Main Bldg. Lecture - Eastern Shore Community College

Update on Prostate Cancer
and BPH
Gary Das MS, FRCS, FRCS (Urol)
Lead Cancer Urologist, Croydon University Hospital
Pelvic Cancer Surgeon, St George’s Hospital
Introduction
Function of the prostate
PSA
Prostate Cancer
Incidence
Symptoms
Management
BPH (Benign Prostatic Hypertrophy)
Incidence
Symptoms
Management
What is the prostate?
Walnut sized gland in
pelvis
Prostate produces about
30% of seminal fluid
Nourishes and activates
sperm
PSA
Blood test for protein produced by prostate cells
May be elevated in benign conditions or cancer
May be raised in benign prostatic enlargement,
retention, prostatitis, urological instrumentation,
sexual activity, cycling
Rises with age
Elevated PSA
Not
specific for prostate cancer
Decision
to investigate also depends on
prostate size, digital rectal examination,
general health, patient’s wishes
NICE guidelines
Key priority:
PSA
6630 male volunteers over 50 years old
PSA (ng/ml)
<4
N (%)
5647 (85%)
Cancer / biopsy
4-10
>10
809 (12%)
174 (3%)
143/548 (26%)
73/138 (53%)
J Urol 1994; 151:1287
Prostate
Cancer
Most common male cancer in UK
35,000 new cases / year
10,000 deaths / year
Cancer Research UK
Incidence & mortality rates
Cancer Research UK
Mortality stable since 1990s
Cancer Research UK
Age distribution
Cancer Research UK
UK does favourably compared to
Western World
Cancer Research UK
Patients are surviving longer
Cancer Research UK
Risk factors
Hereditary
Early age onset
Double risk if one first-line relative
Environmental
Risk increases in Japanese men moving to USA
Diet
Good: lycopenes (tomatoes), vitamin
pomegranate, pumpkin seeds
Bad: red meat, dietary fat
Social
Class
E, selenium,
Symptoms
Often
asymptomatic
Lower
Urinary Tract Symptoms
Bone
pain (pelvis / vertebral)
Lower Urinary Tract Symptoms
Sensation of incomplete emptying of bladder
Frequency – urinating every 2 hours or less
Intermittency – stop/start stream
Hesitancy
Urgency – difficult to postpone urination
Nocturia – number of times urinating at night
Weak stream
Straining
Diagnosis
Digital
rectal examination
Nodular
Firm
Loss of median sulcus
PSA
TRUS
and prostate biopsy
TRUS and prostate biopsy
Antibiotic
prophylaxis
Risk
of bleeding, infection and septicaemia (1 in
1000)
Require
hospitalisation if rigors or fever post
procedure
If
first set of biopsies negative 10-35% detection
rate in second set
Detection
biopsies
rate extremely low after three negative
Imaging
MRI of pelvis
Bone scan
Gleason score
Grading
Sum
system
of two most common patterns (grade 1-5)
Most
cancers are 6 or more
Multidisciplinary meeting
To
discuss histology, imaging and management
Urologists,
oncologists, pathologists, radiologists,
specialist nurses
Local
and regional
Recruitment
To
to clinical trials
improve and standardise patient care and
increase patient choice
Treatment
Few
comparative studies between the different
treatments exist
No
randomised trials between radical
prostatectomy and radiotherapy for localised
prostate cancer exist
Treatment
Organ
confined
Men with a
life expectancy of greater than 10-15
years should be treated with curative intent
Active Surveillance
Radical Prostatectomy
External beam radiotherapy
Brachytherapy
Cryotherapy
HIFU
Treatment
Locally advanced
Watchful waiting
Hormones
Radical prostatectomy and radiotherapy / hormones
Radiotherapy and hormones
Metastatic
Hormones
Oestrogens & corticosteroids for hormone refractory
disease
Chemotherapy – docetaxel, mitoxantrone & steroids
Active surveillance
Well-informed
asymptomatic patients with small
volume disease with a low Gleason score
Reduces over-treatment
and morbidity by
selecting out patients with significant cancers
who would benefit from curative treatments
Choo R et al. J Urol 2002; 167: 1664-9
Parker C. BJU Int 2003; 92: 2-3
Active surveillance
Closely
monitor PSA every 3 months
Repeat
prostate biopsies within 2 years
Radical
treatment if PSA progression (doubling
time <2 years, histological progression (primary
Gleason 4 or 5) or clinical progression.
