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What’s new in PCA...
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Transcript of What’s new in PCA...
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Whats new in PCA...Steven Joniau
University Hospitals Leuven, Belgium
EAU Guidelines 2010 update
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PCA Guideline PanelAxel Heidenreich (Chairman) UrologyGermanyJoacqim BellmuntMedical OncologySpainMichel BollaRadiation OncologyFranceSteven JoniauUrologyBelgiumTheodor van der KwastPathologyCanadaMalcom MasonRadiation OncologyUKVeseled MatveevUrologyRussiaNicolas MottetUrologyFranceHans Peter SchmidUrologySwitzerlandThomas WiegelRadiation OncologyGermanyFrancesco ZattoniUrologyItaly
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ScreeningSchrder et al.New Engl J Med 2009Andriole et al.New Engl J Med 2009Risk reduction 27%Numbers needed to screen 1410Numbers needed to treat 48No significant difference
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ScreeningRisk adapted early detection
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Active SurveillanceActive Surveillanceclose follow-up examinations under strict rules of guidelinesPurpose: Identification & treatment of significant PCA, curative intent
Watchful Waitingwithhold treatment until development of disease-specific symptomsPurpose: symptom-based therapy, palliative intent
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Active Surveillance: why?Because itavoids overtreatment with insignificant or slowly proliferating prostate cancer
avoids unnecessary impairment of quality of life
Is a viable alternative for elderly and co morbid patients who harbour a higher mortality risk from non-cancer specific causes
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Active SurveillanceInclusion CriteriaPSA 10 ng/mlBiopsy Gleason Score 6 2 positive biopsies 50% cancer per biopsycT1c cT2aIntervention requiredBiopsy Gleason Score > 6PSA-DT < 3 yearscancer volume patients preference
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Adjuvant Radiation TherapyBolla et al.EORTC 22911: 60 Gy vs Wait-and-See pT3a, pT3b, pTxpR1 independent on postop. PSAWiegel et al.ARO 96-02: 60 Gy vs Wait-and-SeepT3a-bpN0, PSA negative !Swanson et al.SWOG 8794: 60-64 Gy vs Wait-and-SeepT3a, pT3b, pTxpR1 independent on postop. PSA
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Adjuvant Radiation TherapyEORTC 22911
RadiationW & SR076.2%67.4%R177.6%48.5%*
R0 + RadR1 + RadHR0.870.38Benefit88/1000291/1000
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Adjuvant Radiation Therapy72%54%ARO/AUO German Study
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Adjuvant Radiation TherapyARO/AUO German Study5 year F-up: 25% benefit for progression-free survivalpT3aR1
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SWOG 8794Survellance adj. Radiation Adjuvant Radiation Therapy
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SWOG 8794Adjuvant Radiation Therapy
Wait-and-SeeRadiationPSA 0.2 0.21 1.0 0.20.21 1.0PSA 59%23%77%34%Local relapse20%25%7%9%Metastases12%16%4%12%
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Adjuvant Radiation Therapy
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Intermittend Androgen DeprivationCyclic therapyOn-treatment periodOff-treatment periodIHT aims to Minimise adverse events / improve quality of life (QoL)Delay progression to hormone resistant PcaReduce costs of care
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Intermittend Androgen Deprivation
TrialPopulation# patients randomisedNCIC/PR7PSA relapse after RT300EC 507PSA relapse after RP201ICELANDPSA relapse/locally advanced700SEUGAdvanced PCa626JapanLocally advanced188AP 17/95Advanced PCa and M+335SWOG 9346M+ PCa (PSA > 5 ng/mL)1,345EC 210 M+ PCa (PSA > 20 ng/mL)194EuropeAdvanced PCa (90% T3)914
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Intermittend Androgen DeprivationCalais da Silva FEC et al. ; Eur Urol 2009
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Intermittend Androgen DeprivationEC507: IHT does not affect progression-free survivalTunn U. BJU Int 2007;99(Suppl 1)
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Intermittend Androgen Deprivation
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Follow-up: local
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Follow-up: ADT
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Follow-up: ADTCAVE: Diabetes mellitusMetabolic SyndromCholesterine, TriglycerideCholesterine/HDL - RatioFollow-up: cancer specific: PSA, Tendocrinologicmetaboliccardiovascular