Diagnosis of prostate cancer

1. Diagnosis of prostate cancer

2. Biopsy is required to diagnose prostate cancer

3. Biopsy is required to diagnose prostate cancer Who should be offered a biopsy?

4. Biopsy is required to diagnose prostate cancer Who should be offered a biopsy? 1. any man suspected of having prostate cancer and 2. he would benefit from treatment of the prostate cancer

5. Who would benefit from treatment? Most men with prostate cancer would not be bothered by the cancer and therefore would not require any treatment Autopsy study – men over 50 years 30% and men over 80 years 70% Diagnosis of prostate cancer 17% (1 in 6) Mortality from prostate cancer 3%

6. Prostate cancer has a slow growth rate measured in years

7. DRE Normal low risk Firm moderate risk (30%) Hard/nodular high risk (80%)

8. PSA Glycoprotein produced only by prostate cells High levels in seminal fluid and its function is to liquify the seminal fluid

9. Causes for elevated serum PSA BPH most common cause for PSA levels up to 10ng/ml Prostate cancer increased risk with rising PSA Inflammation can have high levels, return to normal after treatment. May be the cause of fluctuating PSA

10. What is the normal level for PSA? There is no normal level for PSA The higher the PSA the greater the risk that it is due to prostate cancer

11. %CaP PSA 100 4

12. Limitations of PSA Most men with PSA below 10 have BPH A man can have significant high grade prostate cancer with a low PSA PSA can fluctuate Patients ability to understand PSA

13. Concerns with PSA Testing As tumors detected become smaller, the “noise-to-signal ratio” (BPH/prostatitis-to-cancer) increases, and PSA performs less well Limited specificity with consequent unnecessary biopsies Many men with elevated PSA and negative biopsies High prevalence of life-long repetitive testing Costs of repeated PSA and biopsy

14. Baseline PSA at age 40 – 45 years

15. Probability of prostate cancer using DRE and PSA With repeat biopsy the incidence of prostate cancer is about 30%

16. Who should have a biopsy? Risk assessment What is the probability that the man may have significant prostate cancer?

17. How do we identify men who may have prostate cancer? Risk assessment DRE PSA including age specific, ratio, velocity, density Family history Age Previous biopsy

18. Who should have a biopsy?Risk assessment 62 year old man 82 year old man DRE - moderately enlarged, benign feeling PSA - 8.2ng/ml Family history – father No previous biopsy No significant comorbidities Probability of prostate cancer Probability of mortality DRE - moderately enlarged, benign feeling PSA - 8.2ng/ml Family history – father No previous biopsy No significant comorbidities

19. 2 men aged 62 year with prostate cancer risk of 30% Man 1 Man 2 Wants a biopsy His personal priority is to avoid the morbidity and mortality of the prostate cancer Who is right? Both are Decides not to have a biopsy He has different priorities, the treatment side effects may concern him Follow up with PSA and DRE and over time the risk assessment may either increase or decrease

20. If he decides to have a biopsy If the biopsy is positive Transrectal ultrasound guided biopsy (TRUS) LA or sedation/GA Risk of sepsis 3% 10 – 14 cores Extent of tumour – length of core and number of cores Grade of tumour – Gleason score Location of the tumour

21. Concerns about a positive biopsy Overdetection finding insignificant tumours which probably do not require treatment Overtreatment giving unnecessary treatment resulting in side effects

22. Because of concerns about overdetection and subsequent overtreatment Active surveillance Offered to men with low volume, Gleason score of 6 or lower Insignificant tumour – may never need aggressive treatment Significant tumour – delay aggressive treatment and the side effects until a later day

23. Active surveillance First step is to repeat the biopsy and confirm the findings – 30% are upgraded Program involves PSA and DRE every 6 months Repeat biopsy at about 12 months then every 3 years or whenever there is concern about the PSA or DRE findings

24. Active Surveillance - Current Trigger Points Patient anxiety from living with untreated cancer Rising PSA level Repeat biopsy results that suggest greater tumor volume or Gleason grade

25. Progression in Patients on Active Surveillance In most studies 25-50% of patients develop evidence of progression within 5 years The percentage of patients with curable cancer at the time of progression has been reported to be 33% to 92% Patel MI, J Urol, 2004.171, 1520; Neulander EZ et al BJU Int, 2000. 85: 699.

26. Active surveillance in Toronto >200 patients followed for up to 10 years About 60% remained on active monitoring But, of patients who underwent radical prostatectomy for progression, - The tumor was organ confined in only 42% - 58% had tumor extension beyond the prostate, and 8% had lymph node metastases Klotz L, UrolOncol 24: 46, 2006

27. DRE abnormal/PSA low for age (consider possible causes: prostate Ca, BPH, infection, trauma, etc) • PSA high for age, or • DRE abnormal and PSA high Both tests are low/not suspicious Return regularly for PSA and DRE Counsel patient regarding both risks and benefits of biopsy Biopsy not done Biopsy done, extended, local anaesthesia Biopsy negative Biopsy positive Active surveillance or Treatment Management discussion and risk management PSA and DRE

28. Candidate for Early Detection Testing Baseline PSA age 40 years with anticipated lifespan of 10 or more years What should be offered? PSA and Digital rectal examination (DRE) Family history, race, PSA history, prior biopsy