Prostate Cancer Screening

Prostate Cancer and Screening: An Update
December 19th 2004

Phillips, Erwin Arthur MBBS, MPH
This document sets out the answer the following questions:

What do we know about prostate cancer?•

When does it make sense to screen?•

What do we tell patients?•

Prostate Cancer is a significant cause of mortality and morbidity worldwide- we only need turn to the US prostate cancer lobby to learn that in the USA:
"Prostate cancer is diagnosed every 2 1/4 minutes, over 232,000 new cases are expected in 2005. It is the most commonly diagnosed cancer in America among men.
An estimated 30,350 American men will lose their lives to prostate cancer this year alone, one death every 18 minutes. That's more new cases than any other form of cancer.
Prostate cancer incidence rates increased 192 percent between 1973 and 1992." National Prostate Cancer Coalition website

Risk Factors include:
•High animal fat and protein
•Family History•Ethnicity

Clinical Features:
Most often asymptomatic Lower urinary tract symptoms (BPH) Frequent urination, especially at night Inability to urinate Trouble starting or holding back urination A weak or interrupted flow of urine Painful or burning urination Blood in the urine or semen Painful ejaculation Frequent pain in the lower back, hips, or upper thighs

Diagnosis is by:
•Digital Rectal Examination (DRE)
•Prostate Specific Antigen (PSA)
•Transrectal ultrasound with or without Biopsy (TRUS)

Other than the size of the prostate and the age of the person PSA may be raised by the following:Urinary Tract Infections, ejaculation or vigorous exercise in the past 48 hours, biopsy of the prostate in the past 6 weeks and DRE in the past 48 hours

Treatment of Prostate CancerConsidering grade and stage, age and health, values and feelings (about benefits and harms of each option. )
•Radical Prostatectomy •Radical Radiotherapy•Conservative Management

Prevention (this is controversial)•Diet (lowfat)•Exercise ??•Screening(this is very controversial)•High Intensity Focused Ultrasound (experimental)

Lets talk a little bit more about screeningIn 1968 Wilson and Junger came up with some guidelines to help those making decisions about implemeting screening programmes. While 1968 is a very long time ago not much has changed. The guidelines continue to be valuable. This is what they said:The condition is an important health problem Its natural history is well understood It is recognisable at an early stage Treatment is better at an early stageA suitable test exists An acceptable test exists Adequate facilities exist to cope with abnormalities detected Screening is done at repeated intervals when the onset is insidious The chance of harm is less than the chance of benefit The cost is balanced against benefit

Guidelines
The reality is that there is alot of controversy about the benefits of screening for prostate cancer. (That is looking for illness in people who do not have symptoms) If we for example look at the following organisations' positions on prostate cancer screening(PCS) you would find acknowledged that the info supporting its benefits is very limited if not non-existant. Interestingly enough Cancer Societies and Urologists continue to push prostate cancer screening. Hopefully this has nothing to do with the fact that they have financial incentive to do so and instead is explained by their inability to understand the published information on the subject. Most puplic health agencies acknowledge that "Since current evidence is insufficient to determine whether the potential benefits of prostate cancer screening is beneficial." (http://www.cdc.gov/cancer/prostate/prostate.htm)
Some other bodies that have opinions and make recomendations about PCS:

American Cancer Society http://caonline.amcancersoc.org/cgi/content/full/53/1/27#SEC6U.S.