Radical Prostatectomy
Open
Laparoscopic
Robotic
Radical prostatectomy
Similar
oncological and functional outcomes
between techniques
95%
10 year survival
Operative
time
Long-term
data awaited for minimally-invasive
Open Radical Prostatectomy
Complication
Peri-operative death
Major bleeding
Rectal Injury
Severe stress incontinence
Impotence
Urethral stricture
Incidence (%)
European (EAU) Mayday
0-2.1
0.3
1.0-11.5
0-5.4
Rarely transfuse
1
0-15.4
29-100
1
50%
2.0-9.0
EAU Guidelines 2007
External beam radiotherapy
Targeted
conformal beam
Biochemically free from failure (PSA<1ng/ml)
Initial PSA<10
Initial PSA 10-20
Initial PSA >20
75-93% 5 year
60% 5 year
40% 5 year
Zelefsky MJ et al. J Clin Oncol 1998; 16: 3380-5
Pollack A et al. Int J Radiat Oncol Biol Phys 2002; 53:1097-1105
External beam radiotherapy
Toxicity
Cystitis
Incidence (%)
5.3
Haematuria
Urinary Stricture
4.7
7.1
Urinary Incontinence
Overall GU toxicity
5.3
15.9
Proctitis
Chronic diarrhoea
8.2
3.7
Small Bowel Obstruction
Overall GI toxicity
0.5
9.8
Leg oedema
Overall toxicity
1.5
22.8
Potency preservation in up to 50% cases
Late toxicity from EORTC trial 22863
Brachytherapy
Eligibility
criteria
Small prostate
PSA ≤10
Small volume, low grade cancer (Gleason ≤6)
Few LUTS
Permanent
implants
Recurrence-free survival
71-93% (5
year)
65-85% (10 year)
EAU Guidelines 2007
Cryotherapy
Organ-confined
prostate cancer
Volume ≤40ml, PSA<20ng/ml, Gleason <7
Sparse long-term outcome data
Side-effects
Erectile dysfunction 80%
Incontinence 4.4%
Pelvic pain 1.4%
Urinary retention 2%
EAU Guidelines 2007
HIFU
Limited
outcome data
Side-effects
Urinary retention almost 100%
Urinary stress incontinence 12%
Impotence 55-70%
Watchful waiting
Observation
with treatment for symptomatic
progression
Well-informed
asymptomatic patients with
locally advanced disease
Patients
unwilling to accept side effects of active
treatment
Hormones
Surgical
vs. medical castration
LHRH analogues
Desensitise anterior pituitary gland resulting in
cessation of testosterone production
Antiandrogens
Block peripheral testosterone receptors
Maximal androgen
blockade
Continuous vs. intermittent
BPH
Incidence
Benign Prostatic Hyperplasia
50% men aged over 60
Moderate to severe lower urinary tract
symptoms
15-35% men aged over 60
Neal DE et al http://hcna.radcliffe-oxford.com/urinary.html
Lower Urinary Tract Symptoms
Sensation of incomplete emptying of bladder
Frequency – urinating every 2 hours or less
Intermittency – stop/start stream
Hesitancy
Urgency – difficult to postpone urination
Nocturia – number of times urinating at night
Weak stream
Straining
Symptoms
Pain on urinating
May be due to infection
Blood in urine
Always seek urgent medical advice
Investigations
Blood tests
U&Es, PSA
Urine
Dipstick urinalysis
MC&S
Flow tests and post void residual
USS renal tract (possibly)
Flow rates
www.prostateuk.org
Flow rates
www.prostateuk.org
Flow tests
Medical treatment
Alpha blockers
Relax smooth muscle of prostate
Dizziness
Reduction in ejaculate
5 alpha-reductase inhibitors
Block metabolism of testosterone
Cause reduced gland volume and vascularity
Impotence
TURP
Transurethral resection of prostate
Established technique
Resection of prostate tissue
Bleeding
Irrigating catheter
3-4 day hospital stay
Thulium Laser Prostatectomy
Thulium Laser Prostatectomy
2 micron continuous wave
Excellent haemostasis & reduced bleeding
Tissue vapourisation and clean cuts
Useful in anticoagulated patients
Faster recovery compared to TURP
23 hour prostatectomy
Thulium Laser Prostatectomy
First department in South West Thames
Access via Choose & Book system
Green light laser prostatectomy
Green light highly absorbed by oxyhaemaglobin
resulting in tissue vapourisation
Significantly reduced bleeding compared to
TURP
Anti-coagulated patients can be treated
No irrigation
Catheter usually removed next day
Overnight hospital stay
Green light laser prostatectomy
Reduced blood loss
Shorter hospital stay
Heinrich E et al Eur Urol 2007 52:1632-7
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