diagnosis and Treatment After the Introduction of Prostate-Specific Antigen Screening: 1986 -2005 J Natl Cancer Inst 2009; 101: 1 -5 n n n Drs. Welch (VA Outcomes Group & Dartmouth) and Albertsen (UConn) looked at data from NCI’s SEER Program on prostate cancer incidence beginning one year before PSA introduction. Noted that an additional 1. 3 m men were diagnosed with Ca. P, with 1 m undergoing definitive treatment Reported a major increase incidence of younger men being diagnosed, especially age 50 -59, and under age 50. Concluded that PSA screening resulted in more than 1 m ADDITIONAL men being diagnosed and treated. Most of this excess incidence must represent overdiagnosis

Beth Israel Deaconess Medical Center Boston Massachusetts