Peter Albers: Risk adapted screening
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European Prostate Cancer Awareness Day 2019
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Peter Albers: Risk adapted screening
- 1. Peter Albers, MD Professor of Urology Department of Urology Düsseldorf University Hospital Heinrich-Heine-University Düsseldorf, Germany Why Prostate Cancer Screening ?
- 2. German and world-wide PCA Mortality ranks 2nd RKI 2017 www.krebsdaten.de
- 3. Colorectal Cancer / Prostate Cancer same mortality – no early detection program for prostate mortality (2015): 13649 13900 Colorectal Cancer Prostate Cancer (32900 men) (60700 men) standardised mortality (men) 2013: 21,6% 2018: 20.6% (estimate) = - 1% standardised mortality (men) 2013: 20.0% 2018: 19,4% (estimate) = - 0.6% ▵ ▵ RKI 2017 www.krebsdaten.de
- 4. mortality reduction method PAP smear (cervical carcinoma) 64% coniotomy colonoscopy (distal CRC) 50% endoscopy PSA 27%* RP / RT / AS stool test (CRC) 23% endoscopy mammography (breast cancer) 20% (part.) mastect. Comparison of Screening Programs *Schröder F et al. ERSPC, Lancet Oncology 2014 after clearance for non-compliance
- 5. Comparison of Prostate Cancer Screening Trials Martin RM et al. JAMA 2018, Schröder F et al. Lancet Oncology 2014, Andriole GL et al. JNCI 2012
- 6. PSA alone is not sufficient Schröder F NEJM 2009 ERSPC PSA > 3 ng/ml 25% PCA 15% significant
- 7. Aim of future PCA screening programs reduction of overdiagnosis
- 8. Individualised PCA Screening Potential Methods • age-adapted risk groups • hereditary risk • mpMRT for „high risk“ patients • kallikreins (4K) • molecular markers (SNPs, MSI) • combinations (risk calculators)
- 9. The „start early“ hypothesis to reduce overdiagnosis
- 10. Vickers A et al. (MSKCC) BMJ 2013 „baseline“ PSA und prognosis PSA at 45 yrs risk for metastasis after 25 yrs PSA < 1.1 ng/ml 1.38% PSA > 1.6 ng/ml up to 9.82% 10x higher risk > 1.6 ng/ml
- 11. 50% of men are „low risk“ and can be identified with 3 „life-time“ PSA values within 10 yrs below median Lilja H et al, ASCO 2011 Hypothesis: 3 x PSA is enough !
- 12. The „start early“ data
- 13. Risk-adapted prostate cancer (PCa) early detection study based on a “baseline” PSA value in young men – a prospective multicenter randomized trial (PROBASE) Principle Investigators: Peter Albers (Düsseldorf University) Nikolaus Becker / Rudolf Kaas (DKFZ, German Cancer Research Center, Heidelberg)
- 14. 90% 8% 2% „baseline“ PSA < 1.5 ng/ml PSA test interval 5 yrs 1.5 -2.99 ng/ml > 3.0 ng/ml PSA test interval 2 yrs mpMRT and biopsy
- 15. Accrual Feb 2014 – Sep 2018 10/2018: > 40.000 men, end of accrual: 12/2019
- 16. Carlsson S. et al Eur Urol 2017 NN to diagnose (after 17 yrs): 16 NN to diagnose (after 13 yrs): 32 (ERSPC: 27) • early PCA screening reduces mortality • is justified if active surveillance is performed in low risk cancers Sweden: early screening (50-54 J) dramatically reduces number needed to diagnose
- 17. Cost effectiveness of early screening (Markov model) (PSA tests at age 55 – 57 – 59) Heijnsdijk EAM et al Int J Cancer 2017 • organized PCA screening ist cost effective
- 18. Risk-adapted screening „take home“ • risk-adapted screening will prevent unnecessary and „grey“ screening in 90% of men • will identify 1-2% of men with early prostate cancer • can be terminated at age 60 • is cost-effective • must not be followed by treatment in every case („active surveillance“ of low risk cancers)