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Newly-Diagnosed Prostate Cancer

Newly-Diagnosed Prostate Cancer. Mark Scholz MD Prostate Oncology Specialists. The PSA Net. Types of Things We Find in the PSA Net. BPH Recent sexual activity Lab errors Prostate infections High-Grade prostate cancer Low-Grade prostate cancer. 1977. 1979. 1981. 1985. 1987. 1991.

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Newly-Diagnosed Prostate Cancer

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  1. Newly-Diagnosed Prostate Cancer Mark Scholz MD Prostate Oncology Specialists

  2. The PSA Net

  3. Types of Things We Find in the PSA Net • BPH • Recent sexual activity • Lab errors • Prostate infections • High-Grade prostate cancer • Low-Grade prostate cancer

  4. 1977 1979 1981 1985 1987 1991 1993 1997 1999 2001 1975 1983 1989 1995 Annual Age-Adjusted Cancer Incidence Rates Among Males for Selected Cancers, 1975-2002 260 PSA Testing Started 1987 240 220 200 180 Prostate 160 140 Rate per 100,000 Population 120 100 Lung and Bronchus 80 Colon and Rectum 60 40 Urinary Bladder Non-Hodgkin Lymphoma 20 Melanoma of the Skin 0 2002 Year of Diagnosis Adapted from Jemal A, et al. CA Cancer J Clin. 2006;56:106-130.

  5. Epidemic Prostate “Cancer” • Prior to PSA (1987) 1 of 41 men died of PC (2.4%) • In 2009, with screening and early treatment, the risk of dying from PC is 1 of 53 (1.9%) • However: • 200,000 diagnosed annually instead of 90,000 • 1.5 million men are biopsied annually • The lifetime risk of biopsy is 1 out of 2

  6. “Six-Core” Biopsy of 3000 Men Age 55-75 with Normal PSA PSA LevelCancer Diagnosis Rate 1 – 2 17% 2 – 3 24% 3 – 4 27%

  7. radical prostatectomy specimen transition zone prostate cancer urethra peripheral zone

  8. Prostate Biopsy Points of needle entry Posterior View Prostate

  9. Tests to Detect Prostate Cancer • PSA blood test • PCA-3 urine test • Digital rectal examination • Ultrasound and MRI scans

  10. “Risk of Biopsy-Detectable Prostate Cancer” • Age 55 • BMI (are you fat?) 22.5 • Race Not African American • PSA2.0 • Rectal exam normal • PCA-3 not done Risk of any prostate Cancer = 23% Risk of High-Grade prostate cancer = 2.5%

  11. Prostate Cancer Types • Growth rate • Ability to spread

  12. “Gleason” Grading of Prostate Cancer • Low grade (3) • Higher Grade (4) • Highest Grade (5) • Score = “Adding Up” two grades

  13. Staging

  14. Risk Status • Low = Monitor • Intermediate = Seeds, Surgery or IMRT • High-Risk= IMRT with Hormone Blockade

  15. Treatment Selection Flow Chart Active Surveillance Low-Risk Seeds or IMRT or Cryotherapy or Surgery or Hormones or Active Surveillance or IMRT plus Short-Term Hormones Determine Disease Risk Intermediate High-Risk Long-Term Hormones plus IMRT plus Seeds

  16. 10-Year Survival by Risk Category Low More than 100% Brenner: Journal of Clinical Oncology 2005 Intermediate With treatment 98% Mayo Clinic Journal of Urology 2008 High Surgery 95% Mayo Clinic Journal of Urology 2008 Very High Early Hormone blockade: 87% Late Hormone blockade: 59% Messing: New England Journal Medicine 1999

  17. Prostate Snatchers

  18. The Prostate is “Built In”

  19. Collateral Damage Loss of Sexual and Urinary Function

  20. Impotence Five Years after Surgery: 1288 MenDavid Penson Journal of Urology 2005 • Incapable of an erection adequate for intercourse with Viagra Age < 54 39% 55-59 51% 60-64 56% > 65 82%

