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Per-Anders Abrahamsson: Prostate cancer screening in sweden

European Prostate Cancer Awareness Day 2019

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Per-Anders Abrahamsson: Prostate cancer screening in sweden

  1. 1. Case Study – How Screening is organised in Sweden Per-Anders Abrahamsson MD, PhD Professor, Lund University, Sweden Past Secretary General European Association of Urology EPAD, Brussels, January 24, 2019
  2. 2. Most commonly diagnosed and leading cause of cancer deaths among men worldwide Source: GLOBOCAN 2012. Ref: Melissa M. Center et al. Eur Urol 2012;6:1079-1092 (a) (b)
  3. 3. Prostate cancer is a major public health problem in Sweden! Data from 2015: • 10,440 men diagnosed with prostate cancer • 2,356 men died of prostate cancer • 1,423 women died of breast cancer • 268 traffic deaths
  4. 4. Does PSA Screening Decrease Prostate Cancer or All Cause Mortality?
  5. 5. Prostate Cancer Screening RCTs: 21% reduction in death due to prostate cancer No difference PLCO ERSPC Göteborg # men 76,693 182,000 20,000 Results negative NNS=1055 NNT=37 NNS=293 NNT=12 Limitations 52% contamination 30% dilution  underpowered relaxed screening --- Andriole G, JNCI, 2012; Schroder F, NEJM, 2012; Hugosson, Lancet Oncol, 2010 Göteborg trial 44% reduction in death due to prostate cancer 13 yrs 11 yrs 14 yrs
  6. 6. Schröder, et al. Lancet. 2014;384(9959):2027-35. ERSPC trial shows 21% reduction in cancer deaths at 13 years NNI = number needed to invite to screening to save one man from dying from prostate cancer NND = number needed to diagnose to save one man from dying from prostate cancer
  7. 7. Hugosson J, Carlsson S et al. Lancet Oncol. 2010;11:725-32. Prostate cancer deaths reduced by ≈ 44% at more than 14 years follow-up in Göteborg trial
  8. 8. Hugosson J et al. Scand J Urol. 2017 Dec 18:1-11. Absolute mortality reduction continues to increase after 18 years in the Göteborg trial
  9. 9. No effect on prostate cancer mortality opportunistic organised PROSTATE CANCER MORTALITY no screeningno screening Opportunistic PSA-testing has little -- if any -- effect on prostate cancer mortality at 18 years and results in overdiagnosis Arnsrud Godtman R, et al. Eur Urol. 2015;68(3):354-60
  10. 10. •Maximize benefits • Morbidity ↓ • PC mortality ↓ •Minimize harms • Overdiagnosis ↓ • Overtreatment ↓ Roobol M, Carlsson S. Nat Rev Urol. 2013;10:38-48. Finding a balance
  11. 11. Sweden is a world leader in active surveillance - low risk prostate cancer - 2009: 39% 2015: 75% Active surveillance surgery Rdiation Hormonal therapy
  12. 12. Prostate Specific Antigen (PSA) Can a baseline PSA taken at the age of 45 predict the likelihood of being diagnosed with Prostate Cancer? “The Malmö Cohort of 20.000 men followed > 25 years”
  13. 13. Population distribution of PSA (Median: 1 ng/mL) Clinical PCa AUC 0.74 Metastatic AUC 0.89 Risk Curve: PCa and metastasis within 25 years by PSA at age 60 Men with PSA < 1.0 ng/ml at age 60 had 0.2% risk of dying from PCa by age 85
  14. 14. Re-screening guidelines for men age 60 PSA ≥ 2 High risk Regular screening PSA: 1–1.99 Intermediate risk Discussion PSA: 0–0.99 Low risk No further screening Carlsson S, et al. BMJ. 2014;348:g2296.
  15. 15. Five Golden Rules for Transforming PSA Screening 1. Get consent 2. Don´t screen men who won´t benefit 3. Don´t biopsy without compelling reason 4. Don´t treat low-risk disease 5. If you have to treat, do so at a high- volume centre
  16. 16. Summary • With longer follow-up in the trials, the effect of regular PSA-based screening on significantly reducing prostate cancer mortality is sustained • NNI and NND become favourable with longer follow-up • Screening should not start too late in life (likely no later than 50) • Regular, organised, screening may be more beneficial than opportunistic screening in terms of net benefit • Screening can be risk-stratified, taking into account a man’s age, PSA-levels, and general health to determine who, when and how often to screen • New PSA-based tests and MRI can improve the detection of high- grade prostate cancer and reduce unnecessary biopsies
  17. 17. I appreciate your attention