Whats new in PCA...Steven Joniau

University Hospitals Leuven, Belgium

EAU Guidelines 2010 update

PCA Guideline PanelAxel Heidenreich (Chairman) UrologyGermanyJoacqim BellmuntMedical OncologySpainMichel BollