PROSTATE CANCER SYMPOSIUM: BEYOND THE PSA R. SCOTT OWENS, M.D. UROLOGY OF CENTRAL PENNSYLVANIA PROSTATE CANCER SYMPOSIUM: WHY ARE WE HERE? • PROSTATE CANCER AWARENESS MONTH • OUR UNDERSTANDING OF R. Scott Owens, MD-Urology of Central PA 2 9/12/15THE DISEASE HAS CHANGED • OUR STRATEGY IN MANAGEMENT HAS EVOLVED • PROSTATE CANCER SIGNIFICANTLY IMPACTS OUR COMMUNITY AND STATE • MESSAGE TO OUR PATIENTS NEEDS TO BE CLARIFIED PROSTATE CANCER • USPSTF (UNITED STATES PREVENTIVE SERVICES TASK FORCE) RECOMMENDED AGAINST PSA BASED SCREENING FOR PROSTATE CANCER R. Scott Owens, MD-Urology of Central PA 3 9/12/15 • INDICATING THAT THE HARMS OF SCREENING ARE GREATER THAN THE POTENTIAL BENEFIT. GRADE D • MAY, 2012 USPsTF RECOMMENDATIONS : • UROLOGISTS/ONCOLOGISTS: WAKE UP CALL IMPACT • PRIMARY CARE: GUIDELINES • R. ScottPATIENTS: Owens, MD-Urology CONFUSION of Central PA 4 9/12/15 PROSTATE CANCER SYMPOSIUM: ULTIMATE GOAL • ESTABLISH A CLEAR, UNIFIED MESSAGE TO PATIENTS ON • PROSTATE CANCER THAT ENCOMPASSES CLINICAL • SIGNIFICANCE, TESTING AND TREATMENT R. Scott Owens, MD-Urology of Central PA 5 9/12/15 OBJECTIVES PROSTATE CANCER SYMPOSIUM: • RECOGNIZE NOT ALL PROSTATE CANCERS ARE THE SAME: – SIGNIFICANT VS. INSIGNIFICANT • FIND INHERENT VALUE IN PSA TESTING AND ITS DERIVATIVES • ESTABLISH A CLINICAL ALGORITHM FOR PSA TESTING • REVIEW CURRENT TREATMENT OF LOCALIZED AND ADVANCED PROSTATE R. Scott Owens, MD-Urology of Central PA 6 • CANCER9/12/15 • ASSIGN THE “RIGHT” TREATMENT TO THE “RIGHT” CANCER Prostate cancer facts: • 220,000 new cases each year • 27,500 deaths • R. Scott1 Owens,in 6 MD-Urology men of Central PA 7 9/12/15 • 100% 5 year survival for localized disease • 28% 5 year survival for advanced disease Prostate cancer: PENNSYLVANIA STATISTICS (2014) • MOST COMMON CANCER DIAGNOSIS IN MEN - 9,065 CASES • SECOND LEADING CAUSE OF MALE CANCER DEATHS • AFRICAN AMERICAN MEN HAVE A 30% HIGHER INCIDENCE • THAN WHITES AND TWICE THE MORTALITY RATE R. Scott Owens, MD-Urology of Central PA 8 9/12/15 • BY COUNTY: PHILADELPHIA 890 CASES, ALLEGHENY 825 CASES, CUMBERLAND 112 CASES, AND DAUPHIN 104 CASES PROSTATE cancer: anatomy R. Scott Owens, MD-Urology of Central PA 9 9/12/15 Prostate cancer diagnosis: • EXAM/PSA • BIOPSY R. Scott Owens, MD-Urology of Central PA 10 9/12/15 Prostate specific antigen (psa) • Glycoprotein enzyme secreted by prostate epithelial cells • Not cancer specific • Normal levels based on age • Useful for monitoring recurrent disease R.• ScottControversial Owens, MD-Urology role of Central in screeningPA 11 9/12/15 PROSTATE SPECIFIC ANTIGEN (psa) DERIVATIVES • PSA DENSITY • PSA VELOCITY • AGE RELATED PSA • TOTAL AND FREE PSA • PROSTATE HEALTH INDEX (PHI) R. Scott Owens, MD-Urology of Central PA 12 9/12/15 TOTAL AND FREE PSA R. Scott Owens, MD-Urology of Central PA 13 9/12/15 Prostate health index (PHI) SCORE • COMBINES TOTAL PSA, FREE PSA AND NEW BIOMARKER p2 PSA INTO A FORMULA THAT MORE ACCURATELY IDENTIFIES CANCER • COMMERCIALLY AVAILABLE • HIGHER SENSITIVITY AND SPECIFICITY THAN FREE PSA • USEFUL IN MONITORING PTS IN A R. SURVEILLANCEScott Owens, MD-Urology PROTOCOL of Central PA 14 9/12/15 DIAGNOSTIC