Prostate cancer in new zealand

1. Prostate cancer in new zealand LADUCA Group CPD

2. Who Develops Prostate Cancer? • Michael Miliken (junk bond wizard) • Arnold Palmer (golf master) • Francois Mitterand (French president) • Charles de Gaulle (vive le Quebec libre) • Ayatollah Komeini (Ayatollah) • Robert Dole (senior politician) • Rudolph Giuliani (mayor NYC) • Rupert Murdoch (media mogul) • Sir Alec Guinness (Obi-Wan Kenobi) • Sidney Poitier (actor) • Sean Connery (007) • Roger Moore (007) • Pierre Elliott Trudeau (Prime Minister) • Andy Grove (Intel corp) • Marv Levy (Buffalo Bills Head Coach) • Preston Manning (politician) • Linus Pauling (Nobel x 2) • Eddie Shack (‘clear the track’) • Charleton Heston (Moses) • Frank Zappa (musician)

3. Prostate Cancer: New Zealand Statistics

4. Prostate Cancer: Not The Only Cause Of Death In Men

5. Prostate Cancer • What/where is the prostate? • Who is at risk? • Diagnosis • How aggressive is the cancer (grading) • How advanced is the cancer (staging) • What are the treatment options for localised and advanced prostate cancer • What is the outlook after treatment

9. Prostate function • Majority of seminal fluid is prostatic in origin: average ejaculate volume= 2-5 mls; only 0.1-0.2 mls = sperm • “Nourishment and support” of sperm in the ejaculate • Provision of income for Urologists!

10. Prostate Cancer Risk Factors • Beyond Your control: • Age • Testosterone • Race • Family history • Lifestyle • Geography • Diet

11. Race and Nationality Mortality Rates Per 100,000

13. Holistic Approaches to Prevention • Low-fat diet • Soy products • tomatoes • Nutritional supplements • Selenium, vitamin E • Lifestyle - exercise, BMI • Herbal preparations

14. Early Diagnosis of Prostate Cancer Digital Rectal Examination (DRE) Diagnostic Triad Prostate Specific Antigen (PSA) Transrectal Ultrasound (TRUS) • symptoms not helpful

15. Prostate Cancer: Diagnosis • Majority diagnosed on PSA (Prostate Specific Antigen) testing with nil symptoms and normal rectal examination • Presentation with urinary symptoms • Abnormal findings on rectal examination • Presentation with symptoms of advanced disease eg bone pain or fracture due to cancer spread to bone • Incidental diagnosis following prostate surgery

18. Prostate Cancer: Urinary symptoms • “Blockage of the bladder”- poor flow, hesitancy, intermittency of flow, urgency retention of urine • “Irritation” of the bladder- frequency day/night, urgency, urge leakage • Kidney obstruction and kidney failure

24. PSA (Prostate Specific Antigen) • Produced by both benign and malignant prostate disease – benign enlargement, prostate infection and prostate cancer • Not elevated by other cancers • ↑ levels with ↑ age: -age scale 40-50 2-2.5 50-60 2.5-3.5 60-70 3.5-5.0 70-80 5.0-7.0

25. Prostate Cancer Screening Controversy The case for screening • The lengthy preclinical detectable phase of prostate cancer allows for early detection • Devastating effects of metastatic prostate cancer • Availability of convenient and inexpensive screening tests (DRE and PSA) • Treatments for early disease

26. Prostate Cancer Screening Controversy The case against screening • Inconsistency in disease progression • High prevalence of asymptomatic disease • Does screening do more harm than good? • No evidence on benefits available from randomized clinical trials • Excess cost, morbidity and mortality from treatments

27. PSA – Current Recommendations • American, Canadian Cancer Society - annual PSA&DRE men >50 (discuss) • AUA, CUA - annual PSA&DRE men >50 (discuss) • CTFPH (GPs), USPSTF - recommend against screening (grade D evidence) • This will not be resolved until results of PLCO and ER-SPC studies (?2009-10)

28. Conclusions – PSA screening • Does PSA screening predict risk of Prostate Cancer? • Yes • Does PSA screening predict clinically significant prostate cancer? • Probably • Does PSA screening improve survival? • Only future studies can prove

29. Prostate Cancer: Prostate Biopsy • Sample of prostate must be taken to confirm diagnosis: prostate biopsy • Day stay local anaesthetic/sedation procedure • Generally 12 cores taken from throughout the prostate • Risks bleeding infection pain retention

33. Prostate Cancer • Diagnosed on prostate biopsy • Factors determining treatment: Cancer Grade- how aggressive is it? Cancer Stage- has it spread beyond the prostate PSA level General health issues Patient views

37. Prostate Cancer Grade • Gleason Score: Pathologist determines from recognised patterns the aggressiveness of the disease • Gleason score: 6-10 • Gleason 6: favourable • Gleason 10: highly aggresive

38. Prostate Cancer: Stage • Has the cancer extended outside of the prostate? Rectal examination findings X rays MRI pelvis bone scan chest xray

40. Prostate Cancer: Treatment options Localised prostate cancer Prostate removal (radical prostatectomy) Radiation Treatment -external beam radiation -brachytherapy (radioactive seed implantation) Advanced prostate cancer Androgen deprivation treatment Chemotherapy Radiation/palliative measures

44. Prostate Cancer: Radical Prostatectomy • Open surgery, Laparoscopic surgery, Robotic surgery • Works well if cancer confined within the prostate • Long term adverse effects incontinence impotence

47. Prostate Cancer: External Beam Radiation Treatment • Long duration of treatment: 6-8 weeks after planning • Limited resource available • Long term adverse effects overactive bladder/bowel symptoms