Download Update on PSA screening - Afzal -09-11-16

Latest in PSA Screening, How
to Avoid Litigation, Robotics
Mr Naveed Afzal, MBBS, FRCS,
FRCS Urol, Dip Urol, FEBU
Lead Consultant Urologist
Robotic Surgeon & MDT Chair
West Dorset Hospitals NHS FT
BMI The Winterbourne Hospital
www.dorchesterurology.co.uk
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ERSPC – European Randomized Study of
Screening for Prostate Cancer, Oct 2014
 The ERSPC is the largest randomized trial
of screening for prostate cancer with
162,388 men screened with regular
prostate-specific antigen (PSA) testing
every 2-4 years in the intervention arm
and usual care with no screening offered
in the control arm. 900 prostate cancer
related deaths.
ERSPC Published Lancet, Oct 14, 2014
 In this update of the ERSPC with followup truncated at 13 years, a significant
21% relative reduction in prostate cancer
deaths was found in intention to screen
analyses, and 27% in men who actually
attended screening. The absolute risk
reduction of death from prostate cancer
at 13 years, with 1.28 fewer prostate
cancer deaths per 1,000 men.
ERSPC – European Randomized Study of
Screening for Prostate Cancer, Oct 2014
 Despite showing a clear prostate cancer
mortality reduction, the findings are not
sufficient to justify population-based
screening. We still need further quantification
of harms of screening and better strategies to
overcome overdiagnosis and overtreatment for
both more targeted screening and assessment
of prostate cancer risk, such as multivariate
risk stratification. In the meantime, wellinformed men suitable for screening should
have access to PSA-testing.
New Fast Track Ref Guidelines, NICE 2015
EAU Guidelines for screening and early
detection of prostate cancer
 An individualised risk-adapted strategy for
early detection might be offered to a wellinformed man with a good performance
status and at least 10-15 years of life
expectancy. 3 B Early PSA testing should be
offered to men at elevated risk for Pca
EAU Guidelines for screening and early
detection of prostate cancer
 The age at which early screening diagnosis of
PCa should be stopped is influenced by life
expectancy and performance status; men
who have < 15-year life expectancy are
unlikely to benefit based on the PIVOT and
the ERSPC trials.
 Clinical diagnosis Prostate cancer is usually
suspected on the basis of digital rectal
examination (DRE)
EAU Guidelines for screening and early
detection of prostate cancer
 Risk groups are: • men over 50 years of age •
men over 45 years of age and a family
history of PCa • African-Americans • men
with a PSA level of > 1 ng/mL at 40 years of
age • men with a PSA level of > 2 ng/mL at
60 years of age 2b A A risk-adapted strategy
might be considered (based on initial PSA
level), which may be every 2 years for those
initially at risk, or postponed up to 8 years in
those not at risk. 3 C
Who Should Be Screened, and Why?
 AUA’s recommendation:1
Talk to your doctor about a
baseline screening for men
age 40+ with an expected life
of 10+ years
 Why?


Easier to identify changes later
Early diagnosis could mean more
treatment options1
Five-year survival rate is
nearly 100% for localized cancer.2
9
1. http://www.auanet.org/content/media/psa1.pdf
2. http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-survival-rates
Incidence of Prostae cancer in UK
 Prostate cancer is the most common male
cancer in UK
 Nearly 40,000 men are diagnosed every year
• 11,000 people die every year.
 1 out of 8 men will get prostate Cancer in UK
Prostate cancer is the most common cancer
in Europe for males, and the third most
common cancer overall,
 Around 417,000 new cases diagnosed in 2012
(3% of male cases and 12% of the total). In
Europe (2012), the highest World agestandardised incidence rates for prostate
cancer are in Norway; the lowest are in
Albania. UK prostate cancer incidence rates
are estimated to be the 17th highest in
Europe.
Dorset has the highest incidence of
Prostate Ca in UK (NHS England 2015)
 1 in 8 men in UK are at risk of having
Prostate Cancer
 1 in 6 men in Dorset are at risk.
 Is it the elderly population ?
 Is it the dietary habits ?
 Is it the good quality Dorset beef ?
Prostate (C61): 2013 Proportion of
Cancers Diagnosed at Each Stage, All Ages,
England
 Stage at Diagnosis Percentage of Cases (%)
Stage I 29.2
 Stage II 19.1
 Stage III 16.8
 Stage IV 16.7
 Stage Not Known 18.2
What We Will Talk About Today






