1. The document discusses the debate around prostate cancer screening in elderly men over age 65, with arguments on both sides. 2. Screening may detect cancers early that would not have progressed or caused harm in a man's lifetime given his life expectancy. However, screening also risks overdiagnosis and overtreatment of biologically unimportant cancers. 3. Guidelines in the US do not recommend routine screening for low-risk, elderly patients due to the scientific uncertainties around the balance of benefits and harms. Patient-clinician discussion is important to make informed, individual decisions.

2. G. Pourmand MD. Tehran University of Medical Sciences May- June 2008 Point counterpoint: Prostate cancer in the elderly man: Should we screen men after age 65 years?

3. Yes No Is prostate cancer a health care problem?

4. Is cancer prevalence important?  Health planning  Benefits and Harms  Most are small, confined

5. Cancer Incidence Rates * for Men US, 1973-1999

6. When Does Screening Detect Cancer? 9 years before clinical presentation

7. What about the prognosis?  Screen- Detected Prostate Cancer Conventionally Presenting Localized Disease P.W. Nicholson, BJU International 2002,90,686-693

8. To Screen or Not ! • Serious Public Problem. • Asymp. Localized Phase Sensitivity, Specificity and Predictive Values • The Potential for Cure • Improved Outcomes Relation to Screen

9.  Cost- effectiveness  Avoid detecting biologically unimportant cancers  Detect and treat tumors Progress, Produce Symptoms and Reduce Life Expectancy

10. American Cancer Society Modification (Men who eligible for Pca Screening) PSA and DRE Annually Should or Offer?

11. American Academy of Family  Physician And US Preventive Services Task Force  Do not Recommend Routine Screening in Low- Risk Patients

12. National Screening 1996 Counseling Potential Harms  Benefits Scientific Uncertainties

13. Patient- Clinician Process ( Joint Decision Making) and (Agree on a Course of Action)

14. PSA and DRE from 50 years Life expectancy of at least 10 years Discussion

15. PSA < 2 mg/ml Biannually PSA ≥ 2 mg/ml Annually

16. PSA (1980) Most useful tumor marker 1- Detection 2- Monitoring Radiation Radical prostatectomy Systemic therapy

17. PSA  Glycoprotein Almost Exclusively in Prostate Epithelial Cells

18. BPH Prostatitis Prostatic Infarction Is PSA Ideal Tumor Marker?

19. PSA thershold = 4 ng/mL: 65% F. Positive rate 20% F. Negative rate PSA: 3 ng/mL Sensitivity Positive Predictive Value

20. PSA Density PSA Velocity Age Specific Reference May Increase Sensitivity and specificity

21. Age Specific PSA, Reference Range Age, yr Reference Range, ng/ml 40-49 …………………….. 0.0-2.5 50-59 …………………….. 0.0-3.5 60-69 …………………….. 0.0-4.5 70-79 …………………….. 0.0-6.5

22. Use of PSA and PSA density to detect prostate cancer in men with normal DRE PSA density (Threshold) Sensitivity % Specificity % Positive Predictive Value % 0.10 …………… 95 24 29 0.15 …………… 79 50 34 0.30 ……………. 45 85 50 0.50 ……………. 29 95 65

23. Correlation Between PSA and Prostate Cancer

24. Total PSA (ng/mL) PSA Density= Total prostate volume (mL)

25. PSA Velocity PSA ≥ 0.75 ng/mL

26. Digital Rectal Examination • Detect missed Pca by PSA Screening • Able to detect asymptomatic patient • Abnormal DRE (3.2%-10%) • Pca (0.2%-1.7%) in original group

27. ACS  DRE + Occult Blood >40 yrs  The (+ve) Predictive Value 17.8%  Sensitivity of DRE: 53.2%  Specificity of DRE: 83.6%

28. Trans Rectal UltraSonography  Expensive  Not available for family physicians  Suffers from lack of specificity

29. Biopsy 1- Elevated PSA + Benign DRE TRUS Visible abnormal lesions 2- Abnormal DRE + TRUS Regardless of PSA

30. Charecteristics of Screening Tests Test Sensitivity % Specificity % Positive Predictive Value % DRE 45-58 96-97 24-58 TRUS 71-91 89-94 15-43 PSA > 4 ng/ml 67-89 59-97 33-47

32. 1 Andorra 83.53 2 Macau 82.35 … . 47 United States 78.14 … 130 Iran 70.86 … 222 Angola 37.92 223 Swaziland 31.99 World’s Life expectancy report

33. Population Pyramid for USA

34. Population Pyramid for Iran

35. 1384: 2722

36. Points Age-specific Incidence Rate of Prostate cancer per 100,000 Population in Iran (2005-2006)

37. Prostate cancer screening remains widespread, despite recommendations against routine screening by the United States Preventive Services Task Force and the ACP, and recommendations by the AAFP for counseling about the known risks and uncertain benefits of screening for prostate cancer. Recent evidence shows that men older than 75 years are frequently screened for prostate cancer, despite current guidelines suggesting they are unlikely to benefit from treatment as the disease develops slowly in this age group. Counterpoints

38. Table shavad In a national surveys of physician-reported information carried out from 1999 to 2002 by Duke University Medical Center researchers: Counterpoints (Cont.)

39. Counterpoints (Cont.) They concluded that Urologists were more likely to initiate the tests than non-urologists. Excessive PSA testing has direct and indirect costs, and reflects an inefficient allocation of resources.

40. In another National Ambulatory Medical Care Surveys performed in 1995-6: Counterpoints (Cont.)

41. High incidence of Pca in Iranian elderly men - Ethical & moral values Short life following the detection considering the life expectancy Slow growing tumor Death due to other complications Shall we screen elderly?