G. Pourmand MD. Tehran University of Medical Sciences
May- June 2008
Point counterpoint: Prostate cancer in the elderly man:
Should we screen men after age 65 years?
Yes No
Is prostate cancer a health care problem?
Is cancer prevalence important?
Health planning
Benefits and Harms
Most are small, confined
Cancer Incidence Rates * for Men US, 1973-1999
When Does Screening Detect Cancer?
9 years before clinical presentation
What about the prognosis?
Screen- Detected Prostate Cancer
• Conventionally Presenting Localized Disease
P.W. Nicholson, BJU International
2002,90,686-693
To Screen or Not !
• Serious Public Problem.
• Asymp. Localized Phase
• Sensitivity, Specificity and Predictive Values
• The Potential for Cure
• Improved Outcomes Relation to Screen
Cost- effectiveness
Avoid detecting biologically unimportant cancers
Detect and treat tumors Progress, Produce Symptoms and Reduce Life Expectancy
American Cancer Society Modification
(Men who eligible for Pca Screening)
PSA and DRE AnnuallyShould or Offer?
American Academy of Family
Physician And US Preventive Services Task Force
Do not Recommend Routine Screening in Low- Risk Patients
National Screening 1996
Counseling Potential Harms Benefits Scientific Uncertainties
Patient- Clinician Process
( Joint Decision Making)and
(Agree on a Course of Action)
PSA and DRE from 50 years
Life expectancy of at least 10 years
Discussion
PSA < 2 ng/ml Biannually
PSA ≥ 2 ng/ml Annually
PSA (1980)
Most useful tumor marker
1- Detection 2- Monitoring • Radiation • Radical prostatectomy • Systemic therapy
PSA
Glycoprotein
• Almost Exclusivelyin Prostate Epithelial Cells
BPH
Prostatitis
Prostatic Infarction
Is PSA Ideal Tumor Marker?
PSA thershold = 4 ng/mL:
65% F. Positive rate 20% F. Negative rate
PSA: 3 ng/mL Sensitivity Positive Predictive Value
PSA Density
PSA Velocity
Age Specific Reference
May Increase Sensitivity and specificity
Age Specific PSA, Reference Range
Age, yr Reference Range, ng/ml
40-49 …………………….. 0.0-2.5
50-59 …………………….. 0.0-3.5
60-69 …………………….. 0.0-4.5
70-79 …………………….. 0.0-6.5
Use of PSA and PSA density to detect prostate cancer in men with normal DRE
PSA density(Threshold)
Sensitivity%
Specificity%
PositivePredictive Value
%
0.10 …………… 95 24 29
0.15 …………… 79 50 34
0.30 ……………. 45 85 50
0.50 ……………. 29 95 65
Correlation Between PSA and Prostate Cancer
Total PSA (ng/mL)PSA Density= Total prostate volume (mL)
PSA Velocity
PSA ≥ 0.75 ng/mL
Digital Rectal Examination
•Detect missed Pca by PSA Screening
• Able to detect asymptomatic patient
• Abnormal DRE (3.2%-10%)
• Pca (0.2%-1.7%) in original group
ACS
DRE + Occult Blood >40 yrs
The (+ve) Predictive Value 17.8%
Sensitivity of DRE: 53.2%
Specificity of DRE: 83.6%
Trans Rectal UltraSonography
Expensive
Not available for family physicians
Suffers from lack of specificity
Biopsy
1- Elevated PSA + Benign DRE
TRUS
Visible abnormal lesions
2- Abnormal DRE + TRUS Regardless of PSA
Charecteristics of Screening Tests
Test Sensitivity%
Specificity%
PositivePredictive Value
%
DRE 45-58 96-97 24-58
TRUS 71-91 89-94 15-43
PSA> 4 ng/ml
67-89 59-97 33-47
1 Andorra 83.53
2 Macau 82.35
….
47 United States 78.14
…
130 Iran 70.86
…
222 Angola 37.92
223 Swaziland 31.99
World’s Life expectancy report
Population Pyramid for USA
Population Pyramid for Iran
1384:
2722
Age-specific Incidence Rate of Prostate cancer per 100,000 Population in Iran (2005-2006)
Points
• Prostate cancer screening remains widespread, despite recommendations against routine screening by the United States Preventive Services Task Force and the ACP, and recommendations by the AAFP for counseling about the known risks and uncertain benefits of screening for prostate cancer.
• Recent evidence shows that men older than 75 years are frequently screened for prostate cancer, despite current guidelines suggesting they are unlikely to benefit from treatment as the disease develops slowly in this age group.
Counterpoints
Table shavad
• In a national surveys of physician-reported information carried out from 1999 to 2002 by Duke University Medical Center researchers:
Counterpoints (Cont.)
• They concluded that
• Urologists were more likely to initiate the tests than non-urologists.
• Excessive PSA testing has direct and indirect costs, and reflects an inefficient allocation of resources.
Counterpoints (Cont.)
• In another National Ambulatory Medical Care Surveys performed in 1995-6:
Counterpoints (Cont.)
• High incidence of Pca in Iranian elderly men
- Ethical & moral values
• Short life following the detection
considering the life expectancy • Slow growing tumor• Death due to other
complications
Shall we screen elderly?
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