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Clinical evidence and treatment recommendations in localized and locally advanced prostate
cancer
M. Babjuk, L. Dušek FN Motol, 2. LF UK
IBA MUNI, ÚZIS
How should be the care organized and its quality controled?
Data from national databases and
registries
Evaluation of results
Treatment recommendations
System of care providers, centers etc
Quality criteria
Another sources: international
guidelines, evidence analyses
Reimbursement
Incidence and prevalence trends in ČR (epidemiological data from ČR)
7,049 patients with prostate cancer were diagnosed in the Czech
Republic in 2015 (8.2% of all cancers).
53,769 persons with a history of prostate cancer lived in the Czech
Republic on 31/12/2015 (9.9 % of all cancers).
New CNCR data: total prostate cancer burden
1,327 persons died due to prostate cancer in the Czech Republic in
2015 (4.9% of all cancer-related deaths).
2008 2009 2010 2011 2012 2013 2014 2015
Incidence 5 443 6 286 6 942 7 077 7 007 6 967 6 693 7 049
Mortality* 1 291 1 305 1 348 1 314 1 360 1 422 1 509 1 327
Prevalence 28 196 31 612 35 557 39 450 43 193 46 846 50 153 53 769
Czech National Cancer Registry – prostate cancer (C61) Mean
interannual
change
2011–2015
+0.4%
-0.1%
+8.6%
*Source: Czech Statistical Office
0
20
40
60
80
100
120
140
160
197719
7919
8119
8319
8519
8719
8919
9119
9319
9519
9719
9920
0120
0320
0520
0720
0920
1120
1320
15
Poče
t na
100
000
muž
ů
Year
Prostate cancer (C61)
0
5
10
15
20
25
197719
7919
8119
8319
8519
8719
8919
9119
9319
9519
9719
9920
0120
0320
0520
0720
0920
1120
1320
15
Poče
t na
100
000
osob
Year
Bladder cancer (C67)
0
5
10
15
20
25
30
35
197719
7919
8119
8319
8519
8719
8919
9119
9319
9519
9719
9920
0120
0320
0520
0720
0920
1120
1320
15
Poče
t na
100
000
osob
Year
Kidney cancer (C64)
0
5 000
10 000
15 000
20 000
25 000
30 000
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
0
2 000
4 000
6 000
8 000
10 000
12 000
14 000
16 000
18 000
20 000
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
0
10 000
20 000
30 000
40 000
50 000
60 000
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
Poče
t žijí
cích
s ná
dore
m
Year
Poče
t žijí
cích
s ná
dore
m
Year
Poče
t žijí
cích
s ná
dore
m
Year
-6.0%
+4.0%
+9.7%
-17.4%
+153.0%
Main urinary system cancers: time trends
Prostate cancer (C61) Bladder cancer (C67) Kidney cancer (C64)
+24.6% +54.0%
Trend of prevalence
incidence mortality Trends of incidence and mortality
%: trend between years 2005–2015
Source: incidence and prevalence: Czech National Cancer Registry, IHIS CZ; mortality 1994–2015: Czech Statistical Office
!
?
0 %
20 %
40 %
60 %
80 %
100 %
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011
2013
2015
Trends in the diagnosis of clinical stages
Clinical stage:
unknown
–
objective
reasons
unknown
–
incomplete
record
Year
TNM 2nd ed.
TNM 3rd ed.
TNM 4th ed.
TNM 5th ed.
TNM 6th ed.
1 2 3 4
Epidemiology of C61: still existing
high proportion of advanced stages
%: trend between years 2005–2015 TNM
7th ed.
