Prostate Cancer Treatment: What’s Best For You?

1. Prostate Cancer Treatment: What’s Best For You? Rajesh G. Laungani, MD Director, Robotic Urology Chairman, Prostate Cancer Center Saint Joseph’s Hospital, Atlanta Clark Atlanta UniversityCenter for Cancer Research and Therapeutic DevelopmentProstate Cancer SymposiumJuly 17th, 2010

2. 2008 Estimated US Cancer Cases* Men745,180 Women692,000 Prostate 25% Lung and bronchus 15% Colon and rectum 10% Urinary bladder 7% Melanoma of skin 5% Non-Hodgkin 5% lymphoma Kidney 4% Leukemia 3% Oral Cavity 3% Pancreas 3% 26% Breast 14% Lung and bronchus 10% Colon and rectum 6% Uterine corpus 4% Non-Hodgkin lymphoma 4% Melanoma of skin 4% Thyroid 3% Ovary 3% Kidney 3% Leukemia *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, 2008. JEMAL ET AL. CA CANCER J CLIN 2008

3. 2008 Estimated US Cancer Deaths* Men294,120 Women271,530 26% Lung and bronchus 15% Breast 9% Colon and rectum 6% Ovary 6% Pancreas 3% Leukemia 3% Non-Hodgkin lymphoma 3% Uterine corpus 2% Liver & IBD 2% Brain/ONS Lung and bronchus 31% Prostate 10% Colon & rectum 8% Pancreas 6% Leukemia 4% Esophagus 4% Liver and intrahepatic 4%bile duct (IBD) Non-Hodgkin 3% Lymphoma Urinary bladder 3% Kidney 3% ONS=Other nervous system. Source: American Cancer Society, 2005. JEMAL ET AL. CA CANCER J CLIN 2008.

4. Approach To Treatment of Prostate Cancer: A Multidisciplinary & Individualized Approach External Beam Radiation Open Surgery Watchful Waiting Brachytherapy Robotic Surgery

5. Treatment Options for Prostate Cancer • Active Surveillance • Radiation Therapy • External Beam • Brachytherapy aka “seeds” • HDR Therapy • Proton Therapy • Hormonal Therapy • Chemotherapy • Surgery • Robotics • Laparoscopic • Traditional Open • Retropubic • Perineal • Cryosurgery • HIFU

6. “One Size Does NOT Fit All” Age Gleason Grade Stage Co-Morbidities Individual Characteristics

7. What does a positive biopsy mean? 7 8 9 LOW GRADE HIGH GRADE Gleason Grade Gleason 6 Gleason 10

8. Staging • Clinical: • DRE • CT Scan • Bone Scan • MRI • Pathological: • Margins • Lymph nodes • Extracapsular Extension • Seminal Vesical Invasion

10. Robotic Surgery Decreased Pain Shorter Hospital Stay Decreased Blood Loss Quicker Recovery Improved Quality of Life after Surgery

11. Current Trends 36% 63%

12. Robotic Prostatectomy

13. Do Advanced Tools result in Better Outcomes ?

14. Vision and Control

17. How do attributes of robotic surgical systems translate into outcomes? • Operative parameters • Oncologic parameters • Quality of life parameters • Potency & continence

18. Urinary Continence Joseph et al. J Urol 2006 Joseph et al. 2006 N=325 Mean age: 60 Method of Assessment: Questionairre Definition used: No pad Time of assessment: 6 mos Continence Rate: 96%

19. Bilateral Nerve Preservation Technique“The Veil of Aphrodite” Menon et al. Urol Clin of Amer 2004 Menon et al. N=250 Mean age: 59.9 Method of Assessment: Questionairre Definition used: Intercourse Time of Assessment: 6 mos Potency Rate: 64%

20. Oncologic Efficacy Badani et al. Cancer 2007 • Badani et al. • N=2766 • Gleason 7 or >: 64% • Median follow up: 22 mos • PSA recurrence rate: 7.3% • 5 year biochemical free survival: 84%

21. Robotics vs. Open vs. Laparoscopic Parameter RRP LRP daVP Op time (min) 164 248 140 Blood Loss(ml) 900 380 <100 Positive Margins 12% 24% 8% Complications 15% 10% 5% Catheter(d) 15 8 5-7 Hospitalization 3.5 1.3 1.2

22. How do I choose the best surgeon?

23. What questions should I ask? Training? Fellowship? Experience? How many cases have you done? Reputation? Having a robot and knowing how to do robotic surgery are very different things?

24. Steady and Experienced Behind the Wheel

26. Thank You