per-anders abrahamsson, department of urology malmö university hospital sweden eau, berlin, march...
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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?
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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
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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
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Prostate-Specific AntigenProstate-Specific Antigen
Best cancer marker ever discovered
Used for:Detection and screeningPrognosis & Monitoring of prostate cancer
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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
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Is PSA still useful ?
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Prostate CancerProstate Cancer
2 mm3
urethra urethra
15 mm3
1991199120062006
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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.
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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
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The Problem
Normal / BPH
Prostate cancer
Potentially Lethal prostate cancer
IDEAL SCREENING TEST
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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
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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
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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
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How to Predict Development of Prostate Cancer on an Individual
Basis
Can Plasma levels of PSA
predict long-term risk
for Prostate Cancer ?
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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
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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
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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 !
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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
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Digital RectalExam (DRE)
Cells in prostaticurethra