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Updates in the Evaluation and Management of Localized Prostate Cancer

Explore the evolution in prostate cancer evaluation methods, controversies in screening, novel genetic tests, mpMRI utilization, and various treatment options such as active surveillance, radical prostatectomy, and radiation therapy.

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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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