What Men Need to Know about PSA and Prostate Cancer PCa

1
What Men Need to Know about PSA and Prostate
Cancer (PCa)

• All Men slides 1-10
• significance of PSA measurements
• importance of the visit to the urologist
• Men with PCa slides 11-30
• what are the odds of dying of PCa?
• what are the side-effects of the various
  treatments?

2
Prostate Specific Antigen (PSA)

• PSA is made by the prostate gland and, perhaps,
  a prostate cancer tumor
• a raised PSA is most commonly
• a) the result of benign prostatic
  hyperplasia (BPH) -75-, or
• b) an early indication of prostate cancer
  -25-
• knowing your PSA is your responsibility ask for
  copies of blood test reports put them in a
  binder and keep track of them!

3
PSA Screening

• Patients with prostate cancer have a survival
  rate equal to or greater than patients without
  prostate cancer they are tested regularly!
• Screening for prostate cancer may trigger other
  tests and a general health evaluation that may
  lead to treatment not related to prostate cancer.
  Walsh RM, Thompson IM J Urol. 2007
  Apr177(4)1303-6
• People residing near the former Fernald uranium
  processing plant in south-western Ohio are living
  longer and enjoying healthier lifestyles than
  those in the general population. Why? They were
  medically examined frequently. http//healthnews.u
  c.edu/publications/findings/?/4054/4064/

4
PSA Details I

• The first PSA test should be taken at age 40 by
  men with prostate cancer in the family, and by
  Afro-American men. Others should start at 50.
• PSA tests only for those with a life expectancy
  (LE) exceeding 10 years - a 75 year old man with
  average health has an LE of 9.3 years, but it
  could range between 14.2 years and 4.9 years.
  Walter LC et al JAMA. 2006 Nov
  15296(19)2336-42
• PSA measurements can be off because of BPH
  (enlarged prostate), and also ejaculation, or a
  DRE and medications such as Proscar or Avodart,
  or prostatitis (inflammation of the prostate).

5
PSA Details II

• For men in their forties if PSA repeat at age 45 if 0.6 ng/ml, repeat
  annually.
• Determine at each successive measurement the PSA
  Velocity (PSAV) the PSA increase per year.If
  the PSA is 2.6 ng/ml in April 2006, and 3.3 ng/ml
  in April 2007, the PSAV is 3.3-2.60.7
  ng/ml/year. Yu X et al J Urol. 2007
  Apr177(4)1298-302
• the PSA should be repeated if in doubt
• measurement of a PSA should be accompanied by a
  Digital Rectal Examination (DRE)

6
PSA Details III

• 44 of men without known prostate cancer and an
  initial PSA 4 ng/ml had repeat PSA levels ng/ml - patients should undergo repeat PSA
  testing before being referred for prostate
  biopsy. Eastham JA et al JAMA. 2003 May
  28289(20)2695-700
• Median PSA for men 40-49 years 0.7 ng/mL and 0.9
  ng/mL for men 50-59 years. A baseline PSA level
  between the age-specific median and 2.5 ng/mL was
  associated with a 14.6-fold and 7.6-fold
  increased risk of CaP in men aged 40 to 49 and 50
  to 59 years, respectively. Loeb S et al
  Urology. 2006 Feb67(2)316-20

7
Visit the Urologist when .

• the PSA is 2.5 or) 4.0 ng/ml
• the PSAV is 0.3 or) 0.7 ng/ml/year
• the DRE is positive
• only after a repeat PSA (for those with a PSA
  biopsy, particularly when
• the PSA 10,
• the DRE is positive,
• the Free PSA
• the PCa3 Plus Test makes prostate cancer likely
• or) the experts disagree

8
Free PSA Percentage of Men without PCa
Lacher DA et al Adv Data. 2006 Dec 4(379)1-12
9
Free PSA and PCa3 Tests

• a free PSA test can be ordered by any physician
  who orders a PSA test
• free PSA 25 lower risk of PCa
• free PSA et al Urology. 2003 Apr61(4)760-4
• PCa3 Plus 35 high likelihood of PCa the test
  is a urine test prostate-cancer.org/education/pre
  clin/Torres_PCA3.htmlwww.bostwicklaboratories.com
  /about/PCA3.html