0
10 000
20 000
30 000
40 000
50 000
60 000
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
+153.0%
Trend of C61 prevalence
Nu
mb
er o
f p
erso
ns
Epidemiology of the urinary system cancers in the Czech Republic
Source: incidence and prevalence: Czech National Cancer Registry, IHIS CZ; mortality – Czech Statistical Office
*C60–C62, **C64–C67, m per 100 000 men
Czech National Cancer Registry: recent data (year) 2015
Diagnosis
Incidence (2015)
Mortalitay (2015)
Prevalence (on 31/12/2015)
Absol.
number
Number
per 100,000
persons
Absol.
number
Number
per 100,000
persons
Absol.
number
Number
per 100,000
persons
C60 MN of penis 126 2.4m 34 0.7m 822 15.9m
C61 MN of prostate 7,049 136.1m 1,327 25.6m 53,769 1,038.0m
C62 MN of testis 527 10.2m 27 0.5m 9 983 192.7m
C63 MN of other and unspecified male
genital organs 10 0.2m - - 126 2.4m
Total (C60–C63) 7,712 148.9m *1,388 *26.8m 64,563 1,246.3m
C64 MN of kidney, exc. renal pelvis 2,988 28.3 1,055 10.0 24,385 231.3
C65 MN of renal pelvis 177 1.7 101 1.0 1 064 10.1
C66 MN of ureter 87 0.8 23 0.2 456 4.3
C67 MN of bladder 2,158 20.5 813 7.7 18,359 174.1
C68 MN of other and unspecified urinary
organs 16 0.2 - - 146 1.4
Total (C64–C68) 5,426 51.5 **1,992 **18.9 43,687 414.4
0
20
40
60
80
100
120
197719
7919
8119
8319
8519
8719
8919
9119
9319
9519
9719
9920
0120
0320
0520
0720
0920
1120
1320
15
0
20
40
60
80
100
120
197719
7919
8119
8319
8519
8719
8919
9119
9319
9519
9719
9920
0120
0320
0520
0720
0920
1120
1320
15
Source: Cancer Incidence in Five Continents Annual Dataset: Germany-Saarland; Cancer Mortality Database
0
20
40
60
80
100
120
197719
7919
8119
8319
8519
8719
8919
9119
9319
9519
9719
9920
0120
0320
0520
0720
0920
1120
1320
15
0
20
40
60
80
100
120
197719
7919
8119
8319
8519
8719
8919
9119
9319
9519
9719
9920
0120
0320
0520
0720
0920
1120
1320
15
0
20
40
60
80
100
120
197719
7919
8119
8319
8519
8719
8919
9119
9319
9519
9719
9920
0120
0320
0520
0720
0920
1120
1320
15
0
20
40
60
80
100
120
197719
7919
8119
8319
8519
8719
8919
9119
9319
9519
9719
9920
0120
0320
0520
0720
0920
1120
1320
15
0
20
40
60
80
100
120
197719
7919
8119
8319
8519
8719
8919
9119
9319
9519
9719
9920
0120
0320
0520
0720
0920
1120
1320
15
0
20
40
60
80
100
120
197719
7919
8119
8319
8519
8719
8919
9119
9319
9519
9719
9920
0120
0320
0520
0720
0920
1120
1320
15
incidence
mortality
C61 incidence and mortality in international comparison
0
20
40
60
80
100
120
197719
7919
8119
8319
8519
8719
8919
9119
9319
9519
9719
9920
0120
0320
0520
0720
0920
1120
1320
15
incidence
mortality
incidence
mortality
incidence
mortality
incidence
mortality
incidence
mortalita
incidence
mortality
incidence
mortality
incidence
mortality
Source: Czech National Cancer Registry Source: Cancer Incidence in Five Continents Annual Dataset, Cancer Mortality database
Source: Cancer Incidence in Five Continents Annual Dataset; Cancer Mortality Database
Source: Cancer Incidence in Five Continents Annual Dataset: Austria-Tyrol; Cancer Mortality Database
Source: Cancer Incidence in Five Continents Annual Dataset; Cancer Mortality Database
Czech Republic Slovakia Sweden
Germany Austria Norway
Slovenia Netherlands Finland
AS
