prostate cancer: update on screening and managementprostate cancer: update on screening and...
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Prostate cancer: Update on screening
and management
Bruce Jacobs, MD, MPHAssistant Professor, Department of Urology
10/10/19
• P30CA047904 from the National Cancer Institute and the Henry L. Hillman Foundation
• Shadyside Hospital Foundation
Disclosures
2
Siegel RL Ca Cancer J Clin 2019
Common
Siegel RL Ca Cancer J Clin 2019
Deadly
5
~40% decrease in prostate-cancer mortality
Siegel RL et al. Ca Cancer J Clin 2019
To screen
OR
Not to screen?
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In 2012, the U.S. Preventive Services Task Force recommended against PSA-based screening for prostate cancer
None of the Task Force members were urologists, medical oncologists, or radiation oncologists
This recommendation applied to men in the general U.S. population,regardless of age
Grade D recommendation Moyer VA et al. Ann Intern Med 2012;157
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The Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial on prostate-cancer mortality
From 1993-2001, randomly assigned 76,693 men to receive annual screening or usual care (control group)
10 U.S. Centers
Andriole GL et al. NEJM 2009; 360
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Number of prostate-cancer deaths
Andriole GL et al. NEJM 2009; 360
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~50% of the control group received PSA testing
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Randomized 182,000 men between 50-74 to PSA screening at an average of once every 4 years or to a control group that did not receive such screening
7 European countries
Schroder FH et al. NEJM 2009; 360
13Schroder FH et al. NEJM 2009; 360
Screening reduced the rate of death from prostate cancer by 20% but was associated with a high risk of overdiagnosis
https://prostatecancernewstoday.com
New Recommendations for PSA-based Prostate Cancer Screening Fuels DebateAPRIL 13, 2017
Grade C recommendation: shared decision making for men 55 to 69
15Schroder FH, NEJM; 2012
16Schroder FH, NEJM; 2012
Screening reduced the rate of death from prostate cancer by 20% but was associated with a high risk of overdiagnosis
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Men aged 55-69 should be offered biennial screening in the setting of shared decision-making
Men under 40 or over 69 years of age should not be routinely screened
Evidence was insufficient to recommend screening for men aged 40-54 years
Carter HB et al. J Urol 2013; 190
18Hugosson J, Eur Urol; 2019
19Hugosson J, Eur Urol; 2019
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How to manage prostate cancer screening and treatment?
Many options
Type of treatment Prostate cancer severity
Very low risk Low risk Intermediate risk High risk
Active surveillance A B -- --
Surgery -- B A A
Radiation -- B B --
Radiation with androgen deprivation
-- -- A A
Cryotherapy -- C C --
Focal ablation/HIFU -- NE NE --
https://www.auanet.org/guidelines/clinically-localized-prostate-cancer-new-(aua/astro/suo-guideline-2017
Abbreviations: HIFU, high intensity focused ultrasoundEvidence level: A (high certainty), B (moderate certainty), C (low certainty), NE (no evidence)
Bill-Axelson A, NEJM; 2019
• Number needed to treat to avert one death from any cause was 8.4
• Men with clinically detected, localized prostate cancer and a long life expectancy benefited from radical prostatectomy, with a mean of 2.9 years of life gained
Bill-Axelson A, NEJM; 2019
Findings
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(Prostate Testing for Cancer and Treatment): ProtecT Trial
Between 1999-2009, randomized 1643 men with localized prostate cancer to active surveillance (545), surgery (553), or radiotherapy (545)
U.K. study
Hamdy FC et al. NEJM Sept 24, 2016
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Prostate-cancer specific mortality was low for all treatments
No significant difference among treatments (median follow up 10 years)
Hamdy FC et al. NEJM Sept 24, 2016
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Surgery and radiation were associated with lower rates of disease progression and metastases than was active monitoring
Hamdy FC et al. NEJM Sept 24, 2016
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19 Oct 2009
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PRECISION Trial
Goals
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500 men randomized to:
-MRI with or without targeted biopsy-38% clinically significant
-Standard TRUS-guided biopsy-26% clinically significant
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65yoPSA 6.5Healthy
Case 1
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65yoPSA 6.5Healthy
Case 1
Biopsy
Prostate MRI
33Greer MD, AJR; Mar 2019
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65yoPSA 15Palpable noduleHealthy
Case 2
Biopsy
Prostate MRI
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• Receipt of MRI was associated with an additional $447 (95% CI $409–487) in Medicare spending annually
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65yoPSA 6.5Gleason 3+3=6 prostate cancer 2/12 cores (maximum involvement 30%)Healthy
Case 3
Active surveillance
Surgery
Radiation
37Glass AS, BJUI; 2019
“Central to active surveillance is early detection of higher risk or progressive disease when curative intention is still possible.”
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65yoPSA 6.5Gleason 3+4=7 prostate cancer 6/12 cores (maximum involvement 50%)Otherwise healthy
Case 3
Active surveillance
Surgery
Radiation
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65yoPSA 12.0Gleason 4+5=9 prostate cancer 6/12 cores (maximum involvement 80%)Negative CT scan and bone scanOtherwise healthy
Case 4
Active surveillance
Surgery
Radiation
19 Oct 2009
• No randomized trials comparing surgery and radiation for high-risk disease
• Surgery gives most accurate staging information
• With surgery, avoid long-term ADT
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Future
Shared decision making
Better surgical technique and radiation delivery
Better patient selectionActive surveillance versus more aggressive treatment
ImagingRefine role of MRIAdvances in imaging for metastatic disease (e.g., Axumin scan)
New biomarkers and genetic tests
Kallikrein panels (4K score, Prostate Health Index)Urine tets (PCA3 and TMPRSS2-ERG)Oncotype Dx
