PSA & Prostate Cancer
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PSA & PROSTATE CANCER Dan Burke Consultant Urological Surgeon Uro-Oncology & Complex Laparoscopic Surgery
description
PSA & Prostate Cancer. Dan Burke Consultant Urological Surgeon Uro-Oncology & Complex Laparoscopic Surgery. Incidence of Prostate Cancer. 2008 37 051 new cases in UK 10 168 deaths from Ca Prostate 101 men diagnosed every day One new diagnosis every 15 minutes - PowerPoint PPT Presentation
Transcript of PSA & Prostate Cancer
PSA & PROSTATE CANCER
Dan Burke Consultant Urological Surgeon
Uro-Oncology & Complex Laparoscopic Surgery
Incidence of Prostate Cancer
2008
37 051 new cases in UK
10 168 deaths from Ca Prostate
101 men diagnosed every day
One new diagnosis every 15 minutes
Accounts for 3% of male mortality
Incidence
0 10,000 20,000 30,000 40,000
Other cancersBone and connective tissue
Uterus Oral
Malignant melanomaMesothelioma
Multiple myelomaLiver
Brain with central nervous systemKidney
All leukaemiasOvary
Non-Hodgkin lymphomaBladder
StomachOesophagus
PancreasProstate
BreastColorectal
Lung
Number of deaths
MalesFemales
Figure 1.1: The 20 most common causes of death from cancer, UK, 2008
Age at diagnosis
0
2,000
4,000
6,000
8,0000
to 0
4
05 to
09
10 to
14
15 to
19
20 to
24
25 to
29
30 to
34
35 to
39
40 to
44
45 to
49
50 to
54
55 to
59
60 to
64
65 to
69
70 to
74
75 to
79
80 to
84
85+
Age at diagnosis
Num
ber o
f cas
es
0.0
200.0
400.0
600.0
800.0
Male Cases Male Rates
Rate per 100,000 males
PSA
PSA – relative risk
Age related <50 ?? 50-60<2.5 60-70<3.5 70-80<6.0 0ver 80 – abnormal DRE
2 raised readings - beware UTI’s, LUTS(acute), big prostates
PSA Velocity >0.75 / year
Low readings <0.7 Reassurance
PSA velocity / density >0.75 per year Doubling time Patterns over time (fluctuating PSA’s with
large prostates) Accept higher PSA levels with larger
prostates – but obtain a predicted PSA with TRUSS
Changes of PSA with dutasteride / finasteride
Same man different PSAPSA Chances of
detecting a cancer
Chances of detecting a high grade
cancer
0.9 13.2%
1%
12 57.8%
22.1%
Same man different history
Chances of detecting a
cancer
Chances of detecting a high grade
cancerAbnormal DRE & FHPSA 3.2
59% 12.3Abnormal DRE & FH
PSA 12>75%
cMarch 2009
Prostate cancer screening could see every man over
50 tested
All men over the age of 50 could be tested for prostate cancer after the largest international study ever conducted
suggested that screening could save thousands of lives a year in Britain.
The Evidence
Screening and Prostate-Cancer Mortality in a Randomized European StudyPublished at www.nejm.org March 18, 2009 (10.1056/NEJMoa0810084)
182,000 men
Mortality Results from a Randomized Prostate-Cancer Screening TrialPublished at www.nejm.org March 18, 2009 (10.1056/NEJMoa0810696)
76,693 men
The Facts820 / 10,000
Carcinoma of the Prostate diagnosed in screened arm
vs
480 / 10,000Carcinoma of the Prostate diagnosed in control arm
The Facts227/10,000
radical prostatectomies performed in screened arm
Vs
100/10,000 in control arm
214 / 10,000Deaths due to prostate cancer
(Screened arm)
Vs
326 / 10,000Deaths due to prostate cancer
(unscreened arm)
The Facts
1410 people screened
48 treated
1life saved
Over a 10 year period
The conclusion!European Study – Screening has its placeBased on improved rate of cancer deaths
American Study – No role for screening Risk of over treating too many for a small
gain
BUT NEITHER STUDY WAS CONCLUSIVE
Who to screen – risk factors for clinically significant prostate cancer
Afro-Caribbean men – 3x and diagnosed younger
1st degree relative diagnosed at a young age – 3x increase risk
Strong family history – 5x increase risk
The concerned informed [email protected]
The HSC205 referral ?early prostate CAYES NO
Young men
Family history
Afro-caribean
rising PSA
Age related PSA
Symptomatic / advanced CaP
<10year life expectancy
Over 80 with normal DRE
Raised PSA with UTI
0
5
10
15
20
25
30
50 55 60 65 70 75 80 85 90 95 100Current age
Average life expectancy in years
NEW TREATMENT FOR PROSTATE CANCER GIVES 'PERFECT RESULTS' FOR NINE IN TEN MEN: RESEARCH
10:00PM BST 16 APR 2012
A study has found that focal HIFU, high-intensity focused ultrasound, provides the 'perfect' outcome of no major
side effects and free of cancer 12 months after treatment, in nine out of ten cases. Study of 41 patients.
