1. Prostate cancer update Suresh GANTA Consultant urological surgeon Manor Hospital

2. Agenda  Suspected cancer referral update  Management of PSA.  What is new about prostate cancer  Prostate cancer management update  Primary care management  Secondary care management

3. When to do PSA  After the age of 50 yrs  Do earlier (40 yrs) if family history and Afro-Caribbean descent.  Consider PSA and DRE in patients with  Any LUTS (nocturia/frequency/retention/hesitency/urgency)  ED  Visible Hematuria

4. Suspected cancer referrals: urology NICE 2015  PSA above the age specific range.  Malignant feeling prostate on DRE : refer under 2 week pathway  Hard/firm feeling prostate, hard nodule

5. Prostate cancer  41K new cases of prostate cancer each year in the UK, so a full time GP will diagnose one new person with prostate cancer each year.  134 new cancers /100,000 men.  10K die each year from prostate cancer in UK  5 Yr survival is 80%

6. Clinical symptoms  Presenting complaintsPPV  LUTS (voiding/storage)  Hematuria1.8%  ED  Disseminated disease.  Nocturia + abn DRE15%  Loss of weight + nocturia12%  Loss of weight + BPH on DRE9.4%

7. PSA facts  PSA between 3-10 only 20% have cancer on biopsy  PSA >10 upto 50% risk of cancer  Screening: currently not supported by all organisations  13 year follow up from ERSPC shows a 0.11 reduction of death from caP per 1000 person years. 1 caP death averted in 781 screened and 27 additional caP detected.

8. Other PSA related parameters  PSA density (prostate volume)  PSA velocity.  PSA doubling time.

9. Baseline PSA at 40-45 yrs  Early PSA between 40 and 45yrs has a potential to predict risk of advanced caP 30 yrs later.  If the PSA is <1 then low risk and only repeat 8yrs later.  PSA >1.4 to monitor more closely.

10. What is new in the diagnosis of prostate cancer  TRUS biopsy of the prostate :  Multiparametric MRI of the prostate to identify lesions more accurately.  Increased characterization of the lesions  PIRAD scoring system  Improved accuracy of biopsy targeting using fusion software.

11. Background  Peripheral zone 70 %  Central zone 25%  Transitional zone 5%

12. TRUS vs transperineal biopsy prostate  Accessing peripheral zone.  Misses 12-15% of cancer.  Only targeting through ultrasound and hence ‘blind’.

13. NICE guidance CG 175  Magnetic resonance imaging for rebiopsy  Consider multiparametric MRI (using T2- and diffusion-weighted imaging) for men with a negative transrectal ultrasound 10–12 core biopsy to determine whether another biopsy is needed. [new 2014]  Do not offer another biopsy if the multiparametric MRI (using T2- and diffusion-weighted imaging) is negative, unless any of the risk factors listed in recommendation 1.2.5 are present. [new 2014]

14. Risk factors in patients with negative TRUS biopsy.  Men who have had a negative first prostate biopsy still has a risk that prostate cancer is present and  the risk is slightly higher if any of the following risk factors are present:  The biopsy showed high-grade prostatic intra-epithelial neoplasia (HGPIN)  The biopsy showed atypical small acinar proliferation (ASAP)  Abnormal digital rectal examination. [new 2014]

15. MRI pre biopsy  263 consecutive patients with suspicion of prostate cancer were investigated.  All had 3-T multiparametric MRI (mpMRI) applying the European Society of Urogenital Radiology criteria.  All patients underwent MRI/US-fusion biopsy transperineally (mean nine cores) and additionally a systematic transrectal biopsy (mean 12 cores).

16. Benefit of MRI to target  Abnormality on MRI is common.  Significant abnormality is in central and ventral area NOT accessible by TRUS.  45% (69/154) peripheral zone  37% (57/154) central zone  18% (28/154) ventral zone of the prostate All Without previous biopsy Repeat biopsy Number of patients 26368195 Lesions, n531131400 PI-RADS on mpMRI, n (%) PI-RADS < 286 (18.9)22 (20)64 (18.6) PI-RADS 3183 (40.3)31 (28.2)152 (44.2) PI-RADS 4135 (29.8)44 (40)91 (26.4) PI-RADS 550 (11.0)13 (11.8)37 (10.8)

17. Benefit of MRI to target All Without previous biopsy Repeat biopsy Number of patients 26368195 Lesions, n531131400 Men with proven prostate cancer, n (%) Overall137 (52)35 (52)102 (52) Targeted biopsy 116 (44)31 (46)85 (44) Systematic biopsy 91 (34)29 (43)62 (32)  More lesions noted per patient  More cancers in targeted transperineal biopsy 44% vs standard TRUS biopsy34%.  We may have to do both to be able to get best outcomes.  First biopsy the difference is small.

18.  MRI/US-fusion biopsy detected significantly more cancer than systematic prostate biopsy (44% [116/263] vs 35% [91/263]; P = 0.002).  In first biopsy, the detection rate was 46% (31/68) in targeted and 43% (29/68) in systematic biopsy (P = 0.527).

19. Treatment of prostate cancer.  Localised prostate cancer:  Active surveillance  Radical retropubic prostatectomy  Robotic  Laparoscopic  Open.  Radical radiotherapy  Brachy therapy  Locally advanced prostate cancer  Metastatic prostate cancer.  Management of hormone resistant prostate cancer.

20. When to do active surveillance

22. Management of prostate cancer in primary care  Raised PSA and negative prostate biopsy:  Active surveillance  Stable prostate cancer in metastatic prostate cancer.

23. Stable metastatic prostate cancer  Hormone treatment  Zoladex/ prostap/  Intermittent hormone treatment.  Monitor PSA Q 3 mo  Restart if PSA >10

24. Summary  PSA remains the marker of choice.  PPV increases with loss of weight, abnormal DRE +/- LUTS  MRI helps to identify areas of the prostate that are suspicious and allows targeted biopsy and may influence treatment.  Active surveillance is a suitable option in low risk prostate cancer.  Primary care management of patients with stable metastatic prostate cancer on hormone treatment.

25. Questions please?