R (
W)
Source: Cancer Incidence in Five Continents Annual Datase; Cancer Mortality Database
Source: Cancer Incidence in Five Continents Annual Dataset: Nizozemí-Eindhoven; Cancer Mrotality Database
Source: Cancer Incidence in Five Continents Annual Dataset; Cancer Mortality Database
0 50 100 150 200 250 0 50 100 150
ASR (W) WORLD
other countries
European countries
neighbouring countries
Czech Republic CR ranking 34th globally
World
EUROPE
European countries
neighbouring
countries
Czech Republic CR ranking 18th in
Europe
Europe
Norway
Sweden
Ireland
Switzerland
Iceland France (metropolitan)
Finland
Estonia
Denmark
Belgium The Netherlands
Slovenia
Latvia
Luxembourg
Germany Austria
United Kingdom
Czech Republic Italy
Spain Portugal
Lithuania
Cyprus
Malta
Slovakia Croatia
Hungary
Serbia
Poland
Belarus Montenegro
Russian Federation
FYR Macedonia
Romania
Bulgaria Bosnia Herzegovina
Ukraine
Greece
Republic of Moldova
Albania
ASR (W)
67.1 +
32.4–67.1
19.5–32.4
10.8–19.5
< 10.8
No data
ASR (W): world age-standardised incidence per 100,000 persons
92.0 +
73.8–92.0
50.5–73.8
29.6–50.5
< 29.6
No data
C61 incidence in international comparison
Source: Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F.GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide:
IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://globocan.iarc.fr, 22/7/2017
0 5 10 15 20 250 15 30 45 60
C61 mortality in international comparison
ASR (W) WORLD
World
other countries
European countries
neighbouring countries
Czech Republic
CR ranking 98th
globally
ASR (W)
Europe
European countries
neighbouring countries
Czech Republic CR ranking 23rd in Europe
EUROPE
Lithuania
Estonia
Denmark
Slovenia
Latvia Norway
Sweden
Croatia
Iceland
Montenegro FYR Macedonia
The Netherlands
Serbia
Slovakia
United Kingdom Belarus
Belgium
Ireland
Russian Federation
Poland Switzerland
Finland
Czech Republic Portugal
Bulgaria Hungary
Germany
Luxembourg
Austria
Cyprus Ukraine
France (metropolitan)
Republic of Moldova
Greece
Romania Bosnia Herzegovina
Spain
Albania
Italy
Malta
Source: Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F.GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide:
IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2013. Available from: http://globocan.iarc.fr, 22/7/2017
20.2 +
13.9–20.2
10.0–13.9
6.2–10.0
< 6.2
No data
ASR (W): world age-standardised mortality per 100,000 persons
14.8 +
12.8–14.8
10.6–12.8
10.0–10.6
< 10.0
No data
Treatment outcomes in ČR (in different historical periods)
Prostate cancer – year 2015
Incidence in 2015:
- total: 7,049 men
- of which clinical stage III–IV: 24.7%
Prevalence in 2015:
- total: 53,769 men
- of which clinical stage III–IV at diagnosis : 19.4%
0
5
10
15
20
25
30
< 50
50–54
55–59
60–64
65–69
70–74
75–79
80–84
85+
% o
f cases in t
he
resp
ective
ca
teg
ory
Age
Age structure
- 13.8% of men were under 60 years
Newly diagnosed cancers in the period 2011–2015
- 56.6 % of men were under 70 years
Source: Czech National Cancer Registry, IHIS CZ
0
5
10
15
20
25
30
< 50
50–5455–5960–6465–6970–7475–7980–84
85+
% o
f ca
ses
in t
he
resp
ecti
ve
cate
gory
Age at diagnosis
Age structure Age-specific incidence
