Prostate cancer diagnosis and follow up in the Chinese...
Transcript of Prostate cancer diagnosis and follow up in the Chinese...
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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]
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Estimated age-standardised rates per 100,000
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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
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• 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
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Prostate cancer detection rates in patients with PSA 4-10ng/mL.
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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)
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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
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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
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Any there any better markers?
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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
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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%
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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
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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)
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Multi-parametric MRI
• T2 weighed imaging
• Diffusion weighted imaging
• Dynamic contrast enhanced imaging
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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
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T2W in Peripheral Zone
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PI-RADS 1 PI-RADS 2 PI-RADS 3
PI-RADS 4 PI-RADS 5
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DWI in Peripheral Zone
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PI-RADS 1 PI-RADS 2 PI-RADS 3
PI-RADS 4 PI-RADS 5
ADC
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PI-RADS 1 PI-RADS 2 PI-RADS 3
PI-RADS 4 PI-RADS 5
High b value
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DCE in Peripheral Zone
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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
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MRI fusion targeted biopsy
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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!
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Treatment of Prostate Cancer
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Localised prostate cancer
• Radical prostatectomy
• Radiotherapy
• Active surveillance
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Surgical Outcomes Monitoring and
Improvement Program (SOMIP)
0%10%20%30%40%50%60%70%80%90%
100%
Open
Laparoscopic
Robotic
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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)
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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.
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Localized disease
To treat or not to treat?
• Patient factors
– Age
– Comorbidities
• Disease factors
– Clinical T stage
– PSA
– Gleason score
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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
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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!
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Castration resistant prostate cancer
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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)
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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
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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
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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
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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
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Thank you!
Jeremy Teoh (張源津)
Assistant Professor, Department of Surgery,
The Chinese University of Hong Kong.
Email: [email protected]