Prostate Cancer – Indiana

William M. Dugan Jr., MD, FACP

April 27, 2012

Prostate Cancer Statistics – IndianaFrom ACS Facts & Figures

• Incidence all cancer > 30,000• Incidence prostate > 4,000• Mortality prostate > 600

Excluding skin cancer, most common cancer in males and second most common cause of cancer death in males.

Prostate Cancer – IndianaWhat We Know

1. Median age of diagnosis nearly 70 years.2. Median age of death roughly 80 years.3. Incidence and death rate increase with age.4. Race: African American men have a higher

incidence and death rate than Caucasian men in every age group.

5. Socioeconomic factors are important and logical. More education greater incidence and survival. Poverty is mostly an issue of access to care.

6. Geographical and international variations are plagued by reporting problems.

Prostate Cancer – IndianaWhat We Know

7. Indiana is in the top incidence in the US in Caucasian men.

8. Mortality in Indiana from prostate cancer in Caucasians is in the middle tier of 5 tiers (low to high rate)*

9. Incidence rates are decreasing by 2.5%.

10. Mortality rates are decreasing by 4.0% annually.

* Per 100,000 and age adjusted NAACCR

Prostate Cancer – Indiana Risk Factors

1. Increased with positive family history.2. Especially if 1st degree relative has prostate

cancer.3. Even more frequent if multiple 1st degree

relatives with prostate cancer.4. Increased with BRCA-2 mutations (more

aggressive and younger age).5. Reduced with 5 alpha reductase inhibitors

(SWOG, 1996-2004)

Outreach ConsortiumProstate Cancer

1987 – 1997 – 2007

Thanks to Mindy Burch, CTR

and Consultant for ACoS• IU Health as Cancer System Data Coordinator• Coeditor of National Cancer Registrars Association

text

Analytic Prostate Cancer by Age

Source: Outreach Consortium

1987 Prostate Relative Survival By SEER Summary Stage

Source: Outreach Consortium

1997 Prostate Relative SurvivalBy SEER Summary Stage

Source: Outreach Consortium

2007 Prostate Relative Survival By SEER Summary Stage

Source: Outreach Consortium

1987 Prostate Cancer5 Year Relative Survival

Source: Outreach Consortium

1997 Prostate Cancer5 Year Relative Survival

Source: Outreach Consortium

2007 Prostate Cancer4 Year Relative Survival

Source: Outreach Consortium

Lead Time Bias

Dx before PSA

Mean time death

| |Years -5 0 +5 +10

PSA

A. Protein exclusively produced by the prostate.

B. Is increased over normal with• Inflammation of prostate (prostatitis)• Benign enlargement of prostate (BPH)• Malignancy of the prostate (prostate cancer)

C. Discovered 1971, FDA approved 1986, widespread use after 2000.

Lead Time Bias

Dx before PSA

Mean time death

| |Years -5 0 +5 +10

PSA

Carl Sygiel, copy editor of the Indianapolis Star for 18 years and prostate cancer survivor said in November 2011, Indianapolis Star, “I maintain that if there is a problem with testing, it lies not with the process but with what happens after a diagnosis is confirmed.”

PSA

“I maintain that the PSA is good and saves lives.”

Reliable data shows distant metastasis declined from 44 cases in 1987 to 19 in 1997 to 4 in 2007. Relative survival of 5 years for all patients increased from 78% in 1987 to 91% in 1997 to 98% (4 yr not 5 yr survival)

NSABP BREAST CANCER EXPERIENCE

• NSABP B-14 – node negative, ER+ patients opened for randomization June 4, 1982.

• It long continued to provide meaningful additional scientific info.

• The next logarithmic advance came with the Onco Dx test: this test was based on molecular profiling.

• Initial retrospective analyses compared to specific profiling prediction.

• Then confirmatory phase III studies changed the standard of care.

• The NSABP has successfully “married” academia and private practice to achieve these goals.

• Today prostate cancer is at least 30 years behind breast cancer and…

• The expense of new treatments in prostate cancer further threatens an already fragile health care system.

• Provenge over $90,000 for a total of 3 doses for hormone failure prostate cancer for 4 extra months survival.

• Xgeva $7600/month for bone metastasis.

• 85% of prostate cancer patients who die with or from prostate cancer have metastases and are candidates for Xgeva.

• Jevtana, a 3rd generation taxane chemo drug for $35,500/dose every 3 weeks for up to 10 doses.

• Zytiga, a “super-ketoconazole” new androgen inhibitor for $6,000/month.

Molecular Profiling

The answer has to be molecular profiling to accurately separate those patients who need:

A. no treatment.

B. simple hormone treatment.

C. aggressive upfront (neoadjuvant) for cure or unfortunately late palliative treatment not for cure.

Every patient’s need is a scientifically determined individualized approach.