• greatest incidence of all cancers in NZ

    • 16.1% cancer registrations

  • 91/3% men survived past 5 yrs

    • compared to 61.8% with colon cancer

  • majority of men with diagnosis localised prostate cancer undergo definitive treatmetn

    • intent to cure

  • generally slow growing:

    • “active survellance”

  • low risk =

    • \<10µg/L

    • gleason score ≤6

    • CLincial stage T1-T2a

      • confimred tumour no more than 1 half of prosate

Screening

  • PSA = glycoprotein produced by prostate gland

    • organ specific

    • not cancer specific

  • Free;total PSA

    • prostate cancer more likely when ratio is low

      • \<0.25

      • particularly useful when PSA in 4-10 range

  • PSA velocity

    • 0.75/yr = commonly used threshold

  • prostate gland responsible for liquefying seminal fluid

  • changes to prostate (normal and non cancerous + cancer) = elevation

  • every man has right to decide for himself whether or not to be tested

  • PSA should not be measured within 3d of ejaculation

risk increases with age:

  • 40s

    • 1:500 ; \<1:1000 die

  • 50s

    • 1:50; 1:1000

  • 60s

    • 1:14; 1:67

  • 70s

    • 1:9; 1:43

  • family history

    • risk of diagnosis increase

      • 1 relative - 2.5x higher

      • 2 rlatives

        • 4-5 times higher

  • normal range increases for age

    • 40-49 = 2.5

    • 50-59 = 3.5

    • 60-69 = 4.5

    • 70-79 = 6.5

  • 4-10 = mild - moderate inc

  • > 10 = high

    • 67% chance that cancer is there

  • higher PSA more likely presence of prostate cancer

  • no PSA level can be reassured no cancer

  • non cancerous:

    • daily variability

    • BPH

    • urinary infection

    • urinary retention

    • prostatitis or sub-clinical prostate inflammation

    • ejaculation

    • DRE

    • prostatic massage

  • elevated PSA -> biopsy

    • 1/4 = cancer

      • bleeding/infection = 1-4%

  • for those diagnosed with prostate cancer = 90% go on to have therapy

  • give infomration to those aged 50-70

  • screening must be by both PSA and DRE

    • PSA only when DRE barrier to testing

    • most prostate cancer in peripheral zone

      • some may be detected by DRE

  • if LUTS/systemic features of malignancy

    • PSA, Cr, DRE

  • if normal DRE + PSA \<4 - dont warrnat specialist referral

    • suspect DRE in patients with PSA up to 2

      • PPV 5-30%

      • more predictive for more aggressive cancer

      • 18% detected by DRE alone

  • refer if:

    • 50-70 PSA ≥ 4

    • 71-75: ≥ 10

    • ≥ 76: ≥ 20

    • palpable abnormal in prostate on DRA

    • signiifant rise in a man whose PSA previously been low

Asymptomatic men

  • PSA testing not currently recommended

  • men should make informed decision

What is prostate?

  • found only in men

  • lies just beneath bladder

  • normally size of chestnut

  • urethra runs throuhg middle

  • produces fluid which protects and enriches sperm

  • often gets bigger gradually once >50yo

  • by age 70 - 8/10 have enlarged prostate

  • some men develop cancer

What is cancer?

  • cancer = disease of cells of body

  • abnormal and multiply out of control

  • some can spread to otherparts of body = malignant

  • invade and destroy/damage

Prostate cancer

  • common cause in men

Benefits screening

  • may find prostate cancer at early stage - no symptoms and cancer still wihtin prostate only

  • treatment might cure

  • problems of advanced cancer avoided

Harms

  • inconclusive as to whether testing better/longer life

  • unecessary medical tests and side effects when no cancer

  • may lead to treatment for a cancer that is slow growing and may not threaten life

  • treatments for prostate cancer may cause permanent side effects and may not result in cure

DRE

  • normal

    • small

    • 2 lobes

    • smooth surfaced

    • symmetircal

  • BPH

    • enlarges gland

    • preserves symmetry and smoothness

  • cancer

    • best predictive sign = presence of nodule in prostate

    • hard lump/irregularity

    • lack of central sulcus

Surveillance:

  • rise in serum PSA usually only indication of a recurrnece in men who have been treated for localised prostate ca

  • PSA = reliable and sinsitive tumour marker

    • increase in majority of men with recurrent cancer

    • little evidecne that determines frequency

  • PSA testing intervals

    • men who have undergone radical prostatectomy:

      • PSA checked;

        • 6wk after treatment

        • 6mo first 2 yrs

        • annually

    • active surveillance

      • q6mo

      • use PSA velocity

  • signoidoscpy q5yrs if radical radiotherpay

    • individual patient basis

  • if hormonal treatmnet

    • androgen blockade

    • DEXA at baseline

    • follow-up DEXA at 12mo or earlier

  • reassess cardiovascular risk

5a-reductase inhibitors (finasteride) reduce PSA levels by approximately 50%

clinical assessment

  • adverse effects of treatments

    • urinary

    • sexual dysfunction

  • local recurrence

    • men initally asymptomatic

    • PSA rise = first

  • symptoms that may suggest metastatic spread - bone pain or weight loss

  • psychosocial aspects

NZ prostate cancer taskforce

hand out