10
What can be Expected from a Biopsy?

• 20-25 of patients with a PSA 2.5 ng/ml and ng/ml will be found to have cancer
• 30-35 of patients with a PSA 4 ng/ml will be
  found to have cancer
• 67 of patients with a PSA 10 ng/ml will be
  found to have cancer
• extra-prostatic cancer more common with a
  positive DRE than with a negative DRE
• NCCN - Practice Guidelines in Oncology v.1.2004

11
What Should be in the Biopsy Report if there is
Cancer

• type of cancer (most likely adenocarcinoma)
• volume of the prostate
• number of cores and their length (in mm)
• amount of cancer in each core (in mm)
• presence or absence of perineural invasion
• total amount of cancer as a percentage
• Gleason score 6 (3,3), 7 (3,4) or 7 (4,3), 8
  (4,4), 9 (4,5) or 9 (5,4), 10 (5,5)
  agressivity of cancer

12
You have Prostate Cancer!

• dont panic, but learn the basics
• prostate cancer is common
• only a small percentage of men diagnosed with
  prostate cancer will die of prostate cancer

13
Prostate Cancer is Common

• autopsies showed
• men in their 30s 29 have prostate cancer
  men in their 40s 32 have prostate cancer men
  in their 50s 55 have prostate cancer men in
  their 60s 64 have prostate cancer
  Sakr WA et al, In Vivo
  1994, 8(3)439-43
• most men with prostate cancer do NOT develop
  symptoms
• more biopsies simply find more men with prostate
  cancer

14
Few Men with Prostate Cancer die of Prostate
Cancer

• the American Cancer Society estimates that about
  27,050 men will die of prostate cancer in 2007
• this is 16 of those diagnosed with prostate
  cancer
• while 1 man in 6 will get prostate cancer during
  his lifetime, only 1 man in 34 will die of this
  disease.American Cancer Society, 2007 statistics

15
The Odds of Dying of Prostate Cancer

• Average odds is 16 after diagnosis
• For the great majority of men diagnosed with PCa
  the odds are much better, similar to the odds of
  dying of heart disease
• For an unfortunate few the odds are worse

16
Prostate Cancer Mortality

• The chances of dying from prostate cancer are
  high for those diagnosed with cancer in the
  bones, and for those with local cancer and with a
  high Gleason score, 8, or with a PSA 20
• The chances of dying from prostate cancer are
  slim for those diagnosed with localized cancer
  (cancer only in the prostate) and with a Gleason
  score of 7 or less

17
Prostate Cancers Conundrum

• Is cure possible when it is necessary and is
  cure necessary when it is possible? (Willet
  Whitmore )
• Dr. Whitmore recognized two classes of PCa
  patients
• Class 1 diagnosis and treatment are burdens
  because the disease will never cause a problem
  for the patient, and
• Class 2 the disease defies any form of treatment
  and results in death.

18
Prostate Cancers Third Class

• Clinicians involved with prostate cancer believe
  that there is a third class of prostate cancer
  patients
• Evangelists believe that lives may be lost if
  this class is not treated.
• Snails believe that promoting an invasive
  therapy in healthy individuals goes against
  primum non nocere first do no harm. They think
  that standards should be very high when
  advocating treatment of men without symptoms.
  Iscoe NA CMAJ. 1998 159(11)1375-72

19
PCRIs View of the Three Classes
prostatecancer.org/education/preclin/StrumPogliano
_EveryDocShouldKnow.html
1 tortoise no need to stop 2 raven, will
escape 3 hare may be stopped
20
Treatment Choices

• First-line choices local therapies such as
  surgery (open, laparoscopic, or robotic
  laparoscopy) radiation (EBRT, Brachytherapy or
  both) other local therapies
• Second-line choices watchful waiting (WW) or
  active surveillance hormonal therapy (androgen
  deprivation therapy or ADT)

