Presentation on theme: "New Developments In The Management of Prostate Cancer"— Presentation transcript:
1New Developments In The Management of Prostate Cancer Dr. Manish PatelUrological Cancer SurgeonWestmead Public and Private HospitalSydney Adventist HospitalSenior Lecturer, University of Sydney
2New Developments In The Management of Urological Cancers Agenda Prostate Cancer- PSA testingControversy on screening.Prostate Cancer- New developments in treatment.Pros and cons of each treatment.
3Prostate Cancer- PSA testing Mr J.B. 51 year old.Mild LUTSHypertensionAsks his G.P. for a test for prostate cancer?What should the G.P discuss with him?
4Prostate Cancer- PSA testing Digital Rectal ExamImportant15% of cancers have abnormal DRE but “normal” PSAPSABlood testCan detect early Cancer
5Prostate Cancer Screening Potential BenefitsPotential HarmsNot shown to improve survival yet.False positives are common.It is possible to miss a cancerIndolent cancers are treated inadvertantlyPSA screening detects cancers earlier.Treating early CaP does improve survival.What we have attempted to show here is a balance between the potential benefits and harms or side effects of screening and early treatment.On the benefits side, evidence appears strong that PSA screening leads to early detection of prostate cancer. There is evidence that treating PSA-detected prostate cancer may be effective in reducing the likelihood that patients will die from the disease, but other evidence makes this uncertain. PSA use may contribute to the decline in U.S. prostate cancer mortality, but the evidence is not consistent.For harms or side effects, false positives are common. Overdiagnosis is a problem, but we are uncertain about the magnitude. Treatment-related side effects are fairly common.The balance of potential benefits and possible side effects is uncertain. This uncertainty leads the clinician to ask the next question.Need to discuss the individual benefits and risksof screening with all male patients 50-70years.
6Prostate Cancer- PSA testing PSA Test: 3.0 ng/ml, F/T 9%, Normal DREIs this normal?Age Median PSA Normal Rangeng/ml ng/mlng/ml ng/mlng/ml ng/mlng/ml ng/ml
7Risk Of Prostate Cancer Prostate Cancer- PSA testing Risk of Prostate Cancer in Men with Normal DREPSA LevelsRisk Of Prostate Cancer1-1.9917%2-2.9924%3-3.9927%4-1029%10+45%
8Prostate Cancer- PSA testing Free to Total (%) Does Help Specificity.
9Prostate Cancer- PSA testing PSA Velocity is important to calculate Men with PSA below 4.0ng/mlPSA velocity > 10%/yr =30% risk CaPPSA velocity >0.5ng/ml/yr = 45% risk CaPPSA velocity >2.0ng/ml/yr = high risk of deathMore accurate with multiple measures over time.
10Prostate Cancer- PSA testing Prostate Biopsy With Local Anaesthetic Block Mr J.B.’s risk of cancer is approx 50%.Chooses to have a prostate biopsyVery well tolerated under local anaesthetic.Pudendal nerve block.
11Prostate Cancer-Options of Treatment Mr J.B. Has Prostate Cancer Biopsy results:Gleason Score 3+3=6In 2/12 cores involving 25%-50% of the cores.Treatment Decisions Depend On:Patient’s normal life expectancyAggressiveness of cancerCure rates of individual treatmentsTolerability of side effects.What Are His Options Of Treatment?
12Prostate Cancer-Options of Treatment Active SurveillanceRadical ProstatectomySeed BrachytherapyExternal Beam RadiotherapyHIFU (High Intensity Focused Ultrasound)
13Incidence of indolent cancers is increasing (>30%). A cancer that is small and low grade and unlikely to grow in the man’s lifetime.Incidence of indolent cancers is increasing (>30%).Mr J.B. Could have active surveillance.
14Prostate Cancer-Options of Treatment Active Surveillance Treatment for small low grade cancers with low biological potential.Very close monitoring 3 monthlyPSADREBiopsy at 6 months, 18 months and 2 yearly after.Treat curatively if any sign of cancer growth.Patel et.al J Urol 2004
15Pros and Cons of Active Surveillance No major procedureNo side effects of treatmentConsAnxiety will lead to treatment in 15%50% will progress over 10 yearsAlthough no side effects not likely to improve overall quality of life.
16A Biopsy At 6 Months Is Very Predictive Of Cancer Growth. Log Rank Test p=0.0022nd Biopsy -ve2nd Biopsy +vePatel et.al. J Urol. 2004;171(4):1520
17Prostate Cancer-Options of Treatment Radical Prostatectomy
19Recovery of Erections after RP By Extent of Preservation of Neurovascular Bundles
20Sural Nerve Grafts- For patients Undergoing NVB Resection Undergoes radical prostatectomy with unilateral neurovascular bundle resectionAlso has sural nerve graft placed
21Recovery of Potency for Unilateral Resection with Nerve Graft compared to No Nerve Graft Unilateral nerve graft n=45No nerve graft n=17As there are no patients who had normal potency preoperative, who underwent unilateral NVB resection without NG in our cohort, we compared ou published historical series of unilateral resection without NG to our present series of patients with resection and NG, using the previously validated interview scale of potency.Potency grade 1 or 2 correlated to IIEF 17 or greater.You can see that althoug statisitical significance was not reached because of small numbers there does appear to be a difference, which is more marked when the definition of potency is relaxed to include grade 3 as well.Patel et.al. AUA 2003
22Pros and Cons of Surgery Excellent cancer controlEvaluate the lymph nodesAccurate prognosisRadiotherapy possible after surgeryConsRecovery 2-3 weeksMajor SurgeryPossible incontinencePossible impotence
23Prostate Cancer-Options of Treatment Seed Brachytherapy Prostate OutlineRectumUrethra
24Brachytherapy (seed) Toxicity Urinary Rectal Impotence Frequency/UrgencyRetentionBleedingRectalSameImpotenceL/T same as surgery (bilateral nerve sparing)
25Pros and Cons of Brachytherapy Not a major procedureQuick recoveryInitially potency preservedConsOnly controls low risk diseaseL/T outcomes not known thus hesitate in young patients.Won’t know prognosis for 1-2 yearsL/T impotence same as surgerySignificant rectal and urinary side effects.Unable to have surgery after
26Prostate Cancer-Options of Treatment External Beam Radiotherapy MachineTargetDRR Image (AP)
27External Beam Radiotherapy ToxicityUrinaryFrequency/UrgencyRetention/StrictureBleedingRectalSameImpotenceL/T same as surgery (bilateral nerve sparing)
28Pros and Cons of Radiotherapy Not major surgeryInitially potency preservedCons7 weeks treatmentWon’t know prognosis for 1-2 yearsL/T impotence same as surgerySignificant rectal and urinary side effects.Unable to have surgery after
29Prostate Cancer-Options of Treatment New Treatments- HIFU Minimally invasiveUS focused in the prostate causes coagulative necrosisTemporary catheter for 2 weeks.Experimental, but recent results are encouraging.