Period:
1986–1990
1991–1995
1996–2000
2001–2005
2006–2010
2011–2015
N = 7,823 N = 10,192 N = 14,095 N = 20,066 N = 28,877 N = 34,793
Mean 72 years 73 years 72 years 71 years 69 years 69 years
Median 73 years 72 years 73 years 72 years 69 years 68 years
25th–75th perc. 66–78 years 67–79 years 67–78 years 65–77 years 63–76 years 63–74 years
% of persons below 70 35.8% 35.8% 35.1% 40.8% 51.5% 56.6%
0
100
200
300
400
500
600
700
800
900
< 50
50–5455–5960–6465–6970–7475–7980–84
85+
Num
ber
of
case
s per
100,0
00
men
in t
he
resp
ecti
ve
age
cate
gory
Age at diagnosis
Age of prostate cancer patients in time
! Source: Czech National Cancer Registry, IHIS CZ
5Yr OS
Cohort analysis
1990–1994
Cohort analysis
1995–1999
Cohort analysis
2000–2004
Cohort analysis
2005–2008
Cohort analysis
2009–2012
Analysis of the period 2013–2016
Stage 1 + 2 59,7 % 66,6 % 75,2 % 80,7 % 83,7 % 84,1 %
Stage 3 45,0 % 58,8 % 66,6 % 75,5 % 81,3 % 81,8 %
Stage 4 20,8 % 24,6 % 24,5 % 29,4 % 33,6 % 35,1 %
All 42,5 % 51,8 % 61,8 % 71,7 % 76,6 % 77,2 %
0 %
10 %
20 %
30 %
40 %
50 %
60 %
70 %
80 %
90 %
100 %
Analysis of the period 2013–2016
Cohort analysis 2009–2012
Cohort analysis 2005–2008
Cohort analysis 2000–2004
Cohort analysis 1995–1999
Cohort analysis 1990–1994
5Yr OS: treated patients with C61
PCa (C61)
5 Y
r O
S
Stage 3 All cases Stage 4 Stage
1 + 2
Patients with anticancer treatment
Age standardized.
Treatment trends and results in individual treatment modalities
(example: radical prostatectomy)
Trends in number and percentage of patients with PCa and radical prostatectomy
Nu
mb
er o
f ca
ses
Yr of radical prostatectomy
No. Of patients with radical prostatectomy
Perc
enta
ge o
f ca
ses
Yr of radical prostatectomy
Percentage of pts.
Trends in number and percentage of patients with PCa and radical prostatectomy
Open surgery Laparoskopic surgery Robot assisted surgery
Type of surgery:
Yr of radical prostatectomy
Nu
mb
er o
f ca
ses
Perc
enta
ge o
f ca
ses
Open surgery Laparoskopic surgery Robotic assisted surgery
Yr of radical prostatectomy
> 40%
30–40%
< 30%
Kraj bydliště
STC
JHC
PLK
JHM
VYS ZLK
ULK
MSK
OLK
PAK
HKK
LBK
KVK PHA
Ústecký kraj
Olomoucký kraj
Středočeský kraj Karlovarský kraj
Hlavní město Praha
Vysočina
Liberecký kraj
Jihomoravský kraj
Česká republika
Královéhradecký kraj
Pardubický kraj
Jihočeský kraj Plzeňský kraj
Zlínský kraj
Moravskoslezský kraj
Percentage of pts. with radical prostatectomy in regions (2014–2017)
Percentage (%) of surgeries from all detected cases with Pca (2014–2016):
Radical prostatectomies in regions (2014–2017)
Open surgery Laparoskopic surgery Robotic assisted surgery
Type of surgery (average 2014–2017):
Česká republika
Kraj bydliště Olomoucký kraj
Ústecký kraj
Kraj Vysočina
Zlínský kraj
Pardubický kraj
Hlavní město Praha
Jihomoravský kraj
Liberecký kraj
Královéhradecký kraj
Středočeský kraj Karlovarský kraj
Moravskoslezský kraj
Plzeňský kraj Jihočeský kraj
3Yr and 5Yr OS: patients after radical prostatectomy
OS
3Yr 5Yr
All stages 96,1 % 90,4 %
Stage 1+2 96,4 % 91,6 %
Stage 3 95,6 % 86,9 %
Stage 4 94,1 % 81,8 %
3Yr and 5Yr OS after radical prostatectomy achieved 96,1%, and 90,4% respectivelly.
