Utility of PSA and Current Prostate Cancer Diagnosis ... · Utility of PSA and Current Prostate...
Transcript of Utility of PSA and Current Prostate Cancer Diagnosis ... · Utility of PSA and Current Prostate...
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Utility of PSA and Current
Prostate Cancer Diagnosis &
TreatmentDaniel J Lewinshtein, MD
Chief, Urologic Surgery, CH Pierre Boucher
Assistant Clinical Professor
University of Sherbrooke
November 2018
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Disclosure
Sanofi
Astellas
Abvie
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Objectives
Brief overview of the prostate and PSA
When to use PSA
MRI and other predictive tools
TRUS And MRI-fusion Biopsy
Active Surveillance
Treatment of local disease
Treatment of metastatic disease
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Where is it?
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Prostate Cancer: Epidemiology
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Do you Screen?
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PSA: Overdiagnosis and Overtreatment
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PSA: The Molecule
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PSA: Decreased Mortality
Oncology lancet9:445
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USPTF: 2012
Dan Lewinshtein 2014
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Since USPTF: Metastatic disease
JAMA Oncology 3:705
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Since USPTF: BX and RRP
JAMA Surgery 152:192
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N=20 0001
3% contamination
14 yrs FU
Bx if PSA> 3.5
NNT=12 (NNT for Breast CA=20)
1:Lancet Oncol 11:725 (2010)2:NEMJ 363:1203 (2010)
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Goteborg: Mortality
44%
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PLCO: USA
N=76 000
52% contamination
9 yrs FU
BX if PSA> 4.0
No difference overall
• <65 ans: 44% PC mortalité et NNT 5
1:NEMJ 360:1320
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ERSPC: Europe
N=162 0001
15% contamination
14 yr FU
Bx if PSA>3.0
NNT=48
40% M+
1:NEMJ 360:1320
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ERSPC: Mortality
20%
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Van der Kwast, T. H. & Roobol, M. J. (2017) Draft USPSTF 2017 recommendation on PSA testing — a sea-change?
Nat. Rev. Urol. doi:10.1038/nrurol.2017.89
USPTF 2017 : longer follow-up of ERSPC =
Improved PSA utility
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2017 PSA Recommendations
CUA
• PSA to those with >10yr
• 50-70 yr
• 45yr if Black, Family Hx
USPTF: grade C for 55-69 (2017)
CTFPHC: no
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Life Expectancy: Pt dependant
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When not to order PSA!
Retention
UTI
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When to Send to URO?
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Detection: DRE
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PCPT
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MRI: Pre BX utility
-T2W and DWI
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MRI
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MRI Accuracy
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MRI if suspicion for PC after first BX
Wait 8 weeks!
Targeted BX if PIRADS 3-5
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Trans-Rectal Biopsy
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Biopsy Strategy
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Gleason 3,4,5
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MRI Fusion Rationale
Target lesion specifically
Identify Gl7
avoid Gl6
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MRI Fusion Bx
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Thoughts on Treatment for Local
Disease?
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Therapie Standard
Radiation
surgery
• Open
• Lap
• Robot
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UofT & Klotz:
Active Surveillance (AS)
Gleason 61
-
• Risk of progression
+
• Avoid ED et incontinence
cost
1:JCO 28:126
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Klotz: AS failure
40%
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Klotz AS: Cancer specific Survival
Dan Lewinshtein 2014
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PIVOT: RRP vs. AS
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PIVOT: RRP vs. AS
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Pivot:Sub Analysis
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Radical Prostatectomy: Anatomy
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Radical Prostatectomy: LND
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Radical Prostatectomy: Urethra Length
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Radical Prostatectomy: Nerve Sparing
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Robotic Prostatectomy
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Robot:Usage
J UROL 187:2087
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Robot: Results Peri-op?
JAMA 302:1557
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Robot: BCR
JAMA 302:1557
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Robot: Functional Results
JAMA 302:1557
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Radiotherapy
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JNCI 105:711
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Metastatic Disease?
Mets to death 6 yr
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Hormones
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Firmagon: LHRH Receptor
Blocker
x
x
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Firmagon: Rapid Testosterone block
BJU 102:1531
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Bone Protection
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Superscan
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Pathologic Fracture &
Spinal Compression
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Denosumab: Bone Protection
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Hormone Refractory Disease (CRPC)
Chemotherapy
Dan Lewinshtein 2014
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Chemotherapy: Docetaxel
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Abiraterone: 10X ketoconazole
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Abiraterone: mechanism
Hypokalemia HypertensionFluid overload
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Abiraterone in CRPC post-docetaxel
HR = 0.646 (0.54-0.77) P < 0.0001
Placebo: 10.9 months (95%CI: 10.2, 12.0)
0 100
200
300
400
500
600
700
0
20
40
60
80
100
Su
rviv
al
(%
)
Days from Randomization
Abiraterone acetate: 14.8 months (95%CI: 14.1, 15.4)
De Bono et al , ESMO 2010 Dan Lewinshtein 2014
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Enzalutamide
Dan Lewinshtein 2012
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Enzalutamide: Progression Free Survival
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