30HIFU Advantages Minimally invasive Relieves obstructive symptoms Early cancer cure appears similar to XRTTreatment is repeatablePossible to have surgery afterwards.90% potencyDisadvantagesNew technology- L/T results unknown.ExpensiveLimited to small prostates and Gleason 7 or less.
31Mr J.BChose radical prostatectomyContinent after 2 weeks.Started penile rehabilitiation at 6 weeksPotent at 4 months.PSA recurrence free so far.
32Case 2Mr AB72 year oldHTCoronary stentsPSA 15.2ng/mlRectal exam: large hard right sided nodule.
34Following Diagnosis- Need to Be Staged. A CT Scan Will detect metastases to the lymph nodes.Stage T1 (also known as Stage A)a small tumor that is confined to the prostate, (not detected during a digital rectal exam)this stage of prostate cancer usually produces no symptomstreatment may involve observation, surgery to remove the prostate or radiationStage T2 (also known as Stage B)the tumor is confined to the prostate gland but may be detected during digital rectal exampossible symptoms may include a need to urinate frequently, especially at nighttreatment may involve surgery or radiation, possibly combined with hormone therapy (to shrink the tumor)Stage T3 (also known as Stage C)the tumor has begun to spread beyond the prostate to areas surrounding the glandtreatment may involve radiation combined with hormone therapy, or for some patients surgery to remove the prostate.Stage T4 (also known as Stage D1)the tumor has spread beyond the prostate into surrounding structures including the pelvic lymph nodes (N+)possible symptoms may include a need to urinate frequently, painful, obstructed urine flow (blood may appear in urine), and fatiguetreatment may involve hormone therapy, possibly with radiation to ease symptomsStage M+ (also known as Stage D2) When cancer has spread beyond the prostate it is said to have metastasized. Cancer may spread to distant sites such as bone, liver or lung via the lymphatics system and the blood supply. Cancer that has reached this stage may produce symptoms such as difficult or painful urination, obstructed urine flow, pain if the cancer has spread to the bone, and fatigue. Treatment for this stage of cancer is aimed at easing symptoms and slowing the progression of the disease. This usually includes hormone therapy.A Bones Scan will detect cancer in the bones
35Treatment Options Watchful Waiting XRT plus Hormone therapy HDR Brachytherapy plus Hormone TherapyRadical Prostatectomy
36Prostate Cancer-Options of Treatment Need Adjuvant Androgen Deprivation Therapy For High Risk Disease.Hot flushesLethargyDepression/mood swingsWeight gainAnaemiaOsteoporosisImpotenceMuscle loss
37Dose of Radiotherapy is very important in Intermediate and high risk cancer.
38External Beam Radiotherapy On the left is a dose distribution diagram for 3D conformal radiotherapy (3D-CRT), with the highest doses in red. On the right the dose distribution has been modified by intensity modulation (IMRT). There is less exposure to radiation of the anterior rectal wall and of the surrounding tissue with IMRT.From Liebel and Fuks. MSKCC, 2000
39Prostate Cancer-Options of Treatment High Dose Rate Brachytherapy. Increases dose to the prostate locallyFor high risk disease
40HDR Brachytherapy Boost Used for high risk prostate cancersUsed in conjunction with hormones and external beam radiotherapyAdvantagesHigher radiation doseTheoretically better cancer resultDisadvantagesMuch higher urinary side effectsNo Long term studies
41Pros and Cons Of Prostate Cancer Treatments Cancer CureSide EffectsProsConsRadical ProstatectomyHighest Cure RateCancer removedLymph nodes treatedSalvage XRTRecovery timeIncontinenceEDRobotic ProstatectomyLower than open operation.Earlier dischargeWorse incontinenceBrachytherapyOnly effective in low risk diseaseEarly recoverySevere urinary and rectal SEExternal Beam RadiotherapyModerate cure rateSame as aboveHDR BrachytherapyEffective for high risk diseaseSevere urinary SEHIFUPossibly equivalent to XRT.Minimally invasiveMultiple treatmentsIrritative urinay SE
42SummaryAge specific PSA is Important but PSA velocity and F/T ratio are important when PSAs are low.Have a low threshold to refer.Treatment decisions for prostate cancer depend onlikely threat of the cancer to lifecure rate achieved by the treatmentside-effect profile.