Preventive Services Task Force http://www.ahcpr.gov/clinic/uspstf/uspsprca.htm

US Centers for Disease Control http://www.cdc.gov/cancer/prostate/prostate.htm

UK NHS Screening http://www.cancerscreening.nhs.uk/

Australia http://www7.health.gov.au/pubs/ahtac/prostate.htm

University of California Irvine http://www.ucihealth.com/news/UCI%20Health/prostate.htm

Canada http://www.prostatecancer.ca/english/living/screening.html

Recommendations

In theory PCS may help. There is not solid evidence that it does. There is evidence that it may cause harms. We need to communicate this effectively to the public as opposed to saying it is a cure-all or a complete waste of time. Several large studies are underway with preliminary results due out in soon (2006?) and definitive results in the next few years (?2015). For now we need to clearly explaining the risks and potential benefits.•PSA+ DRE may be offered annually from age 50•Informed decision (pros and cons)•High risk from 45•Greater risk from 40

References
•Nelson, W. G. et al Mechanisms of Disease: Prostate Cancer, New England Journal of Medicine 2003:339;366-81

•Mazhar, D and Waxman J Review:Prostate Cancer, Postgraduate Medical Journal 2002; 78,590-595•Kakehi, Y. Watchful waiting as a treatment option for localised prostate cancer in the PSA era, Review Article, Japanese Journal of Clinical Oncology 2003; 33(1) 1-5

•Sabichi, A L et al, Frontiers in Cancer prevention Research, Cancer Research 63, 5649-5655, September 2003

•Selly S et al, Diagnosis Management and Screening of Early Localised Prostate Cancer Health Technology Assessment 1997, Vol 1; No 2
National Prostate Cancer Coalition http://www.pcacoalition.org/

Further Reading (prostate)

•Watson E, Jenkins L, Bukach C Austoker J. The PSA test and prostate cancer: Information for primary care. NHS Cancer Screening Programmes, Sheffield 2002

•Tudiver F,et al What influences family physicians’ cancer screening decisions when practice guidelines are unclear or conflicting? The Journal of Family Practice, September 2002 Vol 51, No 9

•Summary of Evidence Last Modified: 10/20/2004 National Cancer Institute- www. Cancer.gov (see prostate cancer, prevention, screening, treatment and levels of evidence)

•Prostate Cancer Screening Australian Health Technology Advisory Committee Report http://www7.health.gov.au/pubs/ahtac/prostate.htm

•Russell Harris, MD, MPH and Kathleen N. Lohr, PhD Screening for Prostate Cancer: An Update of the Evidence for the U.S. Preventive Services Task Force, Annals of Internal Medicine 3 December 2002 Volume 137 Issue 11 Pages 917-929Further Reading (Screening)

•NHS (UK) Screening Programme. http://www.cancerscreening.nhs.uk/

•Sennfalt K, Sandblom G, Carlsson P, Varenhorst E,Costs and Effects of Prostate Cancer Screening in Sweden: A 15-year follow-up of a randomized trial Scandinavian Journal of Urology & Nephrology. 38(4):291-298, 2004.Guide to Clinical Preventive Services http://www.ahrq.gov/clinic/cps3dix.htm

•Greenhalgh T, How to read a paper: Papers that report diagnostic or screening tests BMJ 1997;315:540-543

Further information (Screening)

the NHS Screening Specialist Library http://libraries.nelh.nhs.uk/screening/

MP Petticrew et al, False-negative results in screening programmes: systematic review of impact and implications Health Technology Assessment 2000; Vol. 4: No. 5 http://www.ncchta.org/execsumm/summ405.htm

Screening to Improve Health in New Zealand: Criteria to assess screening programmes http://www.nhc.govt.nz/publications/ScreeningCriteria.pdf

The Urological Society of Australasia (a very good discussion of the issues) http://www.urosoc.org.au/info/screeningprostate.html

Prostate Cancer Screening. Summary of the review prepared by the Australian Health Technology Advisory Committee http://www7.health.gov.au/pubs/ahtac/prostate.htm


American Geriatric Society. Position Paper. Health Screening Decisions for Older Adults. AGS Ethics Committee http://www.americangeriatrics.org/products/positionpapers/stopscreening.shtml
Chronic Disease Teaching Tools - Disease Screening Chronic Disease Teaching Tools - Disease Screening


Feel free to contact me at:e.arthurphillips@gmail.com