1. A case of localized
Prostate Cancer
Marije Hamaker

2. Disclosure
Nothing to disclose

3. The patient 2014
Born on 1943, worked as police officer, living with wife, with 3 sons ,69 mt x 65 Kg
Comorbidity:
-Hypertension
-Cerebrovascular event 1999, mild left emiparesis
-Left carotid thromboarterectomy 2000
-Hypercholesterolemia
Which is the life expectancy (71 years in 2014)?
Whould you adivise for PSA screening in this patient? 3

4. Urological History The patient undergoes PSA testing in 2014= 3ng/mL
(primary care physician's prescription? Wife-induced prescription?)
PSA repeated in June 2015: 6.5 without urinary symptoms
Urology consultation:
Palpable induration in the left prostatic lobe
Erectal dysfunction (no interest on the matter)
Would you perform prostatic biopsies? 4

5. Prostatic Biopsy
In Oct 2015 the patient undergoes prostatic biopsies and new PSA testing=45.
-8 positive cores out of 12 samples
-Adenocarcinoma of the prostate Gleason 4+5=9
(GRADE GROUP 5)
-Perineural infiltration
Would you proceed with radiological staging ?
Which radiological exams? 5

6. Staging with PSA 45 ng/mL
Abdomen CT scan: negative (apart from enlarged prostate)
Bone scintigraphy: positive on left tibia and several joints
…...previous bike fall
Would you proceed with PET/CT scan?
…...not performed 6

7. What would you do?
Will a Gleason 9 prostate cancer influence life-expectancy of this patient?
-Watchful waiting, no further exams until symptoms of metastatic disease or urinary obstruction
-Active Surveillance not indicated.
-Prostatectomy
-Radiotherapy
-LH-RH analogue 7

8. The First Treatment
The patient starts LH-RH analogue without Radiotherapy consultation
March 2016: PSA 1.3, mild hot-flashes
The patient is advised by a friend to have a multidisciplinary consultation at our Institution
Are LH-RH analogues safe in this patient? 8

9. “Multidisciplinary Prostate Clinic”
March 2015: First visit at our Radioterapy/Oncology Multidisciplinary Clinic, accompanied by a son.
72 years, lives with wife, KPS=90
Mild gait alteration
ABP 125/80
Cholesterol 199 mg/dL
No bladder voiding symptoms 9

10. Full Geriatric Assessment
ADL=6, IADL=3
MMSE: 19
BMI=22.7
GDS=8
3 medications: aspirin, ACE inhibitor, atorvastatine (in the past also antidepressant)
Worried about “progression of tumor” and “approaching end of life” which will prevent him from seeing his grandchildren
Vulnerable for IADL impairment and comorbidity level 10

11. SIOG GUIDELINES 11

12. Need for geriatric intervention?
Long discussion with the patient concerning the prognosis and therapeutic options for his prostate cancer but ALSO for his current comorbidities and “oncogeriatric” issues
SEDENTARY HABITS (walking, but no more bike)
DEPRESSIVE ATTITUDES: psycho-oncological support + psychiatric consultation + increase family meetings
CARDIOLOGICAL EVALUATION? 12

13. RADIOTHERAPY
The patient has aggressive prostate cancer with high risk of micro-metastatic disease.
Surgery is not taken into consideration for this patient (already excluded by urologist)
He accepts the proposal of external radiotherapy (already on LH-RH analogues) in order to potentiate local control of disease
MRI of the pelvis is requested in order to restage local extension of the tumor after hormonal therapy 13

14. DISCUSSION POINTS
SCREENING for prostate cancer in the elderly: not recommended
Hormonal therapy alone may be under-treatment in the elderly with high-risk prostat cancer
Treatment choice is still based on first specialist seen by the patient & comorbidies
Multidisciplinary Team Discussion should be applied in order for the patient to express his own wishes and concerns 14