Prostate CancerProstate CancerWhat a GP Needs to KnowWhat a GP Needs to Know

Dr Manish Patel Dr Manish Patel

Urological Cancer SurgeonUrological Cancer Surgeon Sydney Adventist HospitalSydney Adventist Hospital

Westmead Public and Private HospitalWestmead Public and Private HospitalSenior Lecturer, University of SydneySenior Lecturer, University of Sydney

Prostate CancerProstate CancerWhat a GP Needs to KnowWhat 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 Screening1. Prostate Cancer ScreeningWhat you need to tell your patients.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 Screening1. Prostate Cancer ScreeningWhat you need to tell your patients.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.

Potential Benefits

1. Prostate Cancer Screening1. Prostate Cancer ScreeningWhat you need to tell your patients.What you need to tell your patients.

Potential Harms

Need to discuss the individual benefits and risksof screening with all male patients 50-70years.

• PSA screening detects cancers earlier.

• Treating early CaP improves survival.

• Negative results reduce anxiety

• Test is easy to administer

• False positives are common.

• Indolent cancers are treated inadvertently

2. The PSA Test-When to Refer to a Urologist. 2. The PSA Test-When to Refer to a Urologist.

Risk of Prostate Cancer in Men with Normal DRERisk 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 27%

4-10 29%

10+ 45%

2. The PSA test2. The PSA testWhen to refer to a urologist.When to refer to a urologist.

AgeAge Median PSAMedian PSA Normal RangeNormal 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.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.2. The PSA test- When to refer to a urologist. PSA Velocity is important to calculatePSA 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.

1.5

2

2.5

3

3.5

Jan-06 Jul-06 Jan-07

PSA

Patient 1Patient 2Patient 3

2. The PSA test- When to refer to a urologist.2. The PSA test- When to refer to a urologist.Suggested AlgorithmSuggested Algorithm

3. Localised Prostate Cancer-3. Localised Prostate Cancer-Options of TreatmentOptions of Treatment

1. Active Surveillance

2. Radical Prostatectomy

3. Seed Brachytherapy

4. External Beam Radiotherapy +/- hormone deprivation.

5. HDR Brachytherapy

6. HIFU (High Intensity Focused Ultrasound)

7. Watchful Waiting

3. Localised Prostate Cancer-3. Localised Prostate Cancer-Active SurveillanceActive Surveillance

• Advantages:

• Avoid treatment in 50% of men

• Only treat men who need treatment

• Disadvantages

• Anxiety

• Possibility of “missing the window of opportunity”

Patel et.al. J Urol. 2004;171(4):1520 MONTHS

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3. Localised Prostate Cancer-3. Localised Prostate Cancer-Radical ProstatectomyRadical Prostatectomy

• Advantages:

• Good cure rate

• Quick recovery in young men

• Salvage XRT

• Disadvantages

• Possible incontinence

• Possible impotence

Prostate

Rectum

NVB

3. Localised Prostate Cancer-3. Localised Prostate Cancer-Robotic or Laparoscopic Robotic or Laparoscopic

Radical ProstatectomyRadical 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 Cancer-3. Localised Prostate Cancer-BrachytherapyBrachytherapy

• Advantages:

• Minor procedure

• Disadvantages

• Only for low risk

• Urinary symptoms

• Rectal symptoms

• Unable to have surgery afterwards

Rectum

Prostate

Urethra

3. Localised Prostate Cancer-3. Localised Prostate Cancer-External Beam RadiotherapyExternal Beam Radiotherapy

• Advantages:

• Minor procedure

• Disadvantages

• 7 weeks treatment

• May need hormones

• Urinary symptoms

• Rectal symptoms

• Unable to have surgery afterwards

3. Localised Prostate Cancer-3. Localised Prostate Cancer-HDR BrachytherapyHDR 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 Cancer-3. Localised Prostate Cancer-HIFUHIFU

• Advantages:

• Minimally invasive

• Similar cure to XRT

• High continence and potency

• Repeatable procedure• Disadvantages

• Expensive

• Experimental

4. Androgen Deprivation Therapy4. Androgen Deprivation TherapyHow to Monitor These Men.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