Recent Advances in Prostate Cancer: What the Patients needs to know 2008 Per-Anders Abrahamsson Department of Urology Malmö University Hospital Malmö, Sweden Europa Uomo, Milan, March 29,2008

Incidence Mortality

Anatomical Radical prostatectomy Prostate Cancer: the 1980s PSA: Anatomical Radical prostatectomy Stamey et al, NEJM 1987; Walsh et al, Prostate 1983

G.D. Chisholm Chisholm, BJU 1993

SPCG 4 Holmberg et al, NEJM 347: 781, 2002 Steineck et al, NEJM 347: 790, 2002

SPCG-4: Mortality p = 0.01 RR = 0.56 Years to follow-up Cumulative incidence of death from prostate cancer (%) Radical prostatectomy Watchful waiting p = 0.01 RR = 0.56 Years to follow-up No. at risk Radical prostatectomy 347 343 332 284 210 118 Watchful waiting 348 341 326 279 198 104 Watchful waiting < 65 years Radical prostatectomy < 65 years Radical prostatectomy ≥ 65 years Watchful waiting ≥ 65 years Cumulative incidence of death from prostate cancer (%) Note to Professor Abrahamsson: please check that the animation on this slide is as you would like it. SPCG-4 This trial clearly shows a benefit of radical prostatectomy over watchful waiting when looking at death from PCa, death from any cause, and metastasis Limitations: Non-screen-detected cases Predominantly T2 tumours Lymph-node metastases were found in 10% of patients in the radical prostatectomy group Criteria for local progression unreliable DRE, bladder outflow obstruction requiring transurethral resection High-grade disease excluded Pathological stage insufficiently detailed (positive margins plus upstaging) Morbidity from surgery was high Radiotherapy was not evaluated Years to follow-up Bill-Axelson A, et al. N Engl J Med. 2005;352:1977-84.

Radical prostatectomy Watchful waiting Prostate Cancer: the 1990s Radical prostatectomy Curative surgical ‘gold standard’ Watchful waiting Men with less than 10 years life expectancy Men with co-morbidities

However, We did not anticipate this… “ A ROBOT SAVED MY SEX LIFE…” Daily Mail

Nor forsee Viagra coming.....

But will the robot really replace the surgical hand?

Robotic-assisted surgery The Future?

Prostate-Specific Antigen Best cancer marker ever discovered Used for: Detection and screening Prognosis & Monitoring of prostate cancer

HEALTHY & BENIGN DISEASE Reality of PSA Testing HEALTHY & BENIGN DISEASE CUT OFF PROSTATE CANCER PSA Ng/mL 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 100.0 20% FALSE NEG. 70% FALSE POS.

The Problem……. Normal / BPH Prostate Cancer Potentially Lethal prostate cancer Prostate Cancer IDEAL SCREENING TEST Normal / BPH

DD3...DD3PCA3…PCA3 PCA3DD3 (Bussemakers et al., Cancer Res. 59: 5975-79, 1999) Overexpressed in >95% of PrCa 1 2 3 4 5 6 T B N T N T N T N M (kb) 4.0 DD3 2.0 0.6