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Prostate Cancer
What a GP Needs to Know
Dr Manish Patel
Urological Cancer Surgeon
Sydney Adventist Hospital
Westmead Public and Private Hospital
Senior Lecturer, University of Sydney
Prostate Cancer
What a GP Needs to Know
• Prostate Cancer Screening
– What you need to tell your patients.
• The PSA test
– When to refer to a urologist.
• Localised Prostate Cancer
– What are the newest modalities?
• Androgen Deprivation Therapy
– How to monitor these men.
1. Prostate Cancer Screening
What you need to tell your patients.
• Mr J.B. 57 year old.
• Mild LUTS
• Hypertension
• Asks his G.P. whether he needs a test for prostate
cancer?
• What should the G.P discuss with him?
1. Prostate Cancer Screening
What you need to tell your patients.
• PSA
– Blood test
– Can detect early Cancer
• Digital Rectal Exam
– Important
– 15% of cancers have
“normal” PSA but
abnormal DRE.
1. Prostate Cancer Screening
What you need to tell your patients.
Potential
Benefits
• PSA screening detects
cancers earlier.
• Treating early CaP improves
survival.
• Negative results reduce
anxiety
• Test is easy to administer
Potential
Harms
• False positives are
common.
• Indolent cancers are
treated inadvertently
Need to discuss the individual benefits and risks
of screening with all male patients 50-70years.
2. The PSA Test-When to Refer to a Urologist.
Risk of Prostate Cancer in Men with Normal DRE
PSA Levels
Risk Of
Prostate
Cancer
1-1.99
17%
2-2.99
24%
3-3.99
4-10
27%
29%
10+
45%
2. The PSA test
When to refer to a urologist.
Age
Median PSA
Normal Range
40-49
0.7ng/ml
0-2.5ng/ml
50-59
0.9ng/ml
0-3.5ng/ml
60-69
1.2ng/ml
0-4.5ng/ml
70+
1.4ng/ml
0-6.5ng/ml
2. The PSA test- When to refer to a urologist.
Free to Total (%) Does Help Specificity.
2. The PSA test- When to refer to a urologist.
PSA Velocity is important to calculate
• Men with PSA below 4.0ng/ml
– PSA velocity > 10%/yr =30% risk CaP
– PSA velocity >0.4ng/ml/yr = 45% risk CaP
– PSA velocity >2.0ng/ml/yr = high risk of death
– More accurate with multiple measures over time.
3.5
PSA
3
Patient 1
Patient 2
Patient 3
2.5
2
1.5
Jan-06
Jul-06
Jan-07
2. The PSA test- When to refer to a urologist.
Suggested Algorithm
1.
2.
3.
4.
5.
6.
7.
3. Localised Prostate CancerOptions of Treatment
Active Surveillance
Radical Prostatectomy
Seed Brachytherapy
External Beam Radiotherapy +/- hormone
deprivation.
HDR Brachytherapy
HIFU (High Intensity Focused Ultrasound)
Watchful Waiting
3. Localised Prostate CancerActive Surveillance
99% 8year disease
specific survival
1.0
.8
.6
.4
.2
0.0
0
20
40
60
80
100
120
MONTHS
Patel et.al. J Urol. 2004;171(4):1520
140
• Advantages:
• Avoid treatment in
50% of men
• Only treat men who
need treatment
• Disadvantages
• Anxiety
• Possibility of “missing
the window of
opportunity”
3. Localised Prostate CancerRadical Prostatectomy
Prostate
NVB
• Advantages:
• Good cure rate
• Quick recovery in
young men
• Salvage XRT
• Disadvantages
• Possible incontinence
• Possible impotence
Rectum
3. Localised Prostate CancerRobotic or Laparoscopic
Radical Prostatectomy
• Advantages
• Less blood loss
• 1 day less hospital stay
• Disadvantages
• Unable to palpate the
cancer (Positive margin)
• Poorer continence and
potency
• Learning curve
• Expensive
3. Localised Prostate CancerBrachytherapy
Prostate
• Advantages:
• Minor procedure
•
•
•
•
•
Urethra
Rectum
Disadvantages
Only for low risk
Urinary symptoms
Rectal symptoms
Unable to have
surgery afterwards
3. Localised Prostate CancerExternal Beam Radiotherapy
• Advantages:
• Minor procedure
•
•
•
•
•
•
Disadvantages
7 weeks treatment
May need hormones
Urinary symptoms
Rectal symptoms
Unable to have
surgery afterwards
3. Localised Prostate CancerHDR Brachytherapy
• Advantages:
• Good treatment of
high risk disease
• Disadvantages
• Need hormones
• 5 weeks EBRT
• Urinary symptoms
• Rectal symptoms
• Unable to have
surgery afterwards
3. Localised Prostate CancerHIFU
•
•
•
•
•
•
•
•
Advantages:
Minimally invasive
Similar cure to XRT
High continence and
potency
Repeatable procedure
Disadvantages
Expensive
Experimental
4. Androgen Deprivation Therapy
How to Monitor These Men.
Factor
Treatment
Osteoporosis
Ca, Vit D, Exercise. Annual DEXA scan
Lipid profile
Regular measurements, cholesterol lowering drugs
Weight gain
Exercise
Loss of muscle
mass
Exercise
Cognitive
decline
Social support, Intellectual stimulation
Depression
Understanding, Counselling, Exercise, Medication
Summary
• Prostate Cancer Screening
– Tell your patients all the Pros and Cons.
• The PSA test
– Criteria will continue changing
– Divide in to Definite, Possible and Watch categories.
• Localised Prostate Cancer
– Lots of new modalities
• Androgen Deprivation Therapy
– Monitor their cardiac and bone health