Transcript Dr_Chatterjee - Prostate Cancer Canada Network Brampton

Some Current Issues in the Management of
Prostate Cancer
Suman Chatterjee MD
Active Surveillance
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Concept: A certain subset of prostate cancer is
slow growing
Goals:
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Delay the toxic side effects of definitive treatment
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Have equivalent success in outcome vs immediate
treatment
Active Surveillance
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Vs. Watchfull waiting
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An older paradigm
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Slow nature of progression of prostate cancer
would only necessitate treatment after years
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In the interval other comorbidities would impact
the patients life expectancy
Active Surveilance
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The “ideal” candidate
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Healthy male able to undergoe definitive treatment
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Clinically confirmed INDOLENT disease
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Willing and interested in continued close
observation and monitoring (including repeat
biopsy)
Active Surveillance
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INDOLENT DISEASE
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Initially defined by Epstein as
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Gleason 3+3 disease
<3 cores +
< 50% of any one core
This “classic” definition is now being expanded
although our understanding of this is still limited.
Active Surveillance
Active Surveillance
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Important Points:
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To date 7 large series are available
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Longest median followup is 6.8 years
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PCa mortality is <1%
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~30% progress to definitive therapy
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Median time to “progression” is 2.5 years
Active Surveilance
Active Surveillance
Androgen Deprivation Therapy
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Rationale
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Prostate cancer was the first solid organ
malignancy which was shown to be influenced by
endogenous hormones
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Removing the supply of testosterone “inactivates”
the growing prostate cancer tumor for a period of
time
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Invariably the effects of androgen deprivation are
countered by the tumor as it becomes refractory.
Androgen Deprivation
Androgen Deprivation
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Effects:
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Dramatic reduction in PSA and Testosterone levels
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Within 28 days most men will have become
castrate
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By 3 months radiologic progression of the tumor is
halted
Androgen Deprivation
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Durability
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This is dependent on the pathology of the original
tumor
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Studies seem to indicate as an average 3-5 years
of good PSA (ie tumor) control followed by another
1-2 years where the tumor progresses but
symptoms are minimal
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Clinically response is quite varied.
Androgen Deprivation
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Uses:
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Local Disease
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Improved survival and control in men treated with XRBT
in combination with LHRH agonists
Occasionally in order to facilitate brachytherapy in men
with large prostates
GENERALLY NOT USED WITH SURGERY
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Studies did not identify a benefit
Androgen Deprivation
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Uses:
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Metastatic Disease:
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Still considered first line therapy
Currently intermittent therapy and continous therapy are
used depending on pathology
In patients with castrate resistant disease androgen
deprivation is still given as a subset of the tumor will still
show response
Androgen Deprivation
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Side Effects:
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These are divided as short and long term
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Short term:
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Hot flashes
Mood/ energy effects
Weight gain
Loss of libido/ ED
Androgen Deprivation
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Side effects:
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Long term:
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Loss of bone mineral density
Altered lipid profile
Increased Cardio Vascular Events
Memory/ Cognitive effects
Androgen Deprivation
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Prevention
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Vit D & Ca supplementation
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Weight bearing exercise
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Healthy diet
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Baseline BMD at 1 year post treatment
5ARI's and Prostate Cancer
5 Alpha Reductase
Inhibitors include:
Proscar (Finasteride)
Avodart (Dutasteride)
5 ARIs and Prostate Cancer
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2 Large studies (PCPT and REDUCE) have
shown that low risk prostate cancer is
prevented with the daily use of 5ARI's over
extended periods
The relative risk reduction in both is about 25%
There also appears to be an absolute 1.3%
increase in the detection of high grade disease
5ARI's and Prostate Cancer
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Why is this?
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It's generally not “biologically plausable” that a
treatment that slows one subset of a disease
increases the risk of a more advanced subset of
the same disease
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As we currently understand it gleason 6 disease
and gleason 8 disease are variations of the same
entity so they should react the same way
5ARI's and Prostate Cancer
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Explanations:
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Sampling
5ARI's and Prostate Cancer
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Other explanations:
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Delay in progression
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Pathologic Attributes
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Induction
Thank you