5Yr OS: patients after radical prostatectomy
5Y
r O
S
All Open surgery Laparoscopic surgery
Robotic assisted surgery
All cases 90,4 % (n = 12 647) 88,8 % (n = 4 960) 92,0 % (n = 2 456) 92,5 % (n = 5 231)
Stage 1+2 91,6 % (n = 8 807) 92,1 % (n = 3 308) 94,0 % (n = 1 789) 93,0 % (n = 3 710)
Stage 3 86,9 % (n = 2 177) 86,1 % (n = 915) 88,5 % (n = 387) 85,7 % (n = 875)
Stage 4 81,8 % (n = 483) 82,6 % (n = 265) 86,1 % (n = 70) 83,3 % (n = 148)
Prediction
Prostate cancer: estimated incidence rates
Prostate cancer (C61) Estimated incidence rates (90 % confidence interval)
2016 2017 2018
.
.
.
2020
.
.
.
2025
Stage I+II 4,926
(4,542; 5,311)
4,969
(4,545; 5,394)
4,989
(4,524; 5,456)
5,002
(4,206; 5,799)
4,877
(3,770; 5,984)
Stage III 785
(720; 849)
769
(700; 837)
750
(677; 823)
648
(551; 746)
525
(400; 649)
Stage IV 875
(811; 940)
879
(809; 949)
878
(802; 955)
781
(673; 889)
721
(566; 876)
Stage unknown1 390
(304; 476)
400
(307; 494)
409
(308; 510)
364
(222; 506)
366
(170; 561)
TOTAL 6,976
(6,377; 7,576)
7,017
(6,361; 7,674)
7,026
(6,311; 7,744)
6,795
(5,652; 7,940)
6,489
(4,906; 8,070)
1 Objective reasons for missing clinical stage are DCO/autopsy-diagnosed tumours, early deaths, patients not treated due to
contraindication or refusal of the anticancer therapy. If a reason for missing stage is not explained, the record is considered as
incomplete. The incomplete records are not included in the estimated number of patients with the anticancer therapy.
Prostate cancer: estimated prevalence rates
1 Objective reasons for missing clinical stage are DCO/autopsy-diagnosed tumours, early deaths,
patients not treated due to contraindication or refusal of the anticancer therapy. If a reason for
missing stage is not explained, the record is considered as incomplete.
Prostate cancer (C61)
Estimated prevalence rates (90 % confidence interval)
2016 2017 2018
.
.
.
2020
.
.
.
2025
Stage I+II 43,926
(43,581; 44,271)
46,702
(46,347; 47,057)
49,369 (49,004; 49,734)
55,675
(55,287; 56,063)
66,983 (66,557; 67,409)
Stage III 7,541
(7,398; 7,684)
7,917
(7,771; 8,063)
8,249
(8,100; 8,398)
8,849
(8,694; 9,004)
9,734
(9,572; 9,896)
Stage IV 5,169
(5,051; 5,287)
5,223
(5,104; 5,342)
5,249
(5,130; 5,368)
5,409
(5,288; 5,530)
5,315
(5,195; 5,435)
Stage unknown1 3,714
(3,614; 3,814)
3,628
(3,529; 3,727)
3,565
(3,467; 3,663)
3,529
(3,431; 3,627)
3,546
(3,448; 3,644)
TOTAL 60,350
(59,946; 60,754)
63,470 (63,056; 63,884)
66,432
(66,008; 66,856)
73,462 (73,016; 73,908)
85,578
(85,097; 86,059)
Number of patients referred for treatment
according to region and phase of treatment
0 1 000 2 000 3 000 4 000 5 000
Number
Total number of patients referred for treatment
according to region
Regional estimates of numbers of prostate cancer (C61) patients with anticancer therapy in 2018
Newly diagnosed and treated patients
Non-terminal recurrences and progressions
Terminal recurrences and progressions
Prague
South Moravian Region
Moravian-Silesian Region
Central Bohemian Region
Ústí nad Labem Region
Zlín Region
Olomouc Region
Hradec Králové Region
South Bohemian Region
Pardubice Region
Vysočina Region Plzeň Region
