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 john.brodersen@sund.ku.dk
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4 Hvor mange har prostatakræft? Snak to og to i to minutter: Diskuter udvikling i incidensen Diskuter udviklingen i dødeligheden
6 Incidens af prostatakræft i DK 18000 500 16000 450 14000 400 Antal prøver 12000 10000 8000 6000 4000 350 300 250 200 150 100 Antal incidente cancer prostata 2000 50 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 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):696-700, 2010.
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, 0.95-1.51), biopsy (IRR: 1.76, 95% CI, 1.54-2.02), and getting a prostate cancer diagnosis (IRR: 1.37, 95% CI, 1.23-1.52). More were diagnosed with local stage disease (IRR: 1.61, 95% CI, 1.37-1.89) with no differences regarding regional or distant stage. The IRR for prostatectomy was 2.25 (95% CI, 1.72-2.94) and 1.28 (95% CI, 1.02-1.62) 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.
Bill-Axelson et al. Radical prostatectomy or watchful waiting in early prostate cancer. N Engl J Med 370 (10):932-942, 2014.
9 Incidens af prostatakræft i USA Esserman L., Shieh Y., & Thompson I. Rethinking Screening for Breast Cancer and Prostate Cancer. JAMA: 302 (15):1685-1692, 2009.
10 PSA-screening Ilic et al. Screening for prostate cancer. Cochrane Database, 2013.
11 PSA-screening 1.410 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 PSA-screening 1.055 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 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 PSA-screening i Göteborg Hugosson J et al. Mortality results from the Göteborg randomised population-based prostate-cancer screening trial. www.thelancet.com/oncology Published online July 1, 2010
15 USA: tobaksforbrug og død af lungekræft 1900-1997 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):263-271.
Cancer death and invasive cancer diagnosis with and without screening Lung, breast and prostate. France 1980-2010 Cases per year 60000 50000 40000 30000 20000 10000 Death Lung Without screening Diagnosis Breast (women) Increasing screening Prostate Increasing screening 2010 2005 2000 1995 1990 1985 1980 2010 2005 2000 1995 1990 1985 1980 2010 2005 2000 1995 1990 1985 1980 Years Years Years 1
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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24 Ultralyd i almen praksis Ahn, Kim, Welch. Korea's thyroid-cancer "epidemic"--screening and overdiagnosis. N.Engl.J Med. 371 (19):1765-1767, 2014.
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 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