1. Prostate Cancer – Indiana
William M. Dugan Jr., MD, FACP
April 27, 2012

2. Prostate Cancer Statistics – Indiana
From 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.

3. Prostate Cancer – Indiana
What 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.

4. Prostate Cancer – Indiana
What We Know
1. Indiana is in the top incidence in the US in
Caucasian men.
2. Mortality in Indiana from prostate cancer in
Caucasians is in the middle tier of 5 tiers (low
to high rate)*
3. Incidence rates are decreasing by 2.5%.
4. Mortality rates are decreasing by 4.0%
annually.
* Per 100,000 and age adjusted NAACCR

5. Prostate Cancer – Indiana
Risk Factors
• Increased with positive family history.
• Especially if 1st degree relative has prostate
cancer.
• Even more frequent if multiple 1st degree
relatives with prostate cancer.
• Increased with BRCA-2 mutations (more
aggressive and younger age).
• Reduced with 5 alpha reductase inhibitors
(SWOG, 1996-2004)

6. Outreach Consortium
Prostate 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

7. Analytic Prostate Cancer by Age
Source: Outreach Consortium

8. 1987 Prostate Relative Survival
By SEER Summary Stage
Source: Outreach Consortium

9. 1997 Prostate Relative Survival
By SEER Summary Stage
Source: Outreach Consortium

10. 2007 Prostate Relative Survival
By SEER Summary Stage
Source: Outreach Consortium

11. 1987 Prostate Cancer
5 Year Relative Survival
Source: Outreach Consortium

12. 1997 Prostate Cancer
5 Year Relative Survival
Source: Outreach Consortium

13. 2007 Prostate Cancer
4 Year Relative Survival
Source: Outreach Consortium

14. Lead Time Bias
Dx Mean
before time
PSA death
| |
Years -5 0 +5 +10

15. 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.

16. Lead Time Bias
Dx Mean
before time
PSA death
| |
Years -5 0 +5 +10

17. 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.”

18. 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)

19. 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.

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

21. • Initial retrospective analyses compared to
specific profiling prediction.

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

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

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

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

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

27. • 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.

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

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

30. Molecular Profiling
The answer has to be molecular profiling to
accurately separate those patients who
need:
B. no treatment.
C. simple hormone treatment.
D. aggressive upfront (neoadjuvant) for cure
or unfortunately late palliative treatment
not for cure.

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