Per-Anders Abrahamsson, Per-Anders Abrahamsson, Department of UrologyDepartment of Urology
Malmö University HospitalMalmö University HospitalSwedenSweden
EAU, Berlin, March 24, 2007EAU, Berlin, March 24, 2007
What´s New in Prostate Cancer?What´s New in Prostate Cancer?
Global incidence of Global incidence of prostate cancerprostate cancer**
<7.4
<13.8
<24.5
<40.7
<124.8
*Age-standardised incidence rates per 100,000 GLOBOCAN 2002
Mortality in different countries 1992 - 1995
0 5 10 15 20 25
JapanRussiaGreeceMexico
ItalyIsraelSpain
FranceCanada
GermanyEnglandAustria
USAFinland
IrlandNetherlands
AustraliaNew Zealand
Denmark
SchwitzerlandNorway
Landis et al 1998Mortality per 100,000 men
Sweden
Prostate-Specific AntigenProstate-Specific Antigen
Best cancer marker ever discovered
Used for:Detection and screeningPrognosis & Monitoring of prostate cancer
The Ultimate Goal of Early Detection The Ultimate Goal of Early Detection for Prostate Cancerfor Prostate Cancer
PINPIN
Organ-confinedOrgan-confined
LocallyLocally
advancedadvanced N+N+
M+M+
Vol. (ml) 1 4 25 100 1000Vol. (ml) 1 4 25 100 1000
PSA (ng/ml) 3 10 20 200 300 700PSA (ng/ml) 3 10 20 200 300 700
Window of curabilityWindow of curability
Is PSA still useful ?
Prostate CancerProstate Cancer
2 mm3
urethra urethra
15 mm3
1991199120062006
Reality of PSA TestingReality of PSA Testing
HEALTHY & BENIGN DISEASE
PROSTATE CANCER
CUT OFF
70%FALSE POS.
PSANg/mL0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 100.0
20%FALSE NEG.
PSA and Prostate Cancer
PSA Number Cancer HG Cancer
< 0.5 486 6.6% 0.83%
0.6-1.0 791 10.1% 1%
1.1-2.0 998 17% 2.1%
2.1-3.0 482 23.9% 4.6%
3.1-4.0 193 26.9% 6.7%
Total 2950 15.2% 2.26%
Thompson IM et al. N Engl J Med 2004;350:2239-46
The Problem
Normal / BPH
Prostate cancer
Potentially Lethal prostate cancer
IDEAL SCREENING TEST
European Randomized Study of Screening for Prostate Cancer (ERSPC)
Screen Control
Number 21,145 21,132
Prostate Cancer 1190 189
Incidence 21.5 3.1
Ratio incidence 6.51 1
Ratio incidence/mortality
14.8 2.25
• “Overdiagnosis” remains a concern; Schröder F, WHO, 2004
Andriole GL. J Natl Cancer Inst.
2005;97:433-8.
Gleason score
% of screening-detected prostate cancer
2–4 10%
5–6 45%
7 31%
8–10 12%
•Most screening-detected prostate
cancers are less aggressive
Early Detection/Screening
PSA era is not over:We should use PSA better!
PSA provides a continuum of risk assessment Do not focus only on total PSA cutoff Repeat PSA measurement and rule out prostatitis Use PSA velocity or doubling time, and % free and % complexed PSA, proPSA
Catalona, J Urol, 2005
How to Predict Development of Prostate Cancer on an Individual
Basis
Can Plasma levels of PSA
predict long-term risk
for Prostate Cancer ?
Risk for Prostatate Cancer Diagnosis in Men < 53 years at Blood Sampling and
with follow up 13 to 25 years
7.4-30.514.9> 3.0
7.4-26.213.92.0- 3.0
4.9-14.58.41.5-<2.0
2.1-5.03.21.0-<1.5
1.4-2.92.00.5-<1.0
1< 0.5
95% CI interval
Odds ratioPSA range
Lilja, Abrahamsson et al., J Clin Onc; 2007
Screening Scenario
How avoid overtreatment:
1. Use of the long therapeutic window to guide treatment
2. PSA kinetics: PSA Doubling Time or PSA Velocity as a guide to intervention
The take-home-messages
- PSA Kinetics -
• Simple, inexpensive and readily available
• Should be incorporated into patient Should be incorporated into patient risk risk assessment !assessment !
DD3
2M
654 7 981 2 3 10 11 12 13 14 15 Pr 17 M
• PCA3DD3 is the most prostate-cancer-specific gene described to date
• Over-expressed in >95% of PC
• Expression restricted to the prostate
Digital RectalExam (DRE)
Cells in prostaticurethra