1. Prostate Cancer: Treatment choices Prostate Cancer: Treatment choices Winston W Tan MD FACP Winston W Tan MD FACP Senior Consultant Senior Consultant Genitourinary Oncology Genitourinary Oncology Mayo Clinic Florida Mayo Clinic Florida

2. Incidence 230,000 cases each year 230,000 cases each year 30,000 deaths each year 30,000 deaths each year Indolent Indolent Aggressive disease Aggressive disease Jemal et al 2009 Jemal et al 2009

3. Biopsy Sextant biopsy Sextant biopsy Template biopsy Template biopsy Importance for diagnosis Importance for diagnosis PSA of 50 and above PSA of 50 and above

4. Diagnosis PSA PSA Gleason Score Gleason Score Stage Stage Metastasis or not Metastasis or not

5. Gleason score Microscopic appearance Microscopic appearance 1 well differentiated 1 well differentiated 5 poorly differentiated 5 poorly differentiated Maximum score of each site:5 Maximum score of each site:5 Add score of 2 sites Add score of 2 sites

6. Treatment Options Radical Prostatectomy Radical Prostatectomy External beam radiation External beam radiation Brachytherapy( interstitial seed implant) Brachytherapy( interstitial seed implant) Combination of external beam radiation and seed implant Combination of external beam radiation and seed implant Observation Observation

7. Radical prostatectomy Full evaluation of pathology Full evaluation of pathology Risk of anesthesia Risk of anesthesia Impotence Impotence Urinary incontinence Urinary incontinence Morbidity from surgery Morbidity from surgery

8. External beam radiation Treat more area if there is extracapsular involvement Treat more area if there is extracapsular involvement Gastrointestinal complications Gastrointestinal complications Radiation cystitis Radiation cystitis Radiation proctitis Radiation proctitis Urinary incontinence Urinary incontinence

9. Brachytherapy Not for everybody Not for everybody Low risk Low risk More radiation cystitis More radiation cystitis Inadequate cure of cancer Inadequate cure of cancer

10. Observation Scandinavian studies Scandinavian studies Low gleason score :6 and below Low gleason score :6 and below Elderly patients Elderly patients Less than 10 years to live Less than 10 years to live

11. Options Treatment options are equal based Treatment options are equal based On patients followed On patients followed No randomized clinical trials

12. Medical team Urologist Urologist Radiation oncologist Radiation oncologist Medical oncologist Medical oncologist Nephrologist Nephrologist Nursing Nursing Physical therapy Physical therapy

13. Choice Choice The choice is yours !!! The choice is yours !!!

14. Prostate Cancer You are in charge You are in charge Empower patients Empower patients Educate patients Educate patients Stimulate interest in participation in clinical trials Stimulate interest in participation in clinical trials

15. Thank You Thank You Questions ? Questions ?