A/Prof Nathan Lawrentschuk PhD, MB BS, FRACS (Urol) Urological Surgeon & Urologic Oncologist

1. Prostate Cancer: Active Surveillance A/Prof Nathan Lawrentschuk PhD, MB BS, FRACS (Urol) Urological Surgeon & Urologic Oncologist University of Melbourne, Department of Surgery Austin Hospital & Ludwig Institute for Cancer Research Austin Hospital, Urology Unit Peter MacCallum Cancer Institute, Surgical Oncology Department @lawrentschuk

2. The Debate Continues.. U.S. Preventative Services Task Force… also said Breast Ca Screening should not occur

3. Grading of Prostate Ca • Gleason Score X/10 • 2 most predominant grades added together • 6/10= Low Grade (3+3) • 7/10= Intermediate Grade (3+4 or 4+3) • 8-10/10= High Grade(4+5 or 5+4 or or 5+5)

5. = Cancer

6. = Cancer

7. = Cancer

8. PCa Confusion reigns? A RCT showing BENEFIT of screening Possible overdetection….but mitigated by Active surveillance of low risk tumours Learned Bodies saying Yes, No, Maybe to PSA testing BUT I Have cancer- don’t I NEED Treatment?

9. No PSA CARAVANS SOON… • Men are not the best at deciding to approach medical care • We need to set up the possibility of SURVEILLANCE prior to biopsy

10. TRAFFIC-LIGHT THEORY There are 3 possible outcomes of your biopsy Use of age dependent reference values. • 1) Green- BPH, inflammation orlow grade tumour which wewatch like men with bowel polyps • 2) Amber- Intermediate grade think about and often treat • 2) Red- bad cancer that definitely needs treatment

11. Overtreatment…..

12. Individualised treatment • Birds: Will grow rapidly and “fly out” of the barnyard i.e. metastasise • Turtles: Grow slowly and rarely leave the yard i.e unlikley to metastasize • Rabbits: In between

13. 26th April 2011

14. Low Grade, Low Volume • Low volume, low grade and slow growing tumours (turtles) • Watch them….we did so successfully in men over 75yo so why not younger men? • Many advantages…

15. Patient Selection = Cancer

16. Surveillance “Active” • Check PSA (3-6 monthly) • Check DRE (6 monthly) • Re-biopsy (early then 1-2 yearly) • Monitor for anxiety

18. Benefits of Surveillance • Reduced morbidity and improved QOL • Less anxiety “just like a bowel polyp” • Lower costs so focus on more life threatening cancers

19. Risks of surveillance • Anxiety if frightened of progression (small number) • Progression and mortality • Updated Toronto data 850 men suggests very unlikely after 15 years

21. Triggers for Radical Treatment • Progression of Gleason Score on repeat biopsy • Progression of Volume of Prostate cancer (% and/or No. Cores) • PSA rising continually • Change in DRE findings • (Change in MRI findings) • Patient Anxiety

24. PIVOT STUDYNEJM 2012 Wilt et al • RANDOMISED TRIAL 800 men • Surgery did not reduce mortality more than observation in men with low PSA or low-risk prostate cancer • THIS SUPPORTS SURVEILLANCE for such men • The trial results “suggest a benefit from surgery in men with higher PSA or higher risk disease.”

25. World Literature –Best Practice • Active surveillance now an accepted strategy to manage men with LOW RISK PCa • BENEFITS of Surveillance: preservation of sexual function and continence • Largest risk of surveillance is progression- triggers to do radical treatment assisted by MRI, Biopsy and PSA

26. MR in Active Surveillance • 22% reclassified (only 3% negative MR) • 18% no longer fulfilled AS criteria • Able to alter Mx based on re-biopsy targeting In these patients Thompson et al BJUI, In Press

27. Prostatic Evasive Anterior Tumour Syndrome (“PEATS”)

28. Transperineal Biopsy • The new kid on the block

30. World Literature –Best Practice • Appropriate SELECTION criteria and TRIGGERS for radical treatment • Protocols are evolving but AUSTRALIA is at the forefront, particularly here in Melbourne intervention are CRITICAL

31. Thank You A/Prof Nathan Lawrentschuk PhD, MB BS, FRACS (Urol) Urological Surgeon & Urologic Oncologist University of Melbourne, Department of Surgery Austin Hospital & Ludwig Institute for Cancer Research Austin Hospital , Urology Unit