Prostate cancer diagnosis and follow up in the Chinese...
Transcript of Prostate cancer diagnosis and follow up in the Chinese...
Diagnosis and management of
prostate cancer in the
Jeremy Teoh (張源津)
Assistant Professor, Department of Surgery,
The Chinese University of Hong Kong.
Email: [email protected]
Estimated age-standardised rates per 100,000
Prostate-specific antigen (PSA)
• Glycoprotein secreted by prostatic ductal epithelial cells
which liquefy seminal coagulum
• Organ-specific but NOT tumour-specific marker
• Overall half-life of 2-3 days
• Higher PSA level -> Higher chance of prostate cancer
• First prospective clinical trial on the use
of PSA in early prostate cancer
detection 20 years ago
• Indications of TRUS-PB
– PSA >4.0ng/ml
– Abnormal digital rectal examination
• In patients with PSA 4-9.9ng/mL,
22% had prostate cancer
Prostate cancer detection rates in patients with PSA 4-10ng/mL.
PSA screening
• ERSPC trial (Schorder et al. Lancet 2014)
– 27% relative risk reduction in prostate cancer-specific mortality
(RR 0.73, 95% CI 0.61-0.88)
– No difference in all-cause mortality
• PLCO trial (Andriole et al. JNCI 2012)
– No difference in prostate cancer-specific mortality
– No difference in all-cause mortality other than PLCO cancers
(RR 0.96, 95% CI 0.93-1.00)
Guidelines on PSA screening
• Men who are younger than 40 years old
– Advised against PSA screening
• Men aged 40-55 years old
– Recommended to have PSA screening only if they are at high
risk of cancer development
• Men aged 55-77 years old
– Recommended to have a shared decision making for PSA
screening after pros and cons have been discussed
• Men who are older than 77 years old or have less than
10-year life expectancies
– Advised against PSA screening
Shared decision making?
• Reduction of prostate cancer related mortality and quality of
life impairment due to advanced or metastatic prostate cancer
with early detection and treatment of prostate cancer
• Possibility of increased PSA and the options of management if
PSA result is abnormal
• Limitations of screening tests
• Risk of prostate biopsy
• Chance of over-diagnosis, over-treatment and treatment
related morbidities
• Option of active surveillance to reduce over-treatment
Any there any better markers?
Prostate health index
• US FDA approved test for men aged 50 years and older,
with PSA 4-10ng/mL and normal DRE
• A score derived from total PSA, free PSA and [-2]pro-PSA
• Better delineate between benign prostatic hyperplasia
and prostate cancer
• Better delineate between significant and insignificant
prostate cancer
PHI range Probability of cancer(Catalona series)
Probability of cancer(HK series)
Probability of significantcancer (HK series)
0-24.9 11.0% 3.6% 0.5%
24.0-34.9 18.1% 7.6% 0.9%
35.0-54.9 32.7% 22.9% 6.9%
55.0+ 52.1% 38.1% 19.0%
Adaptation and External validation of
ERSPC risk calculator for Chinese men
in Hong Kong
• Collaborative project between PWH, Erasmus University
Medical Centre (Rotterdam) and QMH
• PWH cohort- development cohort for adaptation to the
ERSPC risk calculator
• QMH cohort- validation cohort for external validation of
the adapted risk calculator
PK Chiu et al. Prostate Cancer Prostatic Dis. 2017
Table 1. Baseline characteristics of the development and validation cohorts
Median
IQR
All
n=5305
Developmentcohort
Hospital1
n=3091
Validationcohort
Hospital2
n=2214
Age(years)68
62-73
67
62-72
68
62-73
PSA(ng/mL)7.3
5.2–11.3
7.3
5.3–11.5
7.2
5.2–11.0
TRUS-PV(ml)43.1
31.0–60.0
46.4
33.0–63.3
39.5
29.5–54.9
AbnormalTRUSfindings 260(8.4%) N/A
AbnormalDRE 825(15.6%) 437(14.1%) 388(17.5%)
TRUSbiopsycores
<6cores
6-8cores
9-10cores
11-12cores
>12cores
Missing
10(0.2%)
1275(24.0%)
3516(66.3%)
493(9.3%)
2(0.04%)
9(0.2%)
6(0.19%)
1153(37.3%)
1911(61.8%)
13(0.4%)
1(0.03%)
7(0.2%)
4(0.2%)
122(5.5%)
1605(72.5%)
480(21.7%)
1(0.05%)
2(0.09%)
Anygradeprostatecancer 970(18.3%) 523(16.9%) 447(20.2%)
Highgradeprostatecancer 461(8.7%) 247(8.0%) 214(9.7%)
PK Chiu et al. Prostate Cancer Prostatic Dis. (In press)
Multi-parametric MRI
• T2 weighed imaging
• Diffusion weighted imaging
• Dynamic contrast enhanced imaging
PI-RADS
• 1- Clinically significant cancer is highly unlikely to be present
• 2- Clinically significant cancer is unlikely to be present
• 3- The presence of clinically significant cancer is equivocal
• 4- Clinically significant cancer is likely to be present
• 5- Clinically significant cancer is highly likely to be present
T2W in Peripheral Zone
PI-RADS 1 PI-RADS 2 PI-RADS 3
PI-RADS 4 PI-RADS 5
DWI in Peripheral Zone
PI-RADS 1 PI-RADS 2 PI-RADS 3
PI-RADS 4 PI-RADS 5
ADC
PI-RADS 1 PI-RADS 2 PI-RADS 3
PI-RADS 4 PI-RADS 5
High b value
DCE in Peripheral Zone
Transrectal ultrasound-guided
prostate biopsy
• Peripheral zone of prostate
gland is located just anterior to
rectum
• Most prostate cancers are
located at the peripheral zone
• Prostate biopsy through the
transrectal route is the most
direct approach
• Systematic biopsy is needed
MRI fusion targeted biopsy
Cancer detection rate
• PI-RADS 2 – 0% (0/33)
• PI-RADS 3 – 11.4% (4/35)
• PI-RADS 4 – 29.2% (7/24)
• PI-RADS 5 – 50% (3/6)
92.9% (13/14) of the detected cancers are clinically significant cancers!
