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LADUCA Group CPD Who Develops Prostate Cancer? •Michael Miliken (junk bond wizard) •Arnold Palmer (golf master) •Francois Mitterand (French president) •Charles de Gaulle (vive le Quebec libre) •Ayatollah Komeini (Ayatollah) •Robert Dole (senior politician) •Rudolph Giuliani (mayor NYC) •Rupert Murdoch (media mogul) •Sir Alec Guinness (Obi-Wan Kenobi) •Sidney Poitier (actor) •Sean Connery (007) •Roger Moore (007) •Pierre Elliott Trudeau (Prime Minister) •Andy Grove (Intel corp) •Marv Levy (Buffalo Bills Head Coach) •Preston Manning (politician) •Linus Pauling (Nobel x 2) •Eddie Shack (‘clear the track’) •Charleton Heston (Moses) •Frank Zappa (musician) 3500 3000 2500 2000 Ca. Prostate: No. Ca. Prostate : Deaths 1500 1000 500 0 1990 1993 1996 1999 2002 2005 Prostate Cancer: Not The Only Cause Of Death In Men What/where is the prostate? Who is at risk? Diagnosis How aggressive is the cancer (grading) How advanced is the cancer (staging) What are the treatment options for localised and advanced prostate cancer What is the outlook after treatment Majority of seminal fluid is prostatic in origin: average ejaculate volume= 2-5 mls; only 0.1-0.2 mls = sperm “Nourishment and support” of sperm in the ejaculate Provision of income for Urologists! Prostate Cancer Risk Factors »Beyond Your control: »Age »Testosterone »Race »Family history »Lifestyle »Geography »Diet Race and Nationality Mortality Rates Per 100,000 Holistic Approaches to Prevention Low-fat diet Soy products tomatoes Nutritional supplements Selenium, vitamin E Lifestyle - exercise, BMI Herbal preparations Early Diagnosis of Prostate Cancer Digital Rectal Examination (DRE) Prostate Specific Antigen (PSA) Diagnostic Triad •symptoms not helpful Transrectal Ultrasound (TRUS) Majority diagnosed on PSA (Prostate Specific Antigen) testing with nil symptoms and normal rectal examination Presentation with urinary symptoms Abnormal findings on rectal examination Presentation with symptoms of advanced disease eg bone pain or fracture due to cancer spread to bone Incidental diagnosis following prostate surgery “Blockage of the bladder”- poor flow, hesitancy, intermittency of flow, urgency retention of urine “Irritation” of the bladder- frequency day/night, urgency, urge leakage Kidney obstruction and kidney failure Produced by both benign and malignant prostate disease – benign enlargement, prostate infection and prostate cancer Not elevated by other cancers ↑ levels with ↑ age: -age scale 40-50 50-60 60-70 70-80 2-2.5 2.5-3.5 3.5-5.0 5.0-7.0 The case for screening The lengthy preclinical detectable phase of prostate cancer allows for early detection Devastating effects of metastatic prostate cancer Availability of convenient and inexpensive screening tests (DRE and PSA) Treatments for early disease The case against screening Inconsistency in disease progression High prevalence of asymptomatic disease Does screening do more harm than good? No evidence on benefits available from randomized clinical trials Excess cost, morbidity and mortality from treatments American, Canadian Cancer Society - annual PSA&DRE men >50 (discuss) AUA, CUA - annual PSA&DRE men >50 (discuss) CTFPH (GPs), USPSTF - recommend against screening (grade D evidence) This will not be resolved until results of PLCO and ER-SPC studies (?2009-10) Does PSA screening predict risk of Prostate Cancer? Does PSA screening predict clinically significant prostate cancer? Yes Probably Does PSA screening improve survival? Only future studies can prove Sample of prostate must be taken to confirm diagnosis: prostate biopsy Day stay local anaesthetic/sedation procedure Generally 12 cores taken from throughout the prostate Risks bleeding infection pain retention Diagnosed on prostate biopsy Factors determining treatment: Cancer Grade- how aggressive is it? Cancer Stage- has it spread beyond the prostate PSA level General health issues Patient views Gleason Score: Pathologist determines from recognised patterns the aggressiveness of the disease Gleason score: 6-10 Gleason 6: favourable Gleason 10: highly aggresive Has the cancer extended outside of the prostate? Rectal examination findings X rays MRI pelvis bone scan chest xray Localised prostate cancer Prostate removal (radical prostatectomy) Radiation Treatment -external beam radiation -brachytherapy (radioactive seed implantation) Advanced prostate cancer Androgen deprivation treatment Chemotherapy Radiation/palliative measures Open surgery, Laparoscopic surgery, Robotic surgery Works well if cancer confined within the prostate Long term adverse effects incontinence impotence Long duration of treatment: 6-8 weeks after planning Limited resource available Long term adverse effects overactive bladder/bowel symptoms Minimally invasive treatment Suitable for early and low grade prostate cancer Not satisfactory for large prostates Overnight stay/return to full function quickly Long term data: ? Better outcome than surgery Long term adverse effects bladder obstruction/overactive bladder symptoms >75% long term disease free survival with treatment. Probably similar outcomes for surgery and radiation treatment Charles Huggins (Nobel 1966) “Discovery is our business” Huggins C, Hodges CV: The effect of estrogen and of androgen injection on serum phosphatases in metastatic carcinoma of the prostate. Cancer Res 1941;1:293–297. Hormone deprivation (androgen deprivation) treatment Can be facilitated by drugs or removal of both testis- adverse effects of hormone loss Eventual “escape” of disease in most patients Not curative Taxol based chemotherapy offers some hope Palliative measures available eg radiation NZ: 3000 new cases diagnosed a year: 600 deaths/year Dramatic rise in incidence since use of PSA testing The use of PSA as a screening test remains controversial Effective treatment for early prostate cancer is available Advanced prostate cancer is not curable