Transcript SPA - Sheffield PRESS Portal

Life after Prostate Cancer and its
treatment
Mr Sanjeev Pathak
Consultant Urological Surgeon and Cancer Lead
Doncaster and Bassetlaw NHS Trust
12th March 2014
Objectives
• Epidemiology
• Prostate cancer treatment and
complications
• Support and life after cancer
• Primary care follow-up
Epidemiology – Prostate Cancer
• Aging population
• Increased awareness of Prostate Cancer (media, friends,
family…..)
• Increased PSA testing
• Increase in survival following treatment of prostate cancer
• Implications on resources in primary and secondary care.
TNM Staging for Prostate Cancer
TNM Staging for Prostate Cancer
TNM Staging for Prostate Cancer
TNM Staging for Prostate Cancer
Treatment of Prostate Cancer
1. Organ-confined prostate cancer
(curative intent)
2. Locally, advanced prostate cancer
(possible cure)
3. Metastatic prostate cancer
(non-curative)
Organ-confined prostate cancer
• Radical Prostatectomy (Open / Robotic)
– Erectile Dysfunction
• Impotence
• Ejaculation
• Penile length
– Urinary Incontinence
Organ-confined prostate cancer
• Radical Radiotherapy
– Erectile Dysfunction
• Impotence
• Ejaculation
– Bowel and Bladder Symptoms.
– Long-term risk of Bowel Cancer.
Organ-confined prostate cancer
• HIFU / Brachytherapy
(significantly less side-effects)
Locally, advanced prostate cancer
Androgen Deprivation Therapy (ADT)
+
Radical Radiotherapy
ADT (Zoladex / Prostap)
Short-term side effects
• Lethargy
• Mood changes
• Hot flushes
• Sexual desire etc…
ADT (Zoladex / Prostap)
Short-term side effects
Long-term side effects
• Lethargy
• Metabolic Syndrome
(Testosterone)
• Mood changes
• Osteoporosis / fracture
• Hot flushes
• Psychological issues
• Sexual desire etc…
• Relationships ?
Metastatic Prostate Cancer
1. ADT
2. Bicalutamide
3. Dexamethasone (Steroids)
4. Chemotherapy
5. Palliative therapy
Life after treatment
• Cured patients
• Non-curative patients
Support for men with
prostate cancer
Primary Care
Secondary Care
Cancer Nurse Specialist
Erectile Dysfunction
• Counselling
• Cialis / Viagra (penile rehabilitation)
• Intracavernosal /urethral therapy
• Vacuum devices
Urinary incontinence
• Counselling
• Pre-operative pelvic floor exercises
• Post-operative pelvic floor exercises
• Urinary incontinence pads
• Artificial Urinary Sphincter
Artificial Urinary Sphincter
ADT
• Hot Flushes
• Lethargy
• Osteoporosis
• Metabolic syndrome
Diet
•
•
•
•
Cooked Tomatoes (Lycopene)
Green Tea
Soy Products
Pumpkin seeds
• Reduce red meat
Life-style changes
• Exercise
• Yoga
• Prostate cancer support groups
NICE guidelines for prostate
cancer (2008, and 2014)
“After, at least 2 years, men with a stable PSA
and who have had no significant treatment
complications should be offered follow up outside
the hospital (primary care) by telephone or
secure electronic communications, unless they
are taking part in a clinical trial that requires
more formal clinic based follow up. Direct access
to the urological cancer MDT should be offered
and explained.”
CCG - GP challenge
• 6/12 reviews on a growing number of men
• PSA
• ADT administration
• Do GP practices have adequate recall systems ?
• Patient choice : prefer community ?
• Chesterfield audit – 93% preferred specialist team follow
up
• Do GP’s want the responsibility of follow up ?
• Additional support – LES payment ?
Discharge to Community care
• Clinical summary from the discharging consultant with
local contact details.
• Expectation that community care will perform 6/12 review
with symptom assessment and PSA estimation.
(DRE not required)
• Rising PSA
• Deteriorating symptoms
• Urgent New Patient Referral to local MDT
Treated – localised disease.
Men treated with curative intent – “classical
survivor”
• Radical surgery. Stable disease at 2 years post treatment,
with controlled continence and potency. PSA < 0.1
• Radical radiotherapy. Stable disease at 2 years post
treatment, with controlled therapy side effects can be
discharged to community care follow up. 6/12 years of ADT
treatment typical.
• Brachytherapy. Likely discharge at 3 yrs. Details awaited from
Leeds
Locally, advanced disease
• Radical surgery. Stable disease at 2 years maybe discharged to
community care at discretion of urological surgeon. Higher risk of
recurrence.
• Radical radiotherapy. Stable disease at 3 years post treatment (ADT)
maybe discharged to community care at the discretion of the
oncologist
• Watchful wait. Where a joint decision to start ADT at a later time with
symptoms or rising PSA; appropriate for community care for 6/12
PSA and referral back at PSA 40, or symptoms.
• Androgen deprivation therapy. Stable disease with PSA responsive
to ADT.