Transcript Uncertainties Prostate Cancer

Controversies
in
Prostate Diseases
Europa Uomo Masterclass
L. Denis
Krakow, February 6, 2009
Understanding Prostate Diseases
Prostate Cancer is a chronic Disease
Purpose of this Chat Session
1. Highlight the uncertainty in prostate
diseases.
2. Address overdetection / overtreatment.
3. Address undertreatment
OCA 2009
Europa Uomo Strategy and Aims
1. Protect the patient with focus on quality of
life & solidarity.
2. Inform and educate evidence based care
and values our business.
3. Collaborate and understand optimal
medical care.
OCA 2009
The Way Forward
1. Individual prevention and treatment
according to optimal treatment and care.
2. Reduce over- and undertreatment.
OCA 2009
The lost patient
Tsunami information
(Professionals, media, friends)
Outcome results
Statistics
PANIC
Loss of personality
The medical
labyrinth
EBM Guidelines
Nomograms
OCA 2009
Request of a Patient
• Professional expertise specialist
• Expertise and guidance general practitioner
• Support from his environment
Cure or Control
Quality of Life
We want our place in Society
OCA 2009
Uncertainties Prostate Cancer
•
•
•
•
•
•
Early prostate cancer has no symptoms
DRE not much help
PSA non specific, variable
Imaging TRUS, MRI not perfect
Biopsy techniques / pathology reports
Treatment choice
We need: - Marker for Progression
- % of trifecta
OCA 2009
Uncertainty with the Doctor
1. Limits of knowledge & training
2. Feels secure in his own specialty
3. Never enough time to communicate with
the patient
OCA 2009
Localized Prostate Cancer
All
Preferred RX Replie
s (%)
U.S. Physicians
Radiotherapy
40
R.O.
(%)
92
Urol.
(%)
8
M.O.
(%)
46
Prostatectomy
40
8
80
42
Other RX
20
0
12
12
Do we have time for a secure
diagnosis / find rest with the idea.
1. PCa begins at age 30, present in half of
men age 50 and increasing with age.
2. These cancers need 20 year (38 doublings)
to be detected.
3. From diagnosis to death 15 years. With
PSA 5 year survival obsolete.
OCA 2009
Relativity of Prostate Cancer
in Belgium KCE (knowledge)
Of 100 Belgian men before 75 years of age
- 64 have latent cancer
- 2 to 6 are diagnosed
- 1 died of PCA
OCA 2009
Overdetection is a fact
Incidence en Mortality 2004 - 2006
Men PCa
2004
2006
Women Bra
Inc.
Mortality
Inc.
Mortality
202,1
68,2
275,1
88,4
301,5
67,8
319,9
85,3
Europa 25 * thousands, IARC
Indolent Cancer is a Fact
PCa and HGca (>7 Gleason) by PSA level (>4 ng/ml) in the
Prostate Cancer Prevention Trial study.
PSA ng/ml
Number
of men
Number (%)
Number (% of cancer) with
with prostate cancer high-grade prostate cancer
< 0.5
486
791
998
482
193
2950
32
80
170
115
52
449
0.6 – 1.0
1.1 – 2.0
2.1 – 3.0
3.1 – 4.0
Total
(6.6)
(10.1)
(17.0)
(23.9)
(26.9)
(15.2)
4
8
20
22
13
67
(12.5)
(10.0)
(11.8)
(19.1)
(25.0)
(14.9)
Bowery Series: Arbitrary Open Biopsy
Age, frequency, and diagnosis of prostatic disease in
300 patients
Age
30 – 39
40 – 49
50 – 59
60 – 69
70 – 79
80 – 89
Total:
BPH
2
46
116
82
14
1
261
Ca
--2
17
17
3
--39
% Ca
--4.2
12.9
16.1
16.9
---
P. Hudson, Cancer 1954
Primary Treatment according to
Specialist Consult (N-85.088)
Specialty
RP %
XRT %
Hormones %
A.S.
Urology (N = 42,309)
65-69 (N = 12,248)
70
5
7
18
70-74 (N = 10,751)
40
8
17
31
75+ (N = 19,310)
5
4
45
46
Urology / Medical Oncology (N = 2,329)
65-69 (N = 601)
53
17
14
16
70-74 (N = 657)
38
22
17
23
75+ (N = 1,071)
5
15
46
34
T. Jang, NCI, 2007
Primary Treatment according to
Specialist Consult (N-85.088)
Specialty
RP %
XRT %
Hormones %
A.S.
Urology / Radiation Oncology (N = 37,540)
65-69 (N = 10,604)
70-74 (N = 14,058)
15
7
78
85
3
4
4
4
75+ (N = 12,878)
2
85
7
6
Urology, Radiation & Medical Oncology (N = 2,910)
65-69 (N = 890)
19
70
6
5
70-74 (N = 1,037)
8
80
7
5
75+ (N = 983)
2
79
12
7
T. Jang, NCI, 2007
Active Surveillance vs. Watchful
Waiting
Fit Patient
Co-Morbidity
Low risk Cancer
High risk Cancer
PSA dynamics
define treatment
(+ biopsies)
Symptoms define
treatment
Option: Cure
Option: Palliation
OCA, 2008
Mismatch
• Organ dysfunction increases toxicity / sideeffects
• Out of 438 patients, 389 (89%) with known
dysfunction.
• More than 1/3 received inappropriate
treatment
• Communication problems ?
Chen 2008
New Technology
1. Not the necessity but availability defines
frequent use.
2. Good treatment not supported by industry
fails.
3. Replacement ‘old’ treatments by new
ones.
4. The learning curve of technology.
W. Oosterlinck 2008
Choice of Curative Treatment
1. Surgery: Anatomic Prostatectomy in T1,
T2 and T3 cases
2. Radiatation: EBRT / Brachytherapy
in T1, T2 well and intermediate risk
in T3 combination hormones
3. Active Surveillance
OCA 2009
Avoid Undertreatment
1. Treatment decision based on SIOG
evaluation
2. Salvage treatment after RP (ECE, rising
PSA) EBRT or reverse
3. A double negation in watchful waiting (no
symptoms, less than calculated life
expectancy)
OCA 2009
Castration Resistant Prostate Cancer
1. About 20% of diagnosed, advanced PCa has
diminished lowering PSA below 4 ng/ml
2. After secondary hormonal treatment:
AA withdrawal – DES – MAB – Abiraterone
seen as resistant
3. Docetaxel & combinations first choice
4. Experimental: Immunotherapy, growth factors,
gen therapy
5. Lifestyle in all cases
OCA 2009
Close Communication Problems
Knowledge
Prevention
Rich
Collaboration
Transparant
Reality
Treatment
Poor
Olympic stand
Obscure
OCA, 2009
Life Expectancy
• Age
• Health
• Activity
• Address
• Social Status
OCA 2009
Partnerships Europa Uomo
EPPOSI
ESU
OECI
ESOP – ESMO
EAU – EONS – ECCO
Europa Uomo - ESO
ECPC
Europa Donna
WWPCC
Eurocan+Plus
PROCABIO
TRANSMARK
Europa Uomo 2009
Thank you for not sleeping.
Don’t shoot the pianist.
OCA, 2009