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Prostate Cancer
• One of the commonest causes of death in the Western World
• USA 2005– 232,090 new cases– 30,350 deaths
• Lifetime risk of disease 16.6%• Lifetime risk of death 3.4%
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Prostate Cancer
• BAUS Cancer Registry 2004– 14,858 new cases
• >70% well / mod differentiated• 66% T1/T2
• CUH – 150+ new diagnosis per year.
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Deaths related to age
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Epidemiology
• Dietary factors– Increased risk with
increased fat– Phytoestrogens reduce
risk– Selenium, lycopenes are
protective
• No definite evidence for formal recommendations
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PSA
• Useful in detection, staging and monitoring of prostate cancer
• Prostate specific but not cancer specific• Other causes of elevated PSA
– BOH, urinary retention, catheter– Prostatitis– Urological intervention– Sexual activity
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Diagnosis and Staging
• DRE• PSA• TRUS and biopsy• MRI• Bone Scan• Partins Tables (PSA,
DRE, Biopsy data)
PSA 34KDa
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TRUS and Biopsy
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Multi parametric MRI
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Multi parametric MRI
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Multi parametric MRI
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Multi parametric MRI
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MRI Fusion biopsies - TP
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Does PSA Testing Influence the Natural History of Prostate Cancer
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Summary
• RCT data does not support routine screening• Screening aids earlier diagnosis and detect cancer at
earlier stage• Screening does not have a significant impact on
mortality• Cost: testing, over treatment, adverse effects, QoL• Therefore discussion at individual level for PSA
testing
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PSA
• Confused?
– I am!!
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The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188
• 1. For men aged 50-69 years, level 1 evidence shows that psa testing reduces the incidence of metastatic prostate cancer and prostate cancer specific mortality rates.
– Population screening not recommended but well informed men should be fully counselled about the positive and negative aspects of psa testing.
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The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188
• 2. Prostate cancer diagnosis must be uncoupled from prostate cancer intervention
– Screening allows diagnosis of high risk cases within the window of curability
– Many with low risk disease do not need aggressive treatment
– Active surveillance protocols need to be standardised and validated
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The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188
• 3. PSA testing should not be considered on its own, but rather as part of a multivariable approach to early prostate cancer detection
– Consider:• Age, ethnicity, FHx, PMHx, DRE findings• F:T, PCA3, biomarkers
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The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188
• 4. Baseline PSA testing for men in their 40s is useful for predicting the future risk of prostate cancer and its aggressive forms
– Median psa for men 40-49yr = 0.5-0.7ng/ml– The higher above median the greater risk of later
developing life-threatening disease– Baseline psa test in 40s has value for risk
stratification
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The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188
5. Older men in good health with a > 10 year life expectancy should not be denied PSA testing based on their age.
– Men should be assessed on an individual basis rather than applying an arbitrary chronological age prohibiting testing.
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The Melbourne consensus statement on the early detection of prostate cancer – BJUI Int 2014; 113:186-188
Summary:
•There is no right answer•Individual based shared decision making process.•Increase in AS•“treatment or non-treatment decisions can be made once cancer is found, but not knowing about it in the first place surely burns bridges”
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CUH – Urology, ahead of the field
• Early OPD• Same day MRI• Full counselling• Move towards targeted
biopsies• Individual based shared
decision making process