SATURDAY 28 APRIL 2012STUDY RAISES DOUBTS OVER
TREATMENT FOR PROSTATE CANCER
USA study of an older age group average age 67, many low grade disease that would not have been
offered surgery in the UK
Experts shaken by verdict suggesting thousands of men go through painful
treatment for nothing
WHY SURGERY?'Currently, radical prostatectomy is the only treatment for localised prostate cancer that has shown a cancer-specific survival benefit...in a prospective, randomized trial.'
European Association of Urologists Guidelines on Prostate Cancer, 2008.
MANCHESTER ROYAL INFIRMARY SURGEONS FIRST TO USE 3D
2 APRIL 2012
Surgeons at Manchester Royal Infirmary claim to be the first in the UK to use a full 3D projection during an operation.
During the operation, a high definition screen carried a 3D image of a hand-held robotic arm developed to carry out intricate surgical techniques
Aberatirone
Mean survival 3 months Cost approx £3000 for 30 days NICE approved 1g a day single dose 4x250mg tablets
Should we be concerned?
Prostate Cancer patients have a worse experience of care including after care than other cancer patients
Department of Health - 2005
Nice guidelines 2008
Post Radical Treatment
PSA at the earliest 6 weeks post treatment
PSA at least every 6 months for the next 2 years
PSA then at least once a year thereafter
Nice guidelines 2008After 2 years
Stable PSA and no complications then follow upshould be offered outside the hospital
Telephone follow up
Primary care
Electronic communications
Nice guidelines 2008
DRE
(changed from 2002)Now NOT recommended in men with localisedprostate cancer while PSA remains stable
Warren KS, McFarlane JPJ Urol 2007 Jul:178(1):11-9
Nice guidelines 2008
Follow-up
Watchful waiting
Should normally be followed up in primary care inaccordance with protocols agreed by the local MDT
PSA should be measured at least once a year
Metastatic Patients
NICE
Primary care manage day to day complications
SwedenMore regular PSA testing
CanadaLess regular PSA testing
My Practice
Post Laparoscopic Radical Prostatectomy
8/52 post op PSA & Clinical assessment3/12 for 1 year6/12 for 1-2 yearsDischarged to Primary Care
Exceptions: Gleason 8/9/10 and/or positive margins and/or BCR
My Practice
Active Surveillance
3/12 PSA1 year repeat TRUSS + biopsy6/12 PSA for 2 yearsPrimary care follow up
Exceptions: unstable/fluctuating PSA, Age <65, patientrequest
My Practice
Watchful waiting
3/12 PSA for 1 year6/12 PSA for 1 yearPrimary Care follow up
Exceptions: GP or patient request
My Practice
Metastatic disease
3/12 PSA initially
Symptomatic management
Patient specific follow-up
Communication with Primary Care
Agreed pathways
Avoids ‘double’ tests
Avoids unnecessary re-referrals
Patient copied into communications
Agreements on costings of follow-up / new appointments
PROPOSED PSA PATHWAY CMFT
Post Radical Surgery
2 years post surgeryNo functional problems
PSA Unrecordable
Discharge for primary care follow-up
6 monthly PSA
PSA unrecordable detectable PSA
Continue PSA referral back tertiary care
Post Radical Radiotherapy
2 years post radiotherapy(+/- hormonal treatment)
No functional Problems + PSA Stable
Discharge for primary care follow upWith instructions on length of hormonal treatment
6 monthly PSA
PSA <2.0 + asympotomatic PSA >2.0 or symptomatic
6 monthly PSA Referral to Urologist or Oncologist
Hormonal Treatment
PSA Stable for 2 years or satisfactory PSA responseAsymptomatic
Discharge to primary careIndividual follow-up plan
PSA every 3 / 6 or 12 months as directed
PSA above designated level PSA stable
or patient symptomatic patient asymptomatic Referral back to UrologistContinue PSA follow-up as directed
Active Survaillence
To remain under consultant care
Watchful waiting
PSA stable for 1 yearPatient asymptomatic
Discharge to primary care for follow-up3/6 or 12 monthly PSA as directed at discharge
PSA below recommended level PSA above commended levelPatient asymptomatic or patient symptomatic
Remain under primary care referred back to urologist
And FinallyPSA PATHWAY
NO DIAGNOSIS OF CA PROSTATE
Individual follow up
Patient specific Clear discharge letter
‘THE DEFINITION OF INSANITY IS DOING THE SAME THING OVER AND OVER AND EXPECTING DIFFERENT RESULTS’
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