Download presentation
Published byTabitha Gaines Modified over 9 years ago
1
PSA & Prostate Cancer Dan Burke Consultant Urological Surgeon
Uro-Oncology & Complex Laparoscopic Surgery
2
Incidence of Prostate Cancer
2008 new cases in UK deaths from Ca Prostate 101 men diagnosed every day One new diagnosis every 15 minutes Accounts for 3% of male mortality
3
Incidence
4
Age at diagnosis
5
PSA
6
2 raised readings - beware UTI’s, LUTS(acute), big prostates
PSA – relative risk Age related <50 ?? 50-60 <2.5 60-70 <3.5 70-80 <6.0 0ver 80 – abnormal DRE 2 raised readings - beware UTI’s, LUTS(acute), big prostates PSA Velocity >0.75 / year Low readings <0.7 Reassurance
7
PSA velocity / density >0.75 per year Doubling time
Patterns over time (fluctuating PSA’s with large prostates) Accept higher PSA levels with larger prostates – but obtain a predicted PSA with TRUSS Changes of PSA with dutasteride / finasteride
8
DRE
9
Prostate Cancer Risk Calculator
11
0.9 13.2% 1% 12 57.8% 22.1% Same man different PSA PSA
Chances of detecting a cancer Chances of detecting a high grade cancer 0.9 13.2% 1% 12 57.8% 22.1%
12
Same man different history
Chances of detecting a cancer Chances of detecting a high grade cancer Abnormal DRE & FH PSA 3.2 59% 12.3 PSA 12 >75% 43%
13
Screening
14
Prostate cancer screening could see every man over 50 tested
March 2009 Prostate cancer screening could see every man over 50 tested All men over the age of 50 could be tested for prostate cancer after the largest international study ever conducted suggested that screening could save thousands of lives a year in Britain.
15
Mortality Results from a Randomized Prostate-Cancer Screening Trial
The Evidence Screening and Prostate-Cancer Mortality in a Randomized European Study Published at March 18, 2009 ( /NEJMoa ) 182,000 men Mortality Results from a Randomized Prostate-Cancer Screening Trial Published at March 18, 2009 ( /NEJMoa ) 76,693 men
16
The Facts 820 / 10,000 Carcinoma of the Prostate diagnosed in screened arm vs 480 / 10,000 diagnosed in control arm
17
The Facts 73,000 men screened 17,000 biopsies
18
The Facts 227/10,000 radical prostatectomies performed in screened arm Vs 100/10,000 in control arm
19
214 / 10,000 Deaths due to prostate cancer (Screened arm) Vs 326 / 10,000 (unscreened arm)
20
1410 people screened 48 treated 1life saved Over a 10 year period
The Facts 1410 people screened 48 treated 1life saved Over a 10 year period
21
The conclusion! European Study – Screening has its place Based on improved rate of cancer deaths American Study – No role for screening Risk of over treating too many for a small gain BUT NEITHER STUDY WAS CONCLUSIVE
22
Who to screen – risk factors for clinically significant prostate cancer
Afro-Caribbean men – 3x and diagnosed younger 1st degree relative diagnosed at a young age – 3x increase risk Strong family history – 5x increase risk The concerned informed patient
23
The HSC205 referral ?early prostate CA
YES NO Young men Family history Afro-caribean rising PSA Age related PSA Symptomatic / advanced CaP <10year life expectancy Over 80 with normal DRE Raised PSA with UTI
24
Average life expectancy in years
Current age
25
New Headlines
26
10:00PM BST 16 Apr 2012 New treatment for prostate cancer gives 'perfect results' for nine in ten men: research A study has found that focal HIFU, high-intensity focused ultrasound, provides the 'perfect' outcome of no major side effects and free of cancer 12 months after treatment, in nine out of ten cases. Study of 41 patients.
27
High Intensity Focused Ultrasound
28
Prostate biopsy / prostate mapping
Standard Template
29
Study raises doubts over treatment for prostate cancer
Saturday 28 April 2012 Study raises doubts over treatment for prostate cancer Experts shaken by verdict suggesting thousands of men go through painful treatment for nothing USA study of an older age group average age 67, many low grade disease that would not have been offered surgery in the UK
30
WHY SURGERY? 'Currently, radical prostatectomy is the only treatment for localised prostate cancer that has shown a cancer-specific survival benefit...in a prospective, randomized trial.' European Association of Urologists Guidelines on Prostate Cancer, 2008.