Liberec Region
Karlovy Vary Region
0–1 250
1 251–2 000
2 001–2 750
2 751–3 500
3 501 and higher
2 942
1 492
1 365
3 295
1 367
2 998
2 101
1 668
642
1 596
1 405
1 678
1 046
3 713
Number of patients referred for treatment
according to region and phase of treatment
3 049
1 566
1 353
3 479
1 467
3 169
2 185
1 756
667
1 660
1 522
1 759
1 083
3 935
Number
Total number of patients referred for treatment
according to region
Regional estimates of numbers of prostate cancer (C61) patients with anticancer therapy in 2020
Expected change +4.9%
from 2018 to 2020
Prague
South Moravian Region
Moravian-Silesian Region
Central Bohemian Region
Ústí nad Labem Region
Zlín Region
Olomouc Region
Hradec Králové Region
South Bohemian Region
Pardubice Region
Vysočina Region Plzeň Region
Liberec Region
Karlovy Vary Region
0 1 000 2 000 3 000 4 000 5 000
0–1 250
1 251–2 000
2 001–2 750
2 751–3 500
3 501 and higher
Newly diagnosed and treated patients
Non-terminal recurrences and progressions
Terminal recurrences and progressions
Number of patients referred for treatment
according to region and phase of treatment
3 239
1 673
1 424
3 724
1 571
3 387
2 327
1 863
710
1 765
1 613
1 871
1 151
4 185
Number
Total number of patients referred for treatment
according to region
Regional estimates of numbers of prostate cancer (C61) patients with anticancer therapy in 2025
Expected change +11.7%
from 2018 to 2025
Prague
South Moravian Region
Moravian-Silesian Region
Central Bohemian Region
Ústí nad Labem Region
Zlín Region
Olomouc Region
Hradec Králové Region
South Bohemian Region
Pardubice Region
Vysočina Region Plzeň Region
Liberec Region
Karlovy Vary Region
0 1 000 2 000 3 000 4 000 5 000
0–1 250
1 251–2 000
2 001–2 750
2 751–3 500
3 501 and higher
Newly diagnosed and treated patients
Non-terminal recurrences and progressions
Terminal recurrences and progressions
Treatment recommendations (source data)
Treatment recommendations available guidelines
International guidelines:
• EAU, ESMO
National guidelines:
• NCCN, AUA, NICE etc.
Prospective controlled trials
• ProtecT study
• Localized CaP
• PSA 4.6ng/ml, 77% GS 6, 76% T1c
Treatment recommendations in localized and locally advanced PCa
critical points
• Staging methods
• Risk assessment and stratification
• Deferred treatment (active surveillance, WW)
• Active treatment (surgery, RT)
• Monitoring
• Definition of treatment failure
• Secundary measures
Prostate cancer as
a subsequent
primary cancer in
cancer patients
Epidemiology of prostate cancer in the Czech Republic Epidemiology-related challenges for organising the healthcare
INSTITUTE OF BIOSTATISTICS AND ANALYSES, Faculty of
Medicine, Masaryk University, Brno
Diagnosis First/subsequent cancer
Period 1986–1995
Period 1996–2005
Period 2006–2015
N per year (% of
newly diagnosed) N per year (% of
newly diagnosed) N per year (% of
newly diagnosed)
Prostate cancer (C61) first cancer 1,646 (91.4%) 2,952 (86.4%) 5,430 (85.3%)
subsequent primary cancer 155 (8.6%) 464 (13.6%) 937 (14.7%)
Incidence: first and subsequent primary cancers in the Czech Republic
Source: Czech National Cancer Registry, IHIS
CZ