  21. Urinary Continence

  22. “Optimal Surgical Competency Requires a minimum of 250 Practice Cases” • In the New York during the whole of the years in 2005: • 25% of the urologists did a single radical prostectomy • 80% of the urologists did <10 cases Savage & Vickers, Memorial Sloan Kettering Journal of Urology December 2009

  23. Radiation

  24. Implant Procedure

  25. Implant Procedure

  26. X-Ray of Seed Implant

  27. Robotic Prostatectomy • Computer enhanced • Surgeon operates at the console within a 3D view • Bedside surgical assistant is next to the patient • Instruments move like a human wrist (↑ dexterity and precision)

  28. The Surgeon Directs The Instruments • The surgeon’s hands are placed in special devices that direct the instrument movement

  29. Robotic Prostatectomy: Difference little, tiny scars Big, Ugly Scar Standard Surgery Robotic Surgery

  30. Robotic vs. Standard Prostatectomy in 2700 Patients • Good: • Shorter hospital stays (1.4 vs. 4.4 days) • Slightly less complications (30 vs. 36%) • Not so Good: • Higher likelihood of needing salvage radiation therapy (28 vs 9%) • More urethral strictures (40% more likely) Hu, Jim et al. Journal of Clinical Oncology, May 2008

  31. Cure Rates: Surgery vs. Seeds 15,000 studies reviewed Expert panel determined inclusion criteria 603 studies met criteria

  32. Criteria for the Study Inclusion • Patients divided into low, intermediate & high-risk groups • Standardized PSA endpoints such as ASTRO, Phoenix, and PSA < 0.2 (surgery)

  33. Intermediate Risk: Percentage Progression Free % Progression Free 1 Brachy 24 40 15 8 23 2 17 37 12 22 Surgery 4 40 16 36 12 32 34 31 43 8 Years

  34. Side EffectsComparison of: Surgery, Brachytherapy and Beam Radiation Talcott, Journal of Clinical Oncology, 2003

  35. Quality of Life Prospective study at MGH and Harvard Questionnaire prior, 3, 12, 24, 36 mo. post Rx. 522 pts treated with, IMRT, Surgery or Average age: Surgery patients younger than Brachytherapy patients, who were younger than IMRT patients

  36. Urinary Obstruction/Irritation (Higher score = worse function)

  37. Incontinence (Higher score = worse function)

  38. Bowel Problems (Higher score = worse function)

  39. Sexual Dysfunction (Higher score = worse function)

  40. Health Related Quality Of LifeValidated Instrument Studies ~ 4230 patients in 7 studies comparing surgery, IMRT and brachytherapy: Davis JW, et al. J Urol. 2001;166:947-952 Wei JT, et al. J Clin Oncol. 2002;20:557-566 Lee WR, et al. IJROBP. 2001;51:614-623 Talcott JA et al. JCO 2003; 21(21): 3979 Miller DC et al. JCO 2005; 23 (12):2772 Frank SJ et al. J Urol 2007; 177: 2151 Sanda MG et al. NEJM 2008; 358(12):1250

  41. Summary Treatment Side Effectsof the Seven Studies Seed implants result in: less incontinence than surgery more urinary symptoms like urgency or frequency Better potency than surgery

  42. Risks for Men with Low-Risk Prostate Cancer • Unskillful or unnecessary therapy • Inaccurate staging “Either this is the wrong chart or —lets just hope this is the wrong chart”

  43. 77777777777777 777777 “Because of your age, I’m going to recommend doing nothing.”

  44. Active Surveillance = Watchful Waiting

  45. Surgery Vs. “Watching”Bill-Axelson, New England Journal Medicine • Randomized prospective trial 695 men • Mean PSA 12.8 • 75% stage B (palpable nodule) • 25% Gleason 7 (6% with Gleason >8) • Cancer detected by DRE, not PSA

  46. Bill-Axelson: 10-Year Results

  47. Benefit of Surgery Compared to Doing Nothing at All • Intermediate risk or High Risk disease • “Watching” not Active Surveillance • No early treatment for a rising PSA 20 men operated to save 1 life 10 years later =

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