21
Treatment Considerations

• no randomized controlled trial to date has proven
  the superiority of one type of treatment in terms
  of cancer control
• primary treatments for localized prostate cancer
  appear to result in equivalent cancer control for
  most patients but with disparate side effects

22
Side Effects I

• Urinary control and sexual function were
  better after EBRT, although bilateral
  nerve-sparing surgery diminished these
  differences among potent men undergoing RP. BT
  caused more obstructive and irritative urinary
  symptoms, while both forms of radiation caused
  more bowel dysfunction. Litwin MS et al Cancer.
  2007 Apr 23
• EBRT External Beam Radiation
• RP Radical Prostatectomy
• BT Brachytherapy

23
Side Effects II

• ..48 had radical prostatectomy (RP) and 52
  had radiotherapy (RT). General wellbeing measures
  demonstrated a definite advantage favoring men
  treated with RP. .. RT-treated men were slightly
  more likely to report bowel-related problems than
  RP treated men. Urinary QOL measures were not
  different between the two groups. RP men reported
  lower level of sexual function than RT men.
  Rodgers JK et al Arch Androl. 2006
  Mar-Apr52(2)129-33

24
Dont Be in a Rush if That is Not Necessary

• Men diagnosed with PCa, but the PSA was less
  than 10
• Some patients were treated within three months
  of diagnosis, other patients were treated later
• no difference in the results!

25
Surgery versus Watchful Waiting (WW)

• A clinical trial showed that fewer men died after
  surgery but in order to have one man survive, 17
  had to be operated.Bill-Axelson et al N Engl J
  Med. 2005 May 12352(19)1977-84
• 32,022 men had been treated with surgery or
  radiation, and 12,608 men with WW.
• After 12 years, prostate cancer
  specific-mortality was 1.9 in the treatment
  group and 2.5 in the WW group.
  Wong YN et al JAMA. 2006 Dec 13296(22)2683-93

26
Hormonal Therapy Seldom in the USA

• In Japan 57 of all patients and 46 of those
  with T1c to T3 disease had primary androgen
  deprivation therapy (PADT). Mizokami A, et al
  BJU Int. 2007 Jan99 Suppl 16-9 discussion 17-8
• Akaza H BJU Int. 2007 Jan99 Suppl
  110-2
• Clinical trials showed that patients with locally
  advanced prostate cancer (stage C) treated with
  PADT were likely to have a life-expectancy
  similar to that of the normal population.Wakami
  J et al Cancer. 2006 Apr 15106(8)1708-14
• Akaza H BJU Int. 2007 Jan99 Suppl 110-2

27
Watchful Waiting (WW) and Active Surveillance (AS)

• WW and AS do not exclude local therapy. For
  example, when the PSA doubling time (PSADT)
  becomes less than 3 years, local therapy may be
  advised. Repeat biopsy is also common.
• Active surveillance based on PSADT and repeat
  biopsy represents a practical compromise between
  radical therapy for all patients which may result
  in overtreatment and watchful waiting which may
  result in undertreatment L Klotz Curr Treat
  Options Oncol. 2006 Sep7(5)355-62

28
Active Surveillance

• 299 patients were followed with active
  surveillance .. Patients had PSA of 7, and T 2b.. . . With a median follow-up of 64
  months, 101 patients (34) came off watchful
  observation 3 for clinical progression, 4 for
  histologic progression, and 12 due to patient
  preference. . . . Only 2/299 patients have died
  of prostate cancer. Klotz L Eur Urol. 2005
  Jan47(1)16-21

29
A Question

• If prostate cancer is detected at any stage,
  grade or volume in almost any age group it is
  almost uniformly treated. Are at least some of
  these men candidates for active surveillance?
  Interestingly, despite the increasing numbers of
  men with favorable disease characteristics,
  prostate cancer treatment patterns appear to be
  more aggressive today compared to those of a
  decade ago. Peter Carroll J.Urology, 173
  (2005), 4, 1061-1062

30
PCNG

• We respect any treatment decision of a newly
  diagnosed patient
• We hope that this decision was made after
  evaluating the risk of dying of prostate cancer
• We assume that the various treatment options and
  their side effects have been investigated and
  compared in detail