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PSA (Prostate Specific Antigen) - what ’ s new

PSA (Prostate Specific Antigen) - what ’ s new. Tom Pickles Professor, Radiation Oncology, UBC Radiation Oncology Program, BC Cancer Agency. Summary. Where PSA has established a useful role Monitoring treatment outcomes To predict treatment outcomes Where the use is less clear

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PSA (Prostate Specific Antigen) - what ’ s new

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  1. PSA(Prostate Specific Antigen)- what’s new Tom Pickles Professor, Radiation Oncology, UBC Radiation Oncology Program, BC Cancer Agency

  2. Summary • Where PSA has established a useful role • Monitoring treatment outcomes • To predict treatment outcomes • Where the use is less clear • In population screening

  3. PSA after treatment • Cured with surgery

  4. PSA after treatment • Cured with seeds

  5. PSA after treatment • PSA bounce

  6. Improvements in outcome 2004 1994 p=0.013

  7. PSA relapse Brachy 95% EBRT 75% p=0.0008

  8. PSA after treatment • Relapse

  9. PSA after treatment • PSA relapse and risk of dying of prostate cancer

  10. Predictive power of PSA • The PSA doubling time is the key. D’Amico et al., Journal of the National Cancer Institute, Vol. 95, No. 18, September 17, 2003

  11. Now, where PSA is not so good • The Screening controversy

  12. Significant overlap No PSA level free of cancer risk Holmström,BMJ 2009;339:b3537

  13. PSA: No safe level Thompson. JCO VOLUME 23 NUMBER 32 NOVEMBER 10 2005

  14. The underlying problem • PSA is not a great test! Receiver Operating Characteristic Curve for PSA Numbers on curve represent PSA cut points. AUC=0.67 Hoffmaan, BMC Fam Pract. 2002; 3: 19.

  15. Prostate cancer in Canada Incidence Canadian Cancer Society Stats 2014

  16. Prostate cancer in Canada Incidence Canadian Cancer Society Stats 2014

  17. PSA screening practices in Canada ~55% have had a PSA in the last 5 years CCHS 2003

  18. Screening trials: 3 proper ones • Europe • few had PSA test before • control patients unaware of study • Urologist handled abnormal result • USA • most had PSA tests before • Patient randomized 50/50 • family doc handled the results • UK • few had PSA test before • GP practices randomized • Patient counseled first

  19. Cumulative number of deaths Study year of death Screening trials: 3 proper ones • Europe • USA • UK

  20. How many benefit? • For every 1000 men screened • How many have an abnormal PSA? • How many have prostate cancer diagnosed? • How many will live longer as a result?

  21. US Services Taskforce infographic http://www.cancer.gov/ncicancerbulletin/112712/page12

  22. US Services Taskforce infographic http://www.cancer.gov/ncicancerbulletin/112712/page12

  23. US Services Taskforce infographic http://www.cancer.gov/ncicancerbulletin/112712/page12

  24. US Services Taskforce infographic http://www.cancer.gov/ncicancerbulletin/112712/page12

  25. US Services Taskforce infographic http://www.cancer.gov/ncicancerbulletin/112712/page12

  26. Governmental recommendations • The USPSTF recommends discussing screening for prostate cancer. • 2017: “Grade C” recommendation • Canadian Task Force on Preventive Health Care • 2014: recommendations recommend against (Grade “D” recommendation) • NHS (UK) • Do it if patient wants • Australia • Do not offer

  27. Prostate cancer in Canada Incidence Deaths Canadian Cancer Society Stats 2014

  28. Prostate cancer in Canada Deaths down 45% Since 1995 Canadian Cancer Society Stats 2014

  29. New ways of screening • Baseline test in mid 40’s • Then adapt screening intensity • E.g. PSA <0.5 • check again at 50, if <1 • Check again at 60, if <1 then stop • If PSA >1 • Repeat annually to 50 • If rising, consider biopsy

  30. PSA testing at 45-50 yrs • Risk of advanced cancer especially predicted • But beware of false positives • infection, ejaculation etc Ulmert BMC Medicine 2008, 6:6

  31. New tests • Not there yet • PCA3 • ProPSA • PSA density • Free PSA • hK2

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