Prostate Cancer Screening in Norway

Dr Freddie Bray Cancer Registry of Norway, Oslo

GEKID / EK NRW Symposium: The Role of Cancer Registries in Cancer Screening Programmes

a European Perspective

DGEpi Conference

Mnster, 16 September 2009

Auvinen et al, Int J Cancer 2002

Only two RCTs included.. high risk of bias in both trials, therefore insufficient evidence to either support or refute the routine use of screening for reducing prostate cancer mortality.

Currently, no robust evidence from RCTs available regarding the impact of screening on quality of life, harms of screening, or its economic value.

Results from two ongoing RCTs that will be available in several years are required to make evidence-based decisions regarding prostate cancer screening.

Ilic et al, Cochrane Database Syst Rev 2006

Schrder et al, New Engl J Med 2009

Schrder et al, New Engl J Med 2009

PSA screening reduces the risk of dying from prostate cancer by up to 31% in men actually screened. This benefit should be weighed against a degree of overdiagnosis and overtreatment inherent in prostate cancer screening.

Prostate Cancer Mortality Reduction by Prostate-Specific Antigen Based Screening Adjusted for Nonattendance and Contamination in the European Randomised Study of Screening for Prostate Cancer (ERSPC)

Monique J. Roobol, Melissa Kerkhof, Fritz H. Schrder, Jack Cuzick, Peter Sasieni, Matti Hakama, Ulf Hakan Stenman, Stefano. Ciatto, Vera Nelen, Maciej Kwiatkowski, Marcos Lujan, Hans Lilja, Marco Zappa, Louis Denisl, Franz Recker, Antonio Berenguer, Mirja Ruutu, Paula Kujala, Chris H. Bangma, Gunnar Aus, Teuvo L.J. Tammela, Arnauld Villers, Xavier Rebillard, Sue M. Moss, Harry J. de Koning, Jonas Hugosson and Anssi Auvinen

Roobol et al, Eur Urol. 2009

Schrder et al, New Engl J Med 2009

Curative treatment for early prostate cancer

Hormonal therapy / radiotherapy for locally advanced disesase

Chemotherapy for hormone refractory patients

Global mortality 2002

Ferlay et al, GLOBOCAN 2002

Kvale et al, JNCI 2009

Prostate cancer incidence and mortality 2001

a age-standardised

rate using the World standard

b rate ratio of age-standardised

(World) rates using Denmark as the baseline

d incidence:mortality

ratio of age-standardised

(World) using Denmark as the baseline

1997

5251

201

3819

9882

1126

806

52

1068

2625

+0.7%

-3.5%

+4.7%

+1.0%

+1.4%

+8.7%

+2.0%

+11.0%

+1.0% -1.9%

+1.0%

+3.9%

+14.8%

-1.8%

+1.6%

+1.1%-0.6%

+5.0%

-3.5%

+1.5%

+1.0%

+3.9%

+14.8%

-1.8%

+1.6%

+1.1%-0.6%

+5.0%

-3.5%

+1.5%

2000

2002

Based on a report from the Norwegian Centre for Health Technolgy Assessment (SMM), leaflets were distributed to GPs/urologists in March 2001:

PSA should not be taken in asymptomatic men

If the test is wanted, the physician is obliged to give information about the possible consequences

Parker et al, 2006

Parker et al, 2006

Treatment in the Nordic countries

Treatment with a curative intent (and hormonal treatment) was used most extensively in Finland and Norway Jonsson et al. Int J Technol Assess Health Care 1995

Denmark has put the emphasis on initiating treatment only at a late stage, and radical prostatectomy was introduced around 1995Borre M et al. Cancer 1997, Brasso K et al, Ugeskr Laeger 1998

However, before the mid-1990s radical treatment was infrequently used in all Nordic countries

Mortality Artefact (e.g. attribution of cause of death) Earlier diagnosis (better awareness) Screening Treatment Changes in risk factors

Prostate cancer: what is going on?

U.S. mortality trends 1980-2000: by 2000, models projected 45%-70% attributable to stage shift induced by PSA screening .

Etzioni et al, CCC 2009

Screening - PLCO set to continue to 13 years ERSPC to report on quality of life, cost-effectiveness

PSA monitoring developmentsTilling et al, Eur Urol, 2009; Roobol et al, Eur Urol 2009; Vickers et al, Eur Urol 2009

Ongoing research

Tilling et al, Eur Urol. 2009

Treatment (Wilt, JNCI, 2008) PIVOT (U.S., radical prostatectomy vs. watchful waiting,

includes 3/4 PSA-detected) ProtecT (U.K., radiotherapy vs. radical prostatectomy

vs. active surveillance, clinically-localised cancers) START (Canada, early interventions vs. active

surveillance)

Ongoing preventative trials (Thompson et al, J Urol 2009)

Chemoprevention with Dutasteride (REDUCE)

Ongoing research

National Prostate Cancer Programme (NPPC)

Clinical Registry established. Collects infromaiton nationally on

prostate cancer incidence, diagnostics, treatment

Aims: provide an empirical base for

scientific studies concerning prognostic factors and treatment outcomes

evaluation of quality of cancer care.

Prostate Cancer Screening in Norway Dr Freddie Bray Cancer Registry of Norway, Oslo GEKID / EK NRW Symposium: The Role of Cancer Registries in Cancer Screening Programmes a European PerspectiveDGEpi Conference Mnster, 16 September 2009Foliennummer 2Foliennummer 3Foliennummer 4Foliennummer 5Foliennummer 6Foliennummer 7Foliennummer 8Foliennummer 9Foliennummer 10Foliennummer 11Foliennummer 12Foliennummer 13Prostate cancer incidence and mortality 2001Foliennummer 15Foliennummer 16Foliennummer 17Foliennummer 18Foliennummer 19Foliennummer 20Foliennummer 21Foliennummer 22Foliennummer 23Foliennummer 24Treatment in the Nordic countriesFoliennummer 26Foliennummer 27Foliennummer 28Foliennummer 29Foliennummer 30Foliennummer 31Foliennummer 32