31
Manchester Royal Infirmary surgeons first to use 3D
2 April 2012 Manchester Royal Infirmary surgeons first to use 3D Surgeons at Manchester Royal Infirmary claim to be the first in the UK to use a full 3D projection during an operation. During the operation, a high definition screen carried a 3D image of a hand-held robotic arm developed to carry out intricate surgical techniques
32
New Medicines
33
Aberatirone Mean survival 3 months Cost approx £3000 for 30 days
NICE approved 1g a day single dose 4x250mg tablets
34
Prostate Cancer Follow-Up
35
Should we be concerned? Prostate Cancer patients have a worse experience of care including after care than other cancer patients Department of Health
36
What’s the evidence / guidelines
Who should do it? Who should have it? What’s the evidence / guidelines
37
Nice guidelines 2008 Post Radical Treatment
PSA at the earliest 6 weeks post treatment PSA at least every 6 months for the next 2 years PSA then at least once a year thereafter
38
Nice guidelines 2008 After 2 years
Stable PSA and no complications then follow up should be offered outside the hospital Telephone follow up Primary care Electronic communications
39
Nice guidelines 2008 DRE (changed from 2002)
Now NOT recommended in men with localised prostate cancer while PSA remains stable Warren KS, McFarlane JP J Urol 2007 Jul:178(1):11-9
40
Nice guidelines 2008 Follow-up Watchful waiting
Should normally be followed up in primary care in accordance with protocols agreed by the local MDT PSA should be measured at least once a year
41
Metastatic Patients NICE Sweden Canada
Primary care manage day to day complications Sweden More regular PSA testing Canada Less regular PSA testing
42
My Practice Post Laparoscopic Radical Prostatectomy
8/52 post op PSA & Clinical assessment 3/12 for 1 year 6/12 for 1-2 years Discharged to Primary Care Exceptions: Gleason 8/9/10 and/or positive margins and/or BCR
43
My Practice Active Surveillance 3/12 PSA 1 year repeat TRUSS + biopsy
6/12 PSA for 2 years Primary care follow up Exceptions: unstable/fluctuating PSA, Age <65, patient request
44
My Practice Watchful waiting 3/12 PSA for 1 year 6/12 PSA for 1 year
Primary Care follow up Exceptions: GP or patient request
45
My Practice Metastatic disease 3/12 PSA initially
Symptomatic management Patient specific follow-up
46
Communication with Primary Care
Agreed pathways Avoids ‘double’ tests Avoids unnecessary re-referrals Patient copied into communications Agreements on costings of follow-up / new appointments
47
Prostate Cancer Pathways
48
Post Radical Surgery PROPOSED PSA PATHWAY CMFT 2 years post surgery
Post Radical Surgery 2 years post surgery No functional problems PSA Unrecordable Discharge for primary care follow-up 6 monthly PSA PSA unrecordable detectable PSA Continue PSA referral back tertiary care
49
Post Radical Radiotherapy
2 years post radiotherapy (+/- hormonal treatment) No functional Problems + PSA Stable Discharge for primary care follow up With instructions on length of hormonal treatment 6 monthly PSA PSA <2.0 + asympotomatic PSA >2.0 or symptomatic 6 monthly PSA Referral to Urologist or Oncologist
50
Hormonal Treatment PSA Stable for 2 years or satisfactory PSA response
PSA Stable for 2 years or satisfactory PSA response Asymptomatic Discharge to primary care Individual follow-up plan PSA every 3 / 6 or 12 months as directed PSA above designated level PSA stable or patient symptomatic patient asymptomatic Referral back to Urologist Continue PSA follow-up as directed
51
Active Survaillence Watchful waiting
To remain under consultant care Watchful waiting PSA stable for 1 year Patient asymptomatic Discharge to primary care for follow-up 3/6 or 12 monthly PSA as directed at discharge PSA below recommended level PSA above commended level Patient asymptomatic or patient symptomatic Remain under primary care referred back to urologist
52
And Finally PSA PATHWAY NO DIAGNOSIS OF CA PROSTATE Individual follow up Patient specific Clear discharge letter
53
‘The definition of insanity is doing the same thing over and over and expecting different results’
Similar presentations
© 2024 SlidePlayer.com Inc.
All rights reserved.