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14
Managing Prostate Cancer was never so easy
Raised Age specific PSA / DRE Abnormality
Fast Track Referral
We will arrange a Multi-parametric MRI
Reviewed at
MDT with the Radiologist
Peripheral abnormality-RAPSA clinic & TRUS
Anterior abnormality-Urgent OPA then TPTB
MRI NAD ? RAPSA & TRUS or OPA ? No Bx
Age specific reference range
Age range
(Years)
PSA ng/ml
40-49
0-2
50-59
0-3
60-69
0-4
70-79
0–6
Diagnosis
TRUS
Transperineal Template Prostate Biopsies
(TPTB)
Dorchester Template Bx Map
Transperineal Template Prostate
Biopsies (TPTB)
HOW TO AVOID LITIGATION
 Considering 2015 new NICE Guidelines re PSA
 Offer a single baseline PSA for all men over
50 with 10 year life expectancy

(Majority of men over 50 have LUTS, Nocturia)
 Separate Doves and Hawks
 PSA <2, Dove. No need for yearly PSA
checks.
 Only concentrate on PSA >2
 Old strategy:Talk out of PSA. New: talk in
Minimally Invasive Robotic-Assisted Surgery
About 80% of prostatectomy patients choose da Vinci® Surgery1
da Vinci® Surgery
Potential Patient Benefits
Excellent Cancer control2,3,4
Faster return of sexual function3,4
Faster return of urinary continence3,4
Open Surgical Incision
Shorter hospital stay4,5,6,7
Low level of pain5
Less blood loss, fewer transfusions3,4,5,6,8,9
Lower risk of infection, complications6,8
Faster recovery and return to normal activities5,7,9
22
1. Based on 2008 U.S. data. Data on file at Intuitive Surgical, Inc. 2. Ahlering TE, et al. Urology. May 2004;63(5):819822. 3. Coelho RF, et al. J Endourol. 2010 Dec;24(12):2003-15. Epub 2010 Oct 13. 4. Ficarra V, et al. BJU Int. 2009
Aug;104(4):534-9. Epub 2009 Mar 5. 5. Menon M, et al. Urology. 2002 Nov;60(5):864-8. 6. Boris RS, et al. Can J Urol.
2007 Jun;14(3):3566-70. 7. Hohwu L, et al. Scand. J. Urol. Nephrol. Apr 7 2009:1-6. 8. Carlsson S, et al. Urology. 2010
May;75(5):1092-7. 9. Miller J, et al J Urol. 2007 Sep;178(3 Pt 1):854-8; discussion 859. Epub 2007 Jul 16.
da Vinci® Surgical Incision
Surgery: da Vinci® Surgery
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Surgery: da Vinci® Surgery
24

Surgeon is immersed in a 3D-HD
surgical field with up to 10x zoom

Surgeon directs every move of the
tiny instruments, using console
controls

Robotic system scales and
replicates movements, while
eliminating hand tremors

Allows surgeon to operate with
increased dexterity & precision,
vital for nerve-sparing surgery
What is the prostate? What does it do?
 Male sex gland
Bladder
 Adds nutrients and
fluids for sperm
 The urethra (urine
channel) runs
through the middle
of the prostate
Rectum
Urethra
Prostate
Testes
25
1. http://cancer.gov/cancertopics/pdq/treatment/prostate/Patient
Seminal
Vesicles
What is Prostate Cancer?
 Abnormal cells
growing out of
control
 Begins in the
prostate gland
 Can spread and
invade other
tissues, organs, and
bones
26
Normal
Prostate
Prostate
Cancer
How Common Is It?
How many men are affected by prostate cancer in America?
(A) 1 in 3 (B) 1 in 6 (C) 1 in 12 (D) 1 in 24
Answer: B, about 1 in 6 men.1
(Compared to 1 in 8 women for breast cancer2)
 Prostate cancer is the 2nd leading cause of
cancer death in men.1
27

Every
minutes, a man is newly diagnosed

Every
minutes, a man dies of prostate cancer
1. http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-key-statistics
2. http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-key-statistics
Risk Factors for Prostate Cancer1
 Age
MYTH: Prostate cancer is only an
old man’s disease.
 Family history
FACT: NOT true! Risk increases
with age, but men of all
ages should know their
personal risk factors.



