This document summarizes information about PSA testing and prostate cancer screening. It discusses large trials like the ERSPC trial which found a 20% reduction in prostate cancer mortality from screening but also found many unnecessary diagnoses and biopsies. It notes the inconsistent use of PSA testing in practice. The document proposes developing a risk prediction tool to help interpret PSA results and identify those at higher risk of aggressive cancer to improve screening decisions in primary care.

1. +
PSA Testing in Primary Care
Dr Jonathan Rees MD MRCS MRCGP
European Prostate Awareness Day, Brussels
September 2015

3. +
PSA
Prostate
Specific
Antigen

4. +
PSA
Patient / Physician
Stimulus of
Anxiety

5. +
The scale of the problem –
Prostate Cancer

6. +
Prostate Cancer in the European
Union (EU-28)
 In 2012:
 345,000 cases of prostate cancer
 72,000 deaths from prostate cancer
WHO / Int Agency for Research on Cancer: GLOBOCAN 2012: Estimated Cancer Incidence, Mortality & Prevalence Worldwide in
2012

8. +
Trends in Incidence & Mortality
Age-standardised rate per 100,000
Prostate Cancer Incidence Prostate Cancer Mortality

9. +Should we have national
screening programmes for
prostate cancer?
Regular PSA testing of asymptomatic men

10. +
ERSPC
 European Randomised Study on Screening for Prostate
Cancer
 Commenced in 1993
 162,000 men aged between 55 and 69, from 8 countries
 Offered PSA screening at an average of once every 4 years or
to a control group
Screening and prostate cancer mortality in a randomised
European study. Schroder FH et al. NEJM 2009; 360: 1320-
8

11. +
ERSPC at 9 years follow up
 Cumulative incidence of prostate cancer:
8.2% (screening group) versus 4.8% (control group)
 Absolute risk difference for death was 0.71 fewer deaths per 1000 men in screening
arm
20% decrease in risk of dying
(27% for those actually screened)
 1410 men invited for screening per CaP life saved (NNI)
 48 men diagnosed with prostate cancer per life saved (NND)
Screening and prostate cancer mortality in a randomised
European study. Schroder FH et al. NEJM 2009; 360: 1320-8

12. +
ERSPC at 13 years follow up
 NNI: dropped from 1410 to 781
 NND: dropped from 48 to 27
 Relative difference in prostate cancer specific mortality
remained similar (22% & 21%)
 No impact on all cause mortality
 “…the time for population-based screening has not arrived.”
Schroder F et al. Lancet 2014

13. +
ERSPC at 13 years follow up
Outcome WITH
screening
WITHOUT
screening
Prostate cancer
Diagnosis
1,016 683
Deaths
- All cause 2,108 2,139
- Prostate cancer 49 61
- Other causes 2,060 2,078
Schroder F et al. Lancet 2014
Numbers per 10,000 men aged 55-69 years old
Derived from 13-year follow-up data ERSPC

14. +
Who gets screening at present?
0
2
4
6
8
10
12
45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89
Association of PSA testing (%) with Age
Williams N et al; BJU Int 2011; 108: 1402-1408

15. +
Who gets screening at present?
3,5
4,4
5,7
7,1
7,4
8,9
Newcastle
Sheffield
Leeds
Leicester
Bristol
Cambridge
Association of PSA testing with study area
Williams N et al; BJU Int 2011; 108: 1402-1408

16. +
Screening the high risk?

17. +
What constitutes ‘high risk’?
 Family History
 BRCA gene mutation
 Ethnicity
 Obesity
 Height
 BASELINE PSA

18. +
Risk Prediction Tools

19. +
Inconsistency
 “The days of using 1 PSA threshold to trigger a biopsy for all
men are over” – BJU Editorial 2015
 “having a PSA test is consenting to having a biopsy if the result
is abnormal” – Local Urologist
 ‘my PSA was 9 2 years ago, 12 last year and now it is 18 – my GP
says now it is a little concerning so they decided to refer me’ –
Patient
 ‘I do a PSA on everyone’ – GP
 “PSA is essentially useless” - GP

20. Welcome to the QRISK®2-2015 risk calculator: http://qrisk.org
This calculator is only valid if you do not already have a diagnosis.
Reset Information Publications About Copyright Contact Us Algorithm Software
About you
Age (25-84): 63
Sex: Male Female
Ethnicity: White or not stated
UK postcode: leave blank if
unknown
Postcode: BS48 1BZ
Clinical information
Smoking
status:
light smoker (less than 10)
Diabetes status: none
Angina or heart attack in a 1st
degree relative < 60?
Chronic kidney disease?
Atrial fibrillation?
On blood pressure treatment?
Rheumatoid arthritis?
Leave blank if unknown
Cholesterol/HDL ratio: 5.1
Systolic blood pressure
(mmHg):
165
Body mass index
Height (cm): 180
Weight (kg): 90
Calculate risk over 10 years.
Calculate risk
Your results
Your risk of having a heart attack or stroke within the next 10 years is:
40%
In other words, in a crowd of 100 people with the same risk factors as you, 40 are
likely to have a heart attack or stroke within the next 10 years.
Risk of
heart attack or stroke
Your score has been calculated using the data you entered.
Your body mass index was calculated as 27.78 kg/m2
.
How does your 10-year score compare?
Your score
Your 10-year QRISK®2 score 40%
The score of a healthy person with the same age, sex, and ethnicity* 11.7%
Relative risk** 3.4
Your QRISK® Healthy Heart Age*** 83
* This is the score of a healthy person of your age, sex and ethnic group, i.e. with no adverse clinical indicators and a cholesterol
ratio of 4.0, systolic blood pressure of 125 and BMI of 25.
** Your relative risk is your risk divided by the healthy person's risk.
*** Your QRISK® Healthy Heart Age is the age at which a healthy person of your sex and ethnicity has your 10-year QRISK®2
score.
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21. +
‘A prostate cancer risk prediction
tool for primary care practice’
 Led by Chris Parker, Institute of Cancer Research & Royal Marsden, UK
 Team includes:
 Mike Kattan, Cleveland Clinic, Ohio
 Robert Nam, Sunnybrook,Toronto
 Monique Roobol, Erasmus, Rotterdam
 Ewout Steyerberg, Erasmus, Rotterdam
 Initial planning meeting also involved:
 Freddie Hamdy, Oxford
 Jan Adolfsson, Karolinska, Stockholm
 Henrik Gronberg, Karolinska, Stockholm
 Sunil Jain, Queens, Belfast
 Peter Albertsen, Connecticut
 Plus a GP from the UK!

22. +
Risk Prediction Tool - Aims
 “Aim is to produce a risk prediction tool that is applicable to
the UK population and acceptable to men in the UK, their
doctors and the NHS, when delivered through primary care,
forming the basis for future international adoption.”
 Help GP’s interpret PSA results & make decisions re referral /
follow up interval
 Reduce numbers of ‘unnecessary biopsies’
 Identify men at higher risk for aggressive forms of prostate
cancer

23. +
Conclusion
 Current use of PSA is disorganised & ineffective
 PSA screening remains controversial despite huge trials
 Risk based assessment / Targeted screening – the way
forward??