Treatment of Prostate Cancer
Localised prostate cancer
• Radical prostatectomy
• Radiotherapy
• Active surveillance
Surgical Outcomes Monitoring and
Improvement Program (SOMIP)
0%10%20%30%40%50%60%70%80%90%
100%
Open
Laparoscopic
Robotic
SOMIP peri-operative results
• July 2015 – June 2016
• 329 radical prostatectomies
• Median hospital stay - 4 days
• Complications
– 2.4% bleeding requiring transfusion (8/329)
– 1.8% sepsis (6/329)
– 0.9% anasmotic leakage (3/329)
– 0.3% pulmonary embolism (1/329)
– 0.3% tissue injury (1/329)
Active surveillance
• Regular PSA blood taking
• Regular DRE
• Repeated prostate biopsy for Gleason score
• If any of the parameters worsen
– offer radical surgery or radiotherapy!
• No difference in 10-year survival when compared to
radical surgery or radiotherapy in PSA screened
prostate cancersHamdy et al. NEJM 2016.
Localized disease
To treat or not to treat?
• Patient factors
– Age
– Comorbidities
• Disease factors
– Clinical T stage
– PSA
– Gleason score
Metastatic prostate cancer
• Hormonal therapy
– Bilateral orchidectomy
– LHRH agonist (3-monthly or 6-monthly injection)
Need short-term anti-androgen coverage
– LHRH antagonist (Monthly injection)
Less CVS adverse events in patients with pre-existing
ischemic heart disease
Metastatic prostate cancer
• Chemohormonal therapy
i.e. Hormonal therapy + docetaxel
Survival benefit in particular for patients with high volume
metastatic disease (up to 17 months!)
Always consider this, especially for young and fit patients
with reasonable renal function!
Castration resistant prostate cancer
Chemo? Symptoms Median overall survival benefit
Hazard ratio(95% CI)
Abiraterone(COU-AA-301)
Post-chemo BPI-SF 0-10 4.6 months 0.74 (0.64-0.86)
Abiraterone(COU-AA-302)
Pre-chemo BPI-SF 0-3 4.4 0.81 (0.70-0.93)
Enzalutamide(AFFIRM)
Post-chemo BPI-SF 0-10 4.8 months 0.63 (0.53-0.75)
Enzalutamide(PREVAIL)
Pre-chemo BPI-SF 0-3 2.2 months 0.71 (0.60-0.84)
Carbazitaxel(TROPIC)
Post-chemo - 2.4 months 0.70 (0.59-0.83)
Radium(ALSYMPCA)
Both pre- and post-chemo
Analgesic or EBRT for cancer-related bone pain
3.6 months 0.70 (0.58-0.83)
Sipuleucel-T Both pre- and post-chemo
Asymptomatic or minimally symptomatic
4.1 months 0.78 (0.61-0.98)
Summary
• Prostate cancer detection rate with reference to PSA
level is much lower in Chinese men
• PSA screening (HKUA recommendation)
– Men aged 40-55 years old
Only if they are at high risk of cancer development
– Men aged 55-77 years old
Shared decision making after the potential benefit and
harm are discussed
Summary
• Prostate health index is a good marker for detecting
prostate cancer/ significant prostate cancer
• The Chinese Prostate Cancer Risk Calculator may help
guide patients and doctors to decide on prostate biopsy
• MRI should be considered in patients with clinical
suspicion of prostate cancer with prior negative biopsy
• Perform systematic biopsy and targeted biopsy of lesion
being identified on MRI
Summary
• Radical prostatectomy, radiotherapy and active
surveillance can be considered in localized prostate
cancer
• Each treatment options has its pros and cons
Need to consider both patient and disease factors
Summary
• Hormonal therapy should be given in metastatic prostate
cancer
• Concurrent chemotherapy should always be considered,
especially in young and fit patients with reasonable renal
function
Thank you!
Jeremy Teoh (張源津)
Assistant Professor, Department of Surgery,
The Chinese University of Hong Kong.
Email: [email protected]