The Laytons Bob December 25 1925 May 9 2002 Jack July 18 1950 August 22 2011 In the news On the streets Disclosure I have a prostate Why I care 17 amp 127 Medical Education ID: 375103
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Slide1
Prostates & Pissing in the WindSlide2
The Laytons
Bob
December
25, 1925 – May 9, 2002
Jack
July 18, 1950 – August 22, 2011Slide3
In the news…Slide4
On the streets…Slide5
Disclosure
I have a prostateSlide6
Why I care…
1:7 & 1:27Slide7
Medical Education
For some reason they forgot the prostate…Slide8
“Prostate cancer is the most common
nonskin
cancer and the second leading cause of cancer death in men in the United States.”Slide9
Current Screening
+/- PSASlide10
DRE
Sensitivity 27%
Specificity 33%
PPV 18%Slide11
PSA
Sensitivity 35%
Specificity 75%
PPV 28%Slide12
Combined
Sensitivity 38%
Specificity 92%
PPV 56%Slide13
Screen PositivePositive DRE – enlarged, irregular, nodular
Elevated PSA – multiple readings recommended
Investigational:
Increasing PSA velocity
PSA densityFree PSA : Total PSASlide14
Biopsy
Pain
Hematuria
Hemospermia
Infection
Emotional stressSlide15
Biopsy Matrix
Chance >55 yo biopsy positive = 25%Slide16
Questions
What is a biologically significant
PCa
?Slide17
AssumptionProstate-specific antigen screening presupposes that most asymptomatic prostate cancer cases will ultimately become symptomatic cases that lead to poor health outcomes.Slide18
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.Slide19
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 OlderDo 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.Slide20
Recent ResearchProstate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial
The European Randomized Study of Screening in Prostate Cancer (ERSPC)Slide21
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
. Slide22
USPSTF 2011 DRAFT Statement
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.Slide23
Homo sapiens non urinat in ventum.-
Man should not piss into the wind.
Paul B. Jones
PGY1Slide24
References
Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement
DRAFT.
http://www.uspreventiveservicestaskforce.org
/draftrec3.htmScreening 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.Slide25
SimpleUnexpected
Concrete
Credible
EmotionalStories