Prostate Cancer in 2005

1
Prostate Cancer in2005

• USA
• Incidence
• 232,090
• Mortality
• 30,350

• LOUISIANA
• Incidence
• 3440
• Mortality
• 450

2
Prostate Cancer Facts

• Louisiana is ranked third nationally in prostate
  cancer deaths, below D.C. and Mississippi.
• Louisiana is ranked fourteenth for prostate
  cancer incidence.
• Cancer due to lack of access to screenings, early
  detection, and treatment.

3
Males 40 yrs and Older Sum of IP and OP
Physician Level Visits in Calendar Years Indicated
Adhoc source PX40
4
Lack of Access?OrLack of Utilization
5
Lack of Access

• Patient Education
• Physician Education
• In-Reach Program
• NCCN Guidelines

6
Encouraging Men to Participate in Prostate
Screenings
7
Increase to 100 the MCLNO outpatient clinic (18)
that provides prostate cancer educational material

• LEED Brochure
• Prostate Cancer Screening Tips/Posters
• Educate Nursing Personnel
• Supplemental Action
• MCLNO specific brochure
• MCLNO Newsletter

8
Increase to 100 the Physicians who are educated
about Prostate Cancer

• Grand Rounds at LSUHSC
• Mass E-Mail
• Statewide Prostate Cancer Symposium

9
Supplemental Action

• Quarterly e-mail to all residents and staff
  physicians
• Web-based learning at LEED website
• Educational CD-ROM
• Grand Rounds at TUHSC

10
In Reach Program
11
In-Reach MCLNOFlow Sheet
List of Elevated PSAs obtained from previous week
Mail Letters
Follow up telephone calls within 1 week
No Response
Navigate and Schedule appointment at GU Clinic
Re-mail Letter, 2nd Telephone Call
Appointment in GU Clinic Within 45 days
Observations
Biopsy
Medications
Biopsy
Observation
12
Enhance Capacity of Prostate Cancer In-Reach
Program

• 94 of patients are seen in GU Clinic within 45
  days
• Supplemental Action CLIQ Logic statements

13
Adopt the National Comprehensive Cancer Network
(NCCN) Guidelines for Prostate Cancer Screening
14
BASELINE EVALUATION
SCREENING EVALUATION
FOLLOW - UP

• Annual follow-up (category 2B)b
• DRE
• PSA

See Initial Evaluation (PROSD-2)
PSA 0.6 ng/mLa
Start risk and benefit discussion and Offer
baseline PSA at age 40
Begin regular screening at age 50
See Initial Evaluation (PROSD-2)
PSA
Repeat at age 45 or See PROSD-2 if individual is
African-American or has a strong history of
prostate cancer
PSA

• Annual follow-up (category 2B)
• DRE
• PSA

See Initial Evaluation (PROSD-2)
PSA 0.6 ng/mL
aThe median value in age 40 49 age range is 0.6
ng/mL. bThere is no evidence in the literature to
support the follow-up recommendations listed
they represent the consensus-based opinions of
the panel based upon their clinical experience.
Cancer detection/prevention trials recommended
15
FOLLOW - UP
SCREENING RESULTS
PSA Velocity
Continue follow-up

• PSA
• PSA velocity 0.75 ng/mL/y if availabled

Annual DRE and PSA
Consider initial TRUS-guided biopsy See PROSD-7
PSA Velocity 0.75 ng/mL/y
See NCCN Prostate Cancer Treatment Guidelines
Cancer
TRUS-guided biopsy performed See PROSD 7)

• PSA 2.6 4 ng/mL or
• PSA velocity 0.75
• ng/mL/yd

Atypia or High-grade PIN
See TRUS guided biopsy (PROSD - 7)
DRE negative PSA performed
6 12 mo. follow up with DRE, and total or
complexed PSAd Consider percent free PSA if not
using complexed PSA
Negative
TRUS-guided biopsy performed See PROSD 7)
PSA 4 10 ng/mL
See PSA 4 to 10 ng/mL (PROSD 5)

• Use of Free PSA
• 25 No biopsy
• 10 25 Discuss risks/benefits

See PSA 10 ng/mL (PROSD 6)
PSA 10 ng/mL
d PSA Velocity For men with PSA data suggest that a PSA velocity of 0.75
ng/mL/yr is suspicious for the presence of
cancer, and biopsy is recommended. Measurement
should be made on three specimens drawn over at
least an 18 mo. Interval, however there is
variability. Longer time periods increase
reliability. The same assay should be used. h
Factors to consider age, comorbid conditions,
percent free PSA, prostate exam/size, strength of
family history, African-American.
16
Corrective Action

• Departmental Acceptance of Policy
• Tract PSA utilization rates for each of the
  outpatient clinics
• Enhance capacity of staff and resident physician
  to comply with Institutional/Departmental Policy

17
Mortality Declines by Year

• Percent Decline from

18
Screening the Bottom Line

• Appears to be doing what its supposed to do
• Finding tumors early tumors that can be cured,
• and tumors that need to be cured
• The natural experiment of PSA screening appears
  also to be saving lives

19
What Do We Tell Our Colleagues?

• First important to correct serious
  misconceptions
• Tumors were finding arent toothless lions
• Men do die from prostate cancer

20
What Do We Tell Our Colleagues? (contd)

• Second we need to inform our colleagues and
  teach them about how we make a diagnosis
• Many of them do not understand prostate biopsy
  they think its an extremely invasive procedure
  with significant complications

21
What Do We Tell Our Colleagues? (contd)

• Third we need to tell our colleagues that even
  with a diagnosis of prostate cancer, we still
  talk with patients about all options including
  observation

22
What Do We Tell Our Colleagues? (contd)

• Fourth, and most importantly
• We need to inform our colleagues about what has
  happened since PSA screening
• Lives have been saved. This is crystal clear
• It is inappropriate for them to summarily deny
  screening for patients

23
In-Reach MCLNO Statewide Prostate Cancer
Symposium

• Louisiana Prostate Cancer Symposium
• Saturday, August 6, 2005
• Xavier University of Louisiana

24
In-Reach MCLNOGoals

• Increase in opportunistic screening 60 by end
  of year
• Increase awareness of Prostate Cancer
• Increase in Prostate Cancer diagnosis as well as
  detection in earlier stages of disease
• Reduction in Prostate Cancer mortality
• Elimination of the disparity in Prostate Cancer
  mortality