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SLIDE1: The Science of Early Detection

Otis W. Brawley, M.D.
Director
Georgia Cancer Center
Professor of Medicine, Oncology and Epidemiology
Winship Cancer Institute
Emory University
Atlanta, Georgia, U.S.A.

SLIDE 2: In the field of cancer screening, "It is particularly important to be able to sort out what is known versus what makes sends…."

Daniel Wolpaw, Medical Clinics of North America, 1996

SLIDE 3: The Hippocratic Injunction

It is worse for a physician to make a patient worse off than it is not to benefit a patient.

SLIDE 4: The Iceburg (Stacked graph)

SLIDE 5: Prostate Cancer Incidence and Mortality in the United tates, 1987 through 1997 (Bar Chart)

SLIDE 6: Improving 5-year Survival of Patients with Localized Prostate Cancer Managed by "Watchful Waiting" (Line Chart)

SLIDE 7: US Incidence of Ductal Carcinoma in situ (Table)

SLIDE 8: US Trends in Female Breast Cancer Incidence Rates by Stage

SLIDE 9: The Early Detection Mission

• Reduce Cancer Mortliaty
• Reduce Cancer Morbdity

SLIDE 10: Potential Biases in Screening Studies

• Selection Bias
• Lead Time Bias
• Length Bias

SLIDE 11: Selection Bias (Chart)

SLIDE 12: Selection Bias in an Ovarian Cancer Screening Program (Table)

SLIDE 13: Lead Time Bias (Chart)

SLIDE 14: Length Bias (Chart)

SLIDE 15: Overdiagnosis (Chart)

SLIDE 16: Mayo Lung Cancer Screening Project (Flow Chart)

SLIDE 17: Mayo Lung Cancer Screening Project LUNG CANCER SURVIVAL (Line chart)

SLIDE 18: Mayo Lung Cancer Screening Project Cumulative Lung Cancer Deaths (Line Chart)

SLIDE 19: Detection Rates of Lung Cancer in Non-Smokers vs. Smokers in a 3-Year CT Screening Program (Nagano, Japan)

(Table)

SLIDE 20: Prostate Cancer Incidence and Mortality in the US and UK (1968-1995 (Line Chart)

SLIDE 21: The Prostate Cancer Prevention Trial)

• Finasteride versus placebo in men median age 62 with PSA < 3.
• Rigorous PSA and DRE for seven years with all men biopsied at end of study.

SLIDE 22: The Prostate Cancer Prevention Trial

• The placebo arm
• 12.2 % had prostate cancer diagnosed due to an abnormal PSA or DRE
• 15% of men with normal PSA and DRE for seven years had prostate cancer diagnosed on terminal biopsy

SLIDE 23: The Prostate Cancer Prevention Trial

• A total of 27% of men median aged 69 had prostate cancer. Less than half were diagnosed due to screening.
• non-screening Western countries 3% of men die from prostate cancer. In the U.S. a 60 year old male has less than a 3% chance of dying from prostate cancer.

SLIDE 24: The Prostate Cancer Prevention Trial

• 6% of participants on the placebo arm diagnosed with high gleason grade disease
• 3% of American men die of prostate cancer

SLIDE 25: Overdiagnosis

• Scientific ability to diagnose cancer has outpaced scientific ability to predict the biologic behavior of tumors.
• Overdiagnosis leads to overtreatment and excess human suffering and other societal costs.

SLIDE 26: Bar Chart (1)

SLIDE 27: Bar Chart (2)

SLIDE 28: Comparison of Survival are Valid

SLIDE 29: Protocol (Chart)

SLIDE 30: "It is amazing what little harm doctors do when one considers all the opportunity they have."

Mark Twain

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