Father
Brother
Son
 Race
African-American men are more than twice as
likely to die from prostate cancer than white men.2
28
1. http://www.cdc.gov/cancer/prostate/basic_info/risk_factors.htm
2. http://www.cancer.org/Cancer/ProstateCancer/DetailedGuide/prostate-cancer-risk-factors
Possible Symptoms of Prostate Cancer1
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
Trouble urinating

Weak flow of urine

Frequent urination,
especially at night

Painful or burning urination

Blood in the urine or semen

Pain in the back, hips or
pelvis that won’t go away

Painful ejaculation
1. http://www.cdc.gov/cancer/prostate/basic_info/symptoms.htm
MYTH: If you don’t have
symptoms, you
don’t have
prostate cancer.
FACT: Maybe. Not all men
experience
symptoms with
prostate cancer.
Your doctors are
often the first ones
to detect signs of
prostate cancer
during check-ups.
What Does Screening Involve?
 Both screening tests
should be used1
MYTH: High PSA = Cancer,
Low PSA = No Cancer
PSA – blood test
DRE – physical exam
FACT: Wrong! High PSA
could be because of
prostate cancer, or
other conditions.
However, low PSA
level does NOT mean
“home free.” A big or
sudden change in PSA
could signal trouble,
too.


 Biopsies are ordered
after evaluating
screening results and
personal risk factors
30
1. http://www.auanet.org/content/media/psa1.pdf
Biopsy and Grading1
 Biopsy


Grading: Gleason Score
To confirm diagnosis
Thin needle to remove small
pieces (typically 12 samples)
 Gleason score (2-10)


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To grade aggressiveness of
the cancer cells
Add the scores from 2 areas
with the most cancer cells
Example: Gleason 7 (3+4)
1. http://www.cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-diagnosis
1
Least
Aggressive
2
3
4
5
Most
Aggressive
Staging1

May use bone scan, CT and MRI


32
T1, T2: localized
T3, T4: spreads outside the prostate
T1
T2
T3
T4
1. http://www.cancer.gov/cancertopics/pdq/treatment/prostate/Patient/page2
Treatment Considerations
 Goals



Improve survival through cancer control
Preserve urinary, sexual and bowel functions
Minimize side effects
 Considerations




33
Benefits vs. side effects
Age and expected life span
Other health conditions
Risk of cancer recurrence
Treatments for Localized Prostate Cancer
34
Active
Radiation
Surveillance
Surgery
What it
means
Active
monitoring of
the prostate
Kills cells, but
does not
remove them
Removes the
prostate and
cancer cells
How it’s
done
Closely monitor
PSA/DRE
Biopsy
External beam Minimally
or implanted
invasive or
“seeds”
open surgery
Other
Treatments
Kills or
inhibits
growth of
cancer cells
Cryotherapy
freezes
cancer cells;
hormone
therapy
inhibits their
growth
Cumulative Survival %
10-Year Survival: Highest with Surgery1
Prostatectomy
(surgery)
Active surveillance
Radiotherapy
Other therapy
Hormone therapy
0 1 2
35
3 4 5 6 7 8 9 10
Years after diagnosis
1. Merglen A, et al. Arch Intern Med 2007; 167:1944-1950.
Active Surveillance

Actively monitors disease progression without
actual treatment1




36
Possibly PSA and DRE every 3-6 months; Biopsy every year
Some older men with low grade prostate cancer may
report a better quality of life2
An option for patients with low risk prostate cancer and a
life expectancy less than 10 years1
Potential for increased risk of erectile dysfunction
(ED) associated with multiple biopsies during active
surveillance3
1. http://www.cancer.gov/aboutnci/ncicancerbulletin/archive/2010/011210/page2
2. Hayes, J. Journal of the American Medical Association. 2009 Dec.
3. Pavlovich C, et al. J Urol. 2009 Dec; Vol. 182, 2664-2669.
Radiation
External Beam
Brachytherapy

Uses computer and CT scan
to target radiation at the
cancer cells from outside
the body

