Transcript Slide 1

Prostate Cancer
David Eedes
11 May 2013
Prostate Cancer
Definition:
Prostate cancer is a disease in which cells in the
prostate gland become abnormal and start to
grow uncontrollably, forming tumours.
Histology: Adenocarcinoma
Prostate Cancer
Symptoms: (similar to benign prostatic hypertrophy)
- frequency
- nocturia
- hesitancy/poor stream
- haematuria
- dysuria.
Bone pain in advanced metastatic disease.
Prostate Cancer
Risk Factors:
The primary risk factors are obesity, age and family
history.
First degree family = 2x
Certain genetic risks or oncogenes have been identified
Prostate Cancer - Screening
• Goals of screening:
– Finds cancer before symptoms appear
– Screens for a cancer that is easier to treat and
cure when found early
– Has few false-negative test results and falsepositive test results
– Decreases the chance of dying from cancer
Stats: 1410 screened/48 treated/1 death
prevented
Prostate Cancer - Screening
Problems of screening:
-over diagnosis
-over treatment
"The real impact and tragedy of prostate cancer
screening is the doubling of the lifetime risk of a
diagnosis of prostate cancer with little if any decrease
in the risk of dying from this disease.”
Screening recommendations: Promote awareness in
patients; discuss pros and cons of regular PSA/DRE
Prostate Cancer Screening
Prostatic Specific Antigen - PSA
Prostate Cancer - screening
Ref: The United
States Preventive
Services Task
Force. 2012 JCO
Prostate Cancer –
Screening/Diagnosis
1. DRE
2. PSA – affected by prostatitis,
ejaculation/medicines (5 alpha reductase
inhibitors)
Age to do screening: 50 – 75 (depends on life
expectancy)
Referral pathways
Prostate Cancer –
Screening/Diagnosis
1. Digital Rectal Examination - DRE
Method
Abnormal DRE to Urologist
Prostate Cancer –
Screening/Diagnosis
2. Prostatic Specific Antigen - PSA
Prostate Cancer - Diagnosis
Transrectal ultrasound guided prostate biopsy
Prostate Cancer - Diagnosis
Transrectal ultrasound guided prostate biopsy
Prostate Cancer - Diagnosis
Histology looks at:
Grade - Gleason score A + B
Prostate Cancer - Diagnosis
Histology looks at:
Grade
Volume of disease
Peri-neural infiltration
(Capsular or seminal
vesicle infiltration)
Prostate Cancer - Staging
Stage I Incidental
Stage II
Palpable/PSA
Stage III Seminal
vesicle or through
capsule
Stage IV into
glands other
organs/distant
mets
Prostate Cancer
Incidence: 150/100 000
Mortality rates 23/100 000/year
Survival by Stage:
Prostate Cancer - Treatment
Watchful Waiting
Active Surveillance
Radical Prostatectomy
External Beam Radiotherapy (EBRT)
Prostate Implant Brachytherapy
Hormonal therapy - LHRH agonists
- Anti-androgens
- Castration
Prostate Implant Brachytherapy
Prostate Implant Brachytherapy
Iodine-125 and Palladium-103 (Gold – 198; Cesium -131
Prostate EBRT
Prostate External Beam Radiation
Therapy (EBRT)
Prostate EBRT
Prostate EBRT
Radical Prostatectomy
Types:
- Radical retropubic
- Radical perineal
- Suprapubic transvesical
- Laparoscopic radical
- Computer-assisted laparoscopic radical
(robotic)
Prostate Hormonal therapy
Neo-adjuvant
Adjuvant
- LHRH agonists
-goserelin
-leuprolide
-buserelin
- anti-androgens
-bicalutamide
-flutamide
-cyproterone (steroidal)
Prostate Cancer - Follow up
Aims:
- identify recurrence - PSA (DRE)
- identify and manage complications (inform
patients what to look out for)
- psycho-social support
- measure outcomes
PSA – 6 weeks then 3 monthly for 2 years then 6
monthly x 2 years; annually
Prostate Cancer – Side effects
Side effects:
Acute vs Late
- Skin
- Urinary
- Rectal
- Erectile dysfunction
- Relapse
Prostate Cancer – Relapse
Relapse:
Biochemical Failure
- Post RT
- Post Sx
Treatment post relapse depends on:
1. primary Rx.
2. local or distant metastases
Prostate Cancer – Relapse Treatment
Local relapse – treatment depends on primary
treatment
Metastases – bone
Hormones
Chemotherapy
GP’s role
Advanced Prostate Cancer –
Palliative Management
Palliation vs terminal care
Active palliation – disease; side effects; psychosocial
Goals:
-Functional independence
-Symptom control
-family support
Advanced Prostate Cancer –
Terminal Care
ECOG Performance Status (PS)
0; 1; 2; 3; 4; (5)
Terminal care goals:
- manage symptoms
- manage psycho-social issues
Pathways of Care
Standardization – reduces variability
Also measures outcomes
Shown to improve outcomes
Multidisciplinary or Cross functional
approach
Team member have defined roles
Focuses on the patient ‘journey’
- patient-centric
Effectiveness
Efficiency
Access
Social
Solidarity
Equity
Key
Principles of
NHI
Appropriateness
Affordability
The Tavistock Principles
1.Health care is a human right.
2.The care of the individual is at the
center of health care, but the whole
system needs to work to improve the
health of populations.
3. The health care system must treat illness, alleviate
suffering and disability, and promote health.
4. Cooperation (with each other, those served, and
those in other sectors) is essential for all that work
in health care.
5. All who provide health care must work to improve
it.
6. Do no harm.
Cancer in South Africa – the Reality
Expected annual cases 2012 – 75 000
Public sector only have capacity to care for 30%
of population (37 EBRT machines)
Private sector only caring for 16 % of that market
Total expenditure on health as % of GDP (2006):
8.4% (UK – 8.7%; Aus – 8.3%;)
Best case scenario
40% of patients - NO access to care
Cost of Cancer Care
CRISIS
or?
CHALLENGE
Thank you!