LADUCA Group CPD

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Who Develops Prostate Cancer?

0

500

1000

1500

2000

2500

3000

3500

1990 1993 1996 1999 2002 2005

Ca. Prostate: No.

Ca. Prostate : Deaths

Prostate Cancer: Not The Only Cause Of Death In Men

What/where is the prostate? Who is at risk? Diagnosis How aggressive is the cancer (grading) How advanced is the cancer (staging) What are the treatment options for

localised and advanced prostate cancer What is the outlook after treatment

Majority of seminal fluid is prostatic in origin: average ejaculate volume= 2-5 mls; only 0.1-0.2 mls = sperm

“Nourishment and support” of sperm in the ejaculate

Provision of income for Urologists!

»Beyond Your control:»Age»Testosterone»Race »Family history

»Lifestyle»Geography»Diet

Prostate Cancer Risk Factors

Race and Nationality Mortality Rates

Per 100,000

Low-fat diet Soy products tomatoes Nutritional

supplements Selenium, vitamin E

Lifestyle - exercise, BMI

Herbal preparations

Holistic Approaches to Prevention

•symptoms not helpful

Digital Rectal Examination (DRE)

Prostate SpecificAntigen (PSA)

TransrectalUltrasound

(TRUS)

DiagnosticTriad

Early Diagnosis of Prostate Cancer

Majority diagnosed on PSA (Prostate Specific Antigen) testing with nil symptoms and normal rectal examination

Presentation with urinary symptoms Abnormal findings on rectal examination Presentation with symptoms of advanced

disease eg bone pain or fracture due to cancer spread to bone

Incidental diagnosis following prostate surgery

“Blockage of the bladder”- poor flow, hesitancy, intermittency of flow, urgency retention of urine

“Irritation” of the bladder- frequency day/night, urgency, urge leakage

Kidney obstruction and kidney failure

Produced by both benign and malignant prostate disease – benign enlargement, prostate infection and prostate cancer

Not elevated by other cancers ↑ levels with ↑ age: -age scale

40-50 2-2.550-60 2.5-3.560-70 3.5-5.070-80 5.0-7.0

The case for screening The lengthy preclinical detectable

phase of prostate cancer allows for early detection

Devastating effects of metastatic prostate cancer

Availability of convenient and inexpensive screening tests (DRE and PSA)

Treatments for early disease

The case against screening Inconsistency in disease progression High prevalence of asymptomatic

disease Does screening do more harm than

good? No evidence on benefits available from

randomized clinical trials Excess cost, morbidity and mortality from

treatments

American, Canadian Cancer Society - annual PSA&DRE men >50 (discuss)

AUA, CUA- annual PSA&DRE men >50 (discuss)

CTFPH (GPs), USPSTF- recommend against screening (grade

D evidence)

This will not be resolved until results of PLCO and ER-SPC studies (?2009-10)

Does PSA screening predict risk of Prostate Cancer? Yes

Does PSA screening predict clinically significant prostate cancer? Probably

Does PSA screening improve survival? Only future studies can prove

Sample of prostate must be taken to confirm diagnosis: prostate biopsy

Day stay local anaesthetic/sedation procedure

Generally 12 cores taken from throughout the prostate

Risksbleedinginfectionpain retention

Diagnosed on prostate biopsy

Factors determining treatment:

Cancer Grade- how aggressive is it?Cancer Stage- has it spread beyond the

prostatePSA levelGeneral health issuesPatient views

Gleason Score: Pathologist determines from recognised patterns the aggressiveness of the disease

Gleason score: 6-10 Gleason 6: favourable Gleason 10: highly aggresive

Has the cancer extended outside of the prostate?

Rectal examination findings

X raysMRI pelvisbone scanchest xray

Localised prostate cancerProstate removal (radical prostatectomy)Radiation Treatment-external beam radiation-brachytherapy (radioactive seed implantation)

Advanced prostate cancerAndrogen deprivation treatmentChemotherapyRadiation/palliative measures

Open surgery, Laparoscopic surgery, Robotic surgery

Works well if cancer confined within the prostate

Long term adverse effectsincontinenceimpotence

Long duration of treatment: 6-8 weeks after planning

Limited resource available Long term adverse effectsoveractive bladder/bowel symptoms

Minimally invasive treatment Suitable for early and low grade prostate

cancer Not satisfactory for large prostates Overnight stay/return to full function quickly Long term data: ? Better outcome than

surgery Long term adverse effectsbladder obstruction/overactive bladder

symptoms

>75% long term disease free survival with treatment.

Probably similar outcomes for surgery and radiation treatment

Huggins C, Hodges CV: The effect of estrogen and of androgen injection on serum phosphatases in metastatic carcinoma of the prostate. Cancer Res 1941;1:293–297.

Charles Huggins (Nobel 1966)“Discovery is our business”

Hormone deprivation (androgen deprivation) treatment

Can be facilitated by drugs or removal of both testis- adverse effects of hormone loss

Eventual “escape” of disease in most patients

Not curative Taxol based chemotherapy offers some

hope Palliative measures available eg radiation

NZ: 3000 new cases diagnosed a year: 600 deaths/year

Dramatic rise in incidence since use of PSA testing

The use of PSA as a screening test remains controversial

Effective treatment for early prostate cancer is available

Advanced prostate cancer is not curable