Uses small radioactive
“seeds” implanted with a
needle throughout the
prostate

Daily visits, usually for up to
9 weeks

1 day outpatient visit, may
require general anesthesia

Some healthy tissue may be
affected

The seeds stay in the
prostate permanently
Side effects may be slow to appear with radiation therapy, and may
include erectile dysfunction, urinary problems, bowel and bladder
problems, scarring, and fatigue.
37
1. http://www.cancer.org/Cancer/ProstateCancer/DetailedGuide/prostate-cancer-treating-radiation-therapy
Predicted 10-Year
Cancer-Specific Death
10-Year Risk of Death: Lowest with Surgery1
Hormone
Radiation
Surgery
100-Kattan Score predicting risk of cancer return
(combines PSA, stage and Gleason score)
38
1. Cooperberg, M. R., et al. Cancer, 116: 5226–5234. doi: 10.1002/cncr.25456
19% of Prostate Cancer Patients Still Had
Urinary Pain 24 Months After Radiation
Urinary Pain
at 24-Month1
Urinary Pain
at 2-Month1
Lower
is
better
Radiation
39
Surgery.
Radiation
1. Buron C, et al. Int J Radiat Oncol Biol Phys. 2007 Mar 1;67(3):812-22.
Surgery .
Surgery (Radical Prostatectomy)
 Total removal of the prostate
“Because the entire prostate gland is
removed with radical prostatectomy, the
major potential benefit of this procedure is
a cancer cure in patients in whom the
prostate cancer is truly localized.”
- 2007 AUA Clinical Guidelines
40
1. King CR. Int J. Cancer (Radiat. Oncol. Invest.) 2000;90,305-311.
Thinking Ahead
What if cancer returns?
 Easier to detect with surgery1


PSA drops to zero post-surgery if there’s no cancer
PSA can fluctuate post-radiation even if there’s no
cancer
 Surgery preserves treatment options2


41
Multiple options if treated with surgery first
Limited options if treated with radiation first
1. Di Blasio, C. J., et al. Semin Oncol. 2003; 30(5):567-86.
2. Carlucci JR, et al. Geriatrics. 2009; 64(2):8-14.
Precision Matters: Better Cancer Control
with da Vinci Surgery
Cancer Control
T2 Positive Margin Rate1
The lower
the positive
margins, the
better
Open Surgery
da Vinci®
Surgery .
1. Di Pierro GB, et al. Eur Urol. 2011 Jan;59(1):1-6. Epub 2010 Oct 21.
42
Precision Matters: Faster Return of
Urinary Continence with da Vinci Surgery
Continence Rates at
3-Month1
Continence Rates at
12-Month1
Higher
is
better
Open
Surgery
43
da Vinci®
Surgery .
Open
Surgery
da Vinci®
Surgery .
1. Rocco B, et al. BJU Int. 2009 Oct;104(7):991-5. Epub 2009 May 5. 12-month rate difference is statistically
significant (P=0.014) while 3-month rate-difference is not statistically significant (P=0.15)
Precision Matters: Faster Return of
Sexual Function with da Vinci Surgery
Sexual Function
at 1-Year1
Higher
is
better
Open
Surgery
44
1. Ficarra V, et al. BJU Int. 2009 Aug;104(4):534-9. Epub 2009 Mar 5.
da Vinci®
Surgery .
Surgical Risks
45

All surgeries involve the risk of major complications. Before
you decide on surgery, discuss all treatment options with your
doctor. Understanding the risks of each treatment can help you
make the best decision for your situation.

Surgery with the da Vinci Surgical System may not be
appropriate for everyone; it may not be applicable to your
condition. Always ask your doctor about all treatment options,
as well as the risks and benefits. Only your doctor can
determine whether da Vinci Surgery is appropriate for you.
Take Action
 Know your personal risk factors
 Talk to your family
 Talk to your doctor about prostate cancer
screening
 If you are 40+, get your baseline PSA
 Discuss all treatment options with your
doctor
46
New Fast Track Ref Guidelines, NICE 2015
RECOMENDATION





Mass population screening not possible in UK
Offer a single base line PSA check
If normal, no need for yearly screening
Target younger high risk patients
Avoid un-necessary Bx on elderly patients
RECOMENDATION





Prevention:
Diet
Life style changes, Regular exercise
Better awareness
www.dorchesterurology.co.uk
Thank You!
While clinical studies support the effectiveness of the da Vinci Surgical System when used in minimally invasive surgery, individual results may vary. There are
no guarantees of outcome. All surgeries involve the risk of major complications. Before you decide on surgery, discuss treatment options with your doctor.
Understanding the risks of each treatment can help you make the best decision for your individual situation. Surgery with the da Vinci Surgical System may
not be appropriate for every individual; it may not be applicable to your condition. Always ask your doctor about all treatment options, as well as their risks
and benefits. Only your doctor can determine whether da Vinci Surgery is appropriate for your situation. All people depicted unless otherwise noted are
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