SCREENING AND EARLY DETECTION: Population or mass screening is defined as the examination of asymptomatic men (at risk). It usually takes place as part of a trial or study and is initiated by the screener. In contrast: early detection or opportunistic screening comprises individual case findings, which are initiated by the person being screened (patient) and/or his physician. The primary endpoint of both types of screening has two aspects: 1. Reduction in mortality from PCa. The goal is not to detect more carcinomas, nor is survival the endpoint because survival is strongly influenced by lead-time from diagnosis. 2. The quality of life is important as expressed by quality-of-life adjusted gain in life years (QUALYs).
CONSERVATIVE MANAGEMENT: 1- WATCHFULL WAITING 2- ACTIVE SURVEILLANCE
Watchful waiting (WW): (stage T1-T2, Nx-N0, M0) Also known as ‘deferred treatment’ or ‘symptom-guided treatment’, this term was coined in the pre-PSA screening era (before 1990) and referred to the conservative management of PCa until the development of local or systemic progression, at which point the patient would be treated palliatively with transurethral resection of the prostate (TURP) or other procedures for urinary tract obstruction and hormonal therapy or radiotherapy for the palliation of metastatic lesions. patients with localised PCa and a limited life expectancy or for older patients with less aggressive cancers.
Active surveillance (AS): Also known as ‘active monitoring’, this is the new term for the conservative management of PCa. Introduced in the past decade, it includes an active decision not to treat the patient immediately and to follow him with close surveillance and treat at pre-defined thresholds that classify progression (i.e. short PSA doubling time and deteriorating histopathological factors on repeat biopsy). In these cases, the treatment options are intended to be curative. INCLUSION CRITERIA: PSA < 10 ng/Ml Gleason score < 6 no Gleason grade > 3 < 33% positive biopsies cT 1-2a
LOCALLIZED PROSTATIC CANCER: ( More than 90% of all CAP )
Low-risk, localized PCa: cT1-T2a and Gleason score 2-6 and PSA < 10: Intermediate-risk, localized PCa: cT2b-T2c or Gleason score = 7 or PSA 10-20 High-risk localized PCa: cT3a or Gleason score 8-10 or PSA > 20 LOW RISK + INTERMEDIATE RISK = 65 – 80% HIGH RISK = 20 – 35%
Low-risk, localized Pca AND Intermediate-risk, localized PCa: Patients should be informed about the results of the randomised trial comparing retropubic RP versus watchful waiting in localized PCa. In this study, RP reduced prostate cancer mortality and the risk of metastases in men younger than 65 years with little or no further increase in benefit 10 or more years after surgery (8). LIFE EXPECTANCY
RADICAL PROSTATECTOMY: ( Gold Standard ) Removal of the entire prostate gland between the urethra and the bladder, and resection of both seminal vesicles along with sufficient surrounding tissue to obtain a negative margin.
There is no consensus regarding the optimal treatment of men with high- risk PCa. High-risk locallized Pca: Increased risk of: 1- PSA failure, 2- Need for secondary therapy, 3- Metastatic progression 4- Death Incidence of organ-confined disease is between 26% and 31%.
RP is a reasonable treatment option in selected patients: If RP is performed, an extended pelvic lymphadenectomy must be performed, as lymph node involvement is common ( 15 -40% ). The patient must be informed about the likelihood of a multimodal approach. In case of adverse tumour characteristics: positive sergical margin extracapsular extension seminal vesicle invasion adjuvant RT immediate ADT versus observation in patients with positive lymph nodes at initial surgery