Transcript Document 303004

Dan Burke
Consultant Urological Surgeon
Uro-Oncology & Complex Laparoscopic Surgery
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2008
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37 051 new cases in UK
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10 168 deaths from Ca Prostate
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101 men diagnosed every day
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One new diagnosis every 15 minutes
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Accounts for 3% of male mortality
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Figure 1.1: The 20 most common causes of death from cancer, UK, 2008
Lung
Colorectal
Breast
Prostate
Pancreas
Oesophagus
Stomach
Bladder
Non-Hodgkin lymphoma
Ovary
All leukaemias
Kidney
Brain with central nervous system
Liver
Multiple myeloma
Mesothelioma
Malignant melanoma
Oral
Uterus
Bone and connective tissue
Other cancers
Males
Females
0
10,000
20,000
Number of deaths
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30,000
40,000
Age at diagnosis
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85+
80 to 84
75 to 79
70 to 74
65 to 69
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
10 to 14
05 to 09
0 to 04
Number of cases
Male Cases
Male Rates
8,000
800.0
6,000
600.0 Rat
e
per
10
400.0
0,0
00
mal
200.0 es
4,000
2,000
0
0.0
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PSA – relative risk
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Age related
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<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
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PSA Velocity >0.75 / year
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Low readings <0.7 Reassurance
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>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
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PSA
Chances of detecting Chances of detecting
a cancer
a high grade cancer
0.9
13.2%
1%
12
57.8%
22.1%
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Chances of detecting Chances of detecting
a cancer
a high grade cancer
Abnormal DRE &
FH
PSA 3.2
Abnormal DRE &
FH
PSA 12
59%
12.3
>75%
43%
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March 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.
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Screening and Prostate-Cancer Mortality in a Randomized European Study
Published at www.nejm.org March 18, 2009 (10.1056/NEJMoa0810084)
182,000 men
Mortality Results from a Randomized Prostate-Cancer Screening Trial
Published at www.nejm.org March 18, 2009 (10.1056/NEJMoa0810696)
76,693 men
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820 / 10,000
Carcinoma of the Prostate
diagnosed in screened arm
vs
480 / 10,000
Carcinoma of the Prostate
diagnosed in control arm
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73,000
men screened
17,000 biopsies
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227/10,000
radical prostatectomies performed
in screened arm
Vs
100/10,000
in control arm
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214 / 10,000
Deaths due to prostate cancer
(Screened arm)
Vs
326 / 10,000
Deaths due to prostate cancer
(unscreened arm)
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1410 people screened
48 treated
1life saved
Over a 10 year period
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European Study – Screening has its place
Based 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
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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 patient
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YES
NO
Young men
<10year life expectancy
Family history
Over 80 with normal DRE
Afro-caribean
Raised PSA with UTI
rising PSA
Age related PSA
Symptomatic / advanced CaP
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Average life expectancy in years
30
25
20
15
10
5
0
50
55
60
65
70
75
Current age
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80
85
90
95
100
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10:00PM BST 16 APR 2012
NEW TREATMENT FOR PROSTATE
CANCER GIVES 'PERFECT RESULTS'
FOR NINE IN TEN MEN: RESEARCH
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.
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STANDARD
TEMPLATE
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SATURDAY 28 APRIL 2012
STUDY RAISES DOUBTS OVER
TREATMENT FOR PROSTATE CANCER
Experts shaken by verdict suggesting thousands of men
go through painful treatment for nothing
USA study of an older age group average age 67, many
low grade disease that would not have been offered
surgery in the UK
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'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.
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2 APRIL 2012
MANCHESTER ROYAL INFIRMARY
SURGEONS FIRST TO USE 3D
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
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Mean survival 3 months
Cost approx £3000 for 30 days
NICE approved
1g a day single dose 4x250mg tablets
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Prostate Cancer patients have a worse
experience of care including after care than other
cancer patients
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Department of Health - 2005
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Who should do it?
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Who should have it?
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What’s the evidence / guidelines
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Post Radical Treatment
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PSA at the earliest 6 weeks post treatment
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PSA at least every 6 months for the next 2 years
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PSA then at least once a year thereafter
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After 2 years
Stable PSA and no complications then follow up
should be offered outside the hospital
Telephone follow up
Primary care
Electronic communications
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DRE
(changed from 2002)
Now NOT recommended in men with localised
prostate cancer while PSA remains stable
Warren KS, McFarlane JP
J Urol 2007 Jul:178(1):11-9
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Follow-up
Watchful waiting
Should normally be followed up in primary care in
accordance with protocols agreed by the local MDT
PSA should be measured at least once a year
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NICE
Primary care manage day to day complications
Sweden
More regular PSA testing
Canada
Less regular PSA testing
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Post Laparoscopic Radical Prostatectomy
8/52 post op PSA & Clinical assessment
3/12 for 1 year
6/12 for 1-2 years
Discharged to Primary Care
Exceptions: Gleason 8/9/10 and/or positive margins
and/or BCR
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Active Surveillance
3/12 PSA
1 year repeat TRUSS + biopsy
6/12 PSA for 2 years
Primary care follow up
Exceptions: unstable/fluctuating PSA, Age <65, patient
request
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Watchful waiting
3/12 PSA for 1 year
6/12 PSA for 1 year
Primary Care follow up
Exceptions: GP or patient request
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Metastatic disease
3/12 PSA initially
Symptomatic management
Patient specific follow-up
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Agreed pathways
Avoids ‘double’ tests
Avoids unnecessary re-referrals
Patient copied into communications
Agreements on costings of follow-up / new
appointments
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PROPOSED PSA PATHWAY CMFT
Post Radical Surgery
2 years post surgery
No functional problems
PSA Unrecordable
Discharge for primary care follow-up
6 monthly PSA
PSA unrecordable
detectable PSA
Continue PSA
referral back tertiary care
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Post Radical Radiotherapy
2 years post radiotherapy
(+/- hormonal treatment)
No functional Problems + PSA Stable
Discharge for primary care follow up
With instructions on length of hormonal treatment
6 monthly PSA
PSA <2.0 + asympotomatic
6 monthly PSA
PSA >2.0 or symptomatic
Referral to Urologist or Oncologist
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Hormonal Treatment
PSA Stable for 2 years or satisfactory PSA response
Asymptomatic
Discharge to primary care
Individual follow-up plan
PSA every 3 / 6 or 12 months as directed
PSA above designated level
or patient symptomatic
Referral back to Urologist
PSA stable
patient asymptomatic
Continue PSA follow-up as directed
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Active Survaillence
To remain under consultant care
Watchful waiting
PSA stable for 1 year
Patient asymptomatic
Discharge to primary care for follow-up
3/6 or 12 monthly PSA as directed at discharge
PSA below recommended level
Patient asymptomatic
PSA above commended level
or patient symptomatic
Remain under primary care
referred back to urologist
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PSA PATHWAY
NO DIAGNOSIS OF CA PROSTATE
Individual follow up
Patient specific
Clear discharge letter
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‘THE DEFINITION OF
INSANITY IS DOING THE
SAME THING OVER AND
OVER AND EXPECTING
DIFFERENT RESULTS’
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