ALTERNATIVES • • PCA 3 MRI PROSTATE • GENE EXPRESSED IN THE • USE OF AN ENDORECTAL URINE FROM PROSTATE COIL CANCER CELLS • IDENTIFIES HIGHER GRADE • USEFUL IN PTS WITH TUMORS PERSISTENTLY ELEVATED • PSA USEFUL IN TARGETING LESIONS • COLLECTED AFTER PROSTATE MASSAGE • PLAYS A ROLE IN SURVEILLANCE R. Scott Owens, MD-Urology of Central PA 15 9/12/15 PROSTATE CANCER: DIAGNOSIS • MRI/ • MRI/DIRECTED DIAGNOSTIC BIOPSY R. Scott Owens, MD-Urology of Central PA 16 9/12/15 PROSTATE CANCER PSA TESTING: A NEW STRATEGY • PSA SCREENING: VALUE IS NOT FULLY SUPPORTED • SELECTIVE SCREENING OF HIGH RISK GROUPS • (FAMILY HISTORY AND AFRICAN AMERICANS) R. Scott Owens, MD-Urology of Central PA 17 9/12/15 • BASELINE TESTING (AGE 45) • DIAGNOSTIC PSA PROSTATE CANCER: DIAGNOSTIC PSA • HEMATURIA • BPH WITH OBSTRUCTION • NODULE • FREQUENCY • NOCTURIA • URGENCY R. Scott Owens, MD-Urology of Central PA 18 9/12/15 Prostate cancer: baseline psa • STRATIFIES MEN INTO RISK GROUPS • ELIMINATES NEED FOR ANNUAL TESTING IN MAJORITY • REPLACES CONCEPT OF SCREENING R. Scott Owens, MD-Urology of Central PA 19 9/12/15 Psa “opens” thE door, but the biopsy directs care R. Scott Owens, MD-Urology of Central PA 20 9/12/15 PROSTATE CANCER GRADING: • GLEASON • PROGNOSTIC SCORE R. Scott Owens, MD-Urology of Central PA 21 9/12/15 GLEASON GRADE/SCORE: PROGNOSIS • GLEASON 6 • GLEASON 7 or higher • Well differentiated • Moderately-poorly tumor differentiated tumor • 20% positive margin rate • 48% positive margin rate • 16 year disease specific survival • 10 year disease specific survival R. Scott Owens, MD-Urology of Central PA 22 9/12/15 PROSTATE CANCER: “BAD ACTORS” • GLEASON 3 + 4 (MORTALITY RATE: 2.1) • GLEASON 4 + 3 (MORTALITY RATE:6.3) • GLAESON 4 + 4 (MORTALITY RATE: 14.5)R. Scott Owens, MD-Urology of Central PA 23 9/12/15 • GLEASON 5 + ? (MORTALITY RATE: 39.1) PROSTATE CANCER: PSA TESTING WHY IS IT IMPORTANT? • IDENTIFIES EARLY STAGE CANCER (WHEN COMBINED WITH DRE) • MAJORITY OF LOCALIZED CANCERS ARE ASYMPTOMATIC • DOES NOT CORRELATE WITH GRADE OF CANCER • NO OTHER TEST AVAILABLE • 60-70% OF PROSATE CANCERS ARE CLINICALLY SIGNIFICANTR. Scott Owens, MD-Urology of Central PA 24 9/12/15 • 30-40% OF PATIENTS WITH ELEVATED PSA ARE DIAGNOSED WITH CANCER IN OUR COMMUNITY PROSTATE CANCER IMPACT ON OUR COMMUNITY: UCPA DATA R. Scott Owens, MD-Urology of Central PA 25 9/12/15 UCPA DATA R. Scott Owens, MD-Urology of Central PA 26 9/12/15 UCPA DATA R. Scott Owens, MD-Urology of Central PA 27 9/12/15 UCPA DATA R. Scott Owens, MD-Urology of Central PA 28 9/12/15 UCPA DATA R. Scott Owens, MD-Urology of Central PA 29 9/12/15 UCPA DATA R. Scott Owens, MD-Urology of Central PA 30 9/12/15 UCPA DATA R. Scott Owens, MD-Urology of Central PA 31 9/12/15 UCPA DATA R. Scott Owens, MD-Urology of Central PA 32 9/12/15 UCPA DATA R. Scott Owens, MD-Urology of Central PA 33 9/12/15 PROSTATE CANCER CONCLUSIONS • 40% OF PTS WITH AN ELEVATED PSA WERE FOUND TO HAVE CANCER • 70% OF CANCERS WERE GLEASON 7 OR HIGHER • TREATMENTS SHOULD BE TAILORED TO RISK OF CANCER • PSA TESTING HAS VALUE • PSA DETECTED CANCER IS CLINICALLY R. Scott Owens, MD-Urology of Central PA 34 9/12/15SIGNIFICANT.