1. Prostate Cancer What a GP Needs to Know
Dr Manish Patel
Urological Cancer Surgeon
Sydney Adventist Hospital
Westmead Public and Private Hospital
Senior Lecturer, University of Sydney

2. Prostate Cancer What a GP Needs to Know
Prostate Cancer Screening
What you need to tell your patients.
The PSA test
When to refer to a urologist.
Localised Prostate Cancer
What are the newest modalities?
Androgen Deprivation Therapy
How to monitor these men.

3. 1. Prostate Cancer Screening What you need to tell your patients.
Mr J.B. 57 year old.
Mild LUTS
Hypertension
Asks his G.P. whether he needs a test for prostate cancer?
What should the G.P discuss with him?

4. 1. Prostate Cancer Screening What you need to tell your patients.
PSA
Blood test
Can detect early Cancer
Digital Rectal Exam
Important
15% of cancers have “normal” PSA but abnormal DRE.

5. 1. Prostate Cancer Screening What you need to tell your patients.
Potential Benefits
Potential Harms
False positives are common.
Indolent cancers are treated inadvertently
PSA screening detects cancers earlier.
Treating early CaP improves survival.
Negative results reduce anxiety
Test is easy to administer
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 risks
of screening with all male patients 50-70years.

6. Risk Of Prostate Cancer
2. The PSA Test-When to Refer to a Urologist. Risk of Prostate Cancer in Men with Normal DRE
PSA Levels
Risk Of Prostate Cancer
1-1.99
17%
2-2.99
24%
3-3.99
27%
4-10
29%
10+
45%

7. 2. The PSA test When to refer to a urologist.
Age Median PSA Normal Range
ng/ml ng/ml
ng/ml ng/ml
ng/ml ng/ml
ng/ml ng/ml

8. 2. The PSA test- When to refer to a urologist
2. The PSA test- When to refer to a urologist. Free to Total (%) Does Help Specificity.

9. 2. The PSA test- When to refer to a urologist
2. The PSA test- When to refer to a urologist. PSA Velocity is important to calculate
Men with PSA below 4.0ng/ml
PSA velocity > 10%/yr =30% risk CaP
PSA velocity >0.4ng/ml/yr = 45% risk CaP
PSA velocity >2.0ng/ml/yr = high risk of death
More accurate with multiple measures over time.

10. 2. The PSA test- When to refer to a urologist. Suggested Algorithm

11. 3. Localised Prostate Cancer- Options of Treatment
Active Surveillance
Radical Prostatectomy
Seed Brachytherapy
External Beam Radiotherapy +/- hormone deprivation.
HDR Brachytherapy
HIFU (High Intensity Focused Ultrasound)
Watchful Waiting

12. 3. Localised Prostate Cancer- Active Surveillance
99% 8year disease
specific survival
Advantages:
Avoid treatment in 50% of men
Only treat men who need treatment
Disadvantages
Anxiety
Possibility of “missing the window of opportunity”
Patel et.al. J Urol. 2004;171(4):1520

13. 3. Localised Prostate Cancer- Radical Prostatectomy
Advantages:
Good cure rate
Quick recovery in young men
Salvage XRT
Prostate
NVB
Disadvantages
Possible incontinence
Possible impotence
Rectum

14. 3. Localised Prostate Cancer- Robotic or Laparoscopic Radical Prostatectomy
Advantages
Less blood loss
1 day less hospital stay
Disadvantages
Unable to palpate the cancer (Positive margin)
Poorer continence and potency
Learning curve
Expensive

15. 3. Localised Prostate Cancer- Brachytherapy
Advantages:
Minor procedure
Disadvantages
Only for low risk
Urinary symptoms
Rectal symptoms
Unable to have surgery afterwards
Urethra
Rectum

16. 3. Localised Prostate Cancer- External Beam Radiotherapy
Advantages:
Minor procedure
Disadvantages
7 weeks treatment
May need hormones
Urinary symptoms
Rectal symptoms
Unable to have surgery afterwards

17. 3. Localised Prostate Cancer- HDR Brachytherapy
Advantages:
Good treatment of high risk disease
Disadvantages
Need hormones
5 weeks EBRT
Urinary symptoms
Rectal symptoms
Unable to have surgery afterwards

18. 3. Localised Prostate Cancer- HIFU
Advantages:
Minimally invasive
Similar cure to XRT
High continence and potency
Repeatable procedure
Disadvantages
Expensive
Experimental

19. 4. Androgen Deprivation Therapy How to Monitor These Men.
Factor
Treatment
Osteoporosis
Ca, Vit D, Exercise. Annual DEXA scan
Lipid profile
Regular measurements, cholesterol lowering drugs
Weight gain
Exercise
Loss of muscle mass
Cognitive decline
Social support, Intellectual stimulation
Depression
Understanding, Counselling, Exercise, Medication

20. Summary Prostate Cancer Screening The PSA test
Tell your patients all the Pros and Cons.
The PSA test
Criteria will continue changing
Divide in to Definite, Possible and Watch categories.
Localised Prostate Cancer
Lots of new modalities
Androgen Deprivation Therapy
Monitor their cardiac and bone health