Hvor mange har egentlig kræft?

Transkript

1 Hvor mange har egentlig kræft? John Brodersen Professor, speciallæge i almen medicin, ph.d. Center for Forskning & Uddannelse i Almen Medicin, IFSV, KU Forskningsenheden for Almen Praksis, Region Sjælland [email protected]

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4 4 Hvor mange har prostatakræft? Snak to og to i to minutter: Diskuter udvikling i incidensen Diskuter udviklingen i dødeligheden

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6 6 Incidens af prostatakræft i DK Antal prøver Antal incidente cancer prostata Almen praksis er rekvirent Speciallæge/sygehus er rekvirent Incidente cancer prostatae 0 T. O. Mukai, F. Bro, K. V. Pedersen, P. Vedsted. Brug af undersøgelse for prostataspecifikt antigen. Ugeskr.Laeger 172 (9): , 2010.

7 included 368 general practices, 303,098 men and 4,199 incident prostate cancers. Men in the highest testing quartile of practices compared to men in the lowest quartile had increased risk of trans-rectal ultrasound (incidence rate ratio (IRR): 1.20, 95% CI, ), biopsy (IRR: 1.76, 95% CI, ), and getting a prostate cancer diagnosis (IRR: 1.37, 95% CI, ). More were diagnosed with local stage disease (IRR: 1.61, 95% CI, ) with no differences regarding regional or distant stage. The IRR for prostatectomy was 2.25 (95% CI, ) and 1.28 (95% CI, ) for radiotherapy. No differences in prostate cancer or overall mortality were found between the groups. These results show that the highest PSA testing general practices may not reduce prostate cancer mortality but increase the downstream use of diagnostic and surgical procedures with potentially harmful side effects. 7 Int.J Cancer, 2014.

8 Bill-Axelson et al. Radical prostatectomy or watchful waiting in early prostate cancer. N Engl J Med 370 (10): , 2014.

9 9 Incidens af prostatakræft i USA Esserman L., Shieh Y., & Thompson I. Rethinking Screening for Breast Cancer and Prostate Cancer. JAMA: 302 (15): , 2009.

10 10 PSA-screening Ilic et al. Screening for prostate cancer. Cochrane Database, 2013.

11 11 PSA-screening mænd (50 69) inviteres til screening hvert 4. år (deltagelse 82%). Follow-up efter 9 år : 1 dødsfald af prostatakræft undgås Incidens øgning 4.8%-8.2% (70%) 47 overdiagnosticeres Schroder Z.H. et al. Screening and Prostate-Cancer Mortality in a Randomized European Study. N Engl J Med., 2009.

12 12 PSA-screening mænd (50 69) inviteres til screening hvert 4. år (deltagelse 82%). Follow-up efter 11 år : 1 dødsfald af prostatakræft undgås Incidens øgning 6,0%-9,6% (60%) 37 overdiagnosticeres Schroder Z.H. et al. Prostate-Cancer Mortality at 11 Years of Follow-up. N Engl J Med., 2011.

13 13 PSA-screening 781 mænd (50 69) inviteres til screening hvert 4. år (deltagelse 82%). Follow-up efter 13 år : 1 dødsfald af prostatakræft undgås Incidens øgning 57% 27 overdiagnosticeres Schroder Z.H. et al. Screening and prostate cancer mortality: results of the ERSPC at 13 years of follow-up. N Engl J Med., 2014.

14 14 PSA-screening i Göteborg Hugosson J et al. Mortality results from the Göteborg randomised population-based prostate-cancer screening trial. Published online July 1, 2010

15 15 USA: tobaksforbrug og død af lungekræft Per 100,000 and age adjusted to 1970 US standard population. Wipfli H, Samet JM. Global economic and health benefits of tobacco control: part 1. Clin Pharmacol Ther 2009; 86(3):

16 Cancer death and invasive cancer diagnosis with and without screening Lung, breast and prostate. France Cases per year Death Lung Without screening Diagnosis Breast (women) Increasing screening Prostate Increasing screening Years Years Years 1

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19 19 Hvorfor ser vi dette mønster? Snak to og to i to minutter: Hvad er årsagerne til en 10 dobling i incidensen malignt melanom? Hvad er årsagerne til en 3-4 dobling i incidensen malignt melanom?

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22 Big data & Personalised Medicine 22 2

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24 24 Ultralyd i almen praksis Ahn, Kim, Welch. Korea's thyroid-cancer "epidemic"--screening and overdiagnosis. N.Engl.J Med. 371 (19): , 2014.

25 25 Survivors stories drive screening towards more overdiagnosis More Intensive Screening More Useful Screening Appears To Be Popularity paradox More Overdiagnosis More Survivor Stories 2

26 26 Cochrane & Holland "If a patient asks a medical practitioner for help, the doctor does the best possible. The doctor is not responsible for defects in medical knowledge. If, however, the practitioner initiates screening procedures the doctor is in a very different situation. The doctor should, in our view, have conclusive evidence that screening can alter the natural history of disease in a significant proportion of those screened." Validation of screening procedures. Br Med Bull 1971; 27: 3-8