Transcript Prostate cancer in new zealand

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