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Updates in the Evaluation and Management of Localized Prostate Cancer

Updates in the Evaluation and Management of Localized Prostate Cancer. Adam Oppenheim, D.O. January 26 th , 2019. Case example – 20 years ago. 66 male w/ elevated PSA (5.2) TRUS Bx: no evidence of malignancy 6 months later  PSA 5.6 Repeat Bx: no evidence of malignancy

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Updates in the Evaluation and Management of Localized Prostate Cancer

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  1. Updates in the Evaluation and Management of Localized Prostate Cancer Adam Oppenheim, D.O. January 26th, 2019

  2. Case example – 20 years ago • 66 male w/ elevated PSA (5.2) • TRUS Bx: no evidence of malignancy • 6 months later PSA 5.6 • Repeat Bx: no evidence of malignancy • Hospital admission for urosepsis

  3. Case example – 20 years ago • 6 months later PSA 6.2 • 3rd TRUS Bx: 2 cores positive for GS 3+3 adenoca • CTAP and bone scan negative • Elects for surgery

  4. Open Prostatectomy

  5. Case example – 20 years ago • Open radical prostatectomy • Blood transfusion • Anastomotic stricture • Stress urinary incontinence • ED

  6. Case example – 20 years ago • Radiation? • ED • Radiation cystitis • Proctitis

  7. ?

  8. Case example – 20 years ago • Risk vs benefit?? • $$$$$$ • USPSTF 2012 don’t screen

  9. Background • Prostate Cancer (PCa) is common • In the U.S. • ~165,000 new cases/year in U.S. • ~29,000 deaths/year in U.S. Siegel, R et al. CA Cancer J Clin, 2018

  10. Prostate Cancer • #1 MC cancer and #2 cancer killer in men

  11. PCa: Risk Factors • Age • Ethnicity • AA 1.6x more likely to have disease • AA 2.2x more likely to die of disease • Family history • Father 2x more likely • Brother 4x more likely • Father and brother 8x more likely

  12. PCa: Screening • Elevated PSA PCa, infection, inflammation, BPH, instrumentation, foley catheter • Recent controversies

  13. USPSTF - 2012

  14. “PLCO” – 2009 NEJM • 1993-2001 76,693 men randomized • Screening vs “usual care” • 7-10 years f/u: 50 vs 44 deaths from PCa (no difference)

  15. Control group reported rate of testing limited to men who responded that they were tested within the previous one year

  16. “Usual care”  ~90% of patients were screened …? Shoag, et al. NEJM 2016

  17. “ERSPC” – NEJM 2009 • 182,000 men: screening vs control • RR for PCa death • 0.85 0.78 0.79 • 9 yrs 11 yrs 13 yrs

  18. : To prevent one death from Pca: Screen 781 men Diagnose and treat 27

  19. 2018 – JAMA • 415,357 randomized to single PSA vs none • 50-69 years old • 10 years f/u more cancer in intervention arm but cancer mortality and survival – no difference

  20. Screening group: only 34% had valid PSA result • 85% of those with elevated PSA had TRUS Bx • ?? How many were treated

  21. Screening: AUA Guidelines • Age 40-54: no routine screening • ***does not apply to high-risk pts • Age 55-69: shared-decision making • Age 70+: against routine screening (or anyone life expectancy <10-15 yrs)

  22. Screening - USPSTF 2018

  23. PCA3 PHI 4Kscore Promark Apifny ARV7 Novel Genetic Tests • ConfirmDx • OncotypeDx • Prolaris • Decipher • BRCA 1/2

  24. Genetic Tests • To biopsy or not? • Negative Biopsy repeat or stop? • Prostatectomy enough or further treatment?

  25. Novel Tests - PCA3 • screening adjunct • urine voided after DRE

  26. Novel Tests - 4K Score • identify aggressive cancer • blood test - pre-biopsy

  27. Novel Tests - ConfirmDx • Elevated PSA but negative Bx- repeat? • Genetic test of prostate tissue from Bx

  28. Novel Tests - Decipher • Genetic test of post-RP specimen • chance of 5 year clinical mets

  29. New Age - Genetic Tests • Decrease number of unnecessary biopsies • Improve ability to identify aggressive disease • none are perfect

  30. PCa - Game Changer • Multi-parametric MRI of prostate (mpMRI) • multiple uses • highly accurate • no risk of PNBx urosepsis

  31. mpMRI • 1) T2W • 2) DCE • 3) DWI Sidhu, Et al. “Textural analysis of multiparametric MRI detects transition zone prostate cancer”. 2017. European Radiology

  32. PIRADS – Prostate Imaging Reporting and Data System

  33. mpMRI - but wait, there’s more • UroNav - uses mpMRI images to target the worrisome lesion on TRUS Bx “Rastinehad Fusion Guided Prostate Biopsy UroNav” 2015

  34. Lancet, 2017 • 576 men underwent mpMRI • PSA up to 15 ng/mL • TRUS vs TMP (MRI templated) biopsies

  35. Avoid 27% of Bx’s • 5% less dx of insignificant cancers • mpMRI highly sensitive (93%) compared to TRUS Bx

  36. Urology, 2017 • 670 men underwent mpMRI + TRUS Bx • 100 men negative mpMRI • only 3 men with Gleason 7 PCa

  37. New Grading System • Gleason </= 6 Group 1 • Gleason 3+4 Group 2 • Gleason 4+3 Group 3 • Gleason 8 Group 4 • Gleason 9-10 Group 5

  38. Management of Local Disease • Active Surveillance (AS) • Radical Prostatectomy (RP) • External Beam Radiation (XRT) • Brachytherapy (seeds) • ADT • Watchful Waiting

  39. Active Surveillance • **Patient Selection • low PSA, low Gleason score • PSA, DRE ~q 3 months x 1 year then q 6 months • Repeat Biopsy at 1 year, 3,6,9,12 • mpMRI • Treatment if: rapidly increasing PSA, biopsy concerning

  40. Active Surveillance • SAFE

  41. PROTECT Trial

  42. AS 545 men • XRT 545 men • RP 553 men • 10 years follow-up: no difference in CSS, 99%

  43. 993 patients, Toronto • 267 patients treated • 28 pts with metastatic disease • 15 deaths from PCa

  44. 98% 10 year CSS • 94% 15 year CSS

  45. Radical Prostatectomy • Davinci Robot • Pelvic lymphadenectomy • MC post-op course: • LOS overnight • Foley catheter x 1 week

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