Prostate Cancer Screening 2012: Next Steps to End the PSA Controversy Matthew R. Cooperberg, MD,MPH Department of Urology

Advanced Robotic Urology and Prostate Cancer Update Napa, CA August 2, 2012

Two paths forward…

…or we can screen smarter Department of Urology

Rationale for earlier screening (AUA)  A baseline PSA level above the median for age 40 is

a strong predictor of prostate cancer

 The age adjusted mortality rate for prostate cancer

between ages 55 and 64 is significant. Such men may have been cured by earlier diagnosis and treatment

 Younger men are more likely to have curable cancer  PSA is a more specific test for cancer in younger

men

 Earlier and less frequent testing might reduce

mortality and costs compared to annual testing beginning later

 Patients at risk for, but who do not have cancer may

be candidates for chemoprevention

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Greene et al. J Urol 2009; 182:2232

Establishing a baseline  PSA at 60 predicts long-term prostate cancer

mortality

• Analysis of 1167 samples from 1981-2 matched to Malmö registry data • 11.4% diagnosed, 2.7% died of prostate cancer • If PSA 34%

1

Gleason

1-3/1-3

0

(primary/ secondary)

1-3/4-5

1

50

1

% of biopsy cores positive

Age

Sum points from each variable for 0-10 score Department of Urology

Cooperberg et al. J Urol 2005; 173:1938

CAPRA: Cancer-specific survival HRC-index 1.39 (1.31-1.48) = 0.80

# at risk

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4892

1430

350

Cooperberg et al. JNCI 2009; 101:878

Surveillance: Recent Experiences

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Cooperberg et al. J Clin Oncol 29:3669, 2012.

Active Surveillance: UCSF

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Dall’Era et al. Cancer 2008; 112:2664

Surveillance: Recent Experiences

We need better biomarkers, imaging tests, and psychosocial interventions

Department of Urology

Cooperberg et al. J Clin Oncol 29:3669, 2012

Active Surveillance: UCSF 

Upgrading/upstaging based on preop criteria for surveillance

Progression vs. undersampling? Department of Urology

Conti et al. J Urol 2009; 181:1628

Active Surveillance: Anxiety 

Treatment decision driven by PSA velocity and “anxiety velocity”

Change nomenclature? PUNLUMP IDLE

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Latini et al. J Urol 2007; 178:826

So what explains this graph? 40% drop in age-adjusted prostate cancer mortality since early 1990s

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Siegel et al. CA Cancer J Clin 2012; 62:10

Treatment Changes Explain Only a Fraction of the Mortality Decline

No treatment Treatment

Cases diagnosed since 1975

Cancer, epub 2012. Courtesy of Ruth Etzioni

Mortality Trends Suggest a Clear Role for PSA Screening

No treatment Treatment Treatment and screening

ERSPC benefit

Cases diagnosed since 1975

Cancer, epub 2012. Courtesy of Ruth Etzioni

What if we listened to the USPSTF?

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The D Recommendation

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Moyer et al. Ann Intern Med, epub 2012.

“D” is the wrong conclusion!

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“D” is the wrong conclusion!

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A Decision Aid for the USPSTF

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How to save the baby: screen smarter  Start earlier (e.g., 40) — but see below!  Screen less frequently if baseline is low  Focus on populations at highest risk  Screen for high-risk prostate cancer, don’t

over-treat low-risk disease • • • •

Embrace active surveillance Fix incentives Refer early — and wisely Change nomenclature

 Continue to develop novel biomarkers Department of Urology

Conclusions  Screening saves lives, period.  The USPSTF analysis downplays benefits,

overestimates harms, and is predicated on far too short of a time horizon.

 Overtreatment is without question a major

public health problem.

 But the answers lie in smarter screening and

better treatment decisions, not in wholesale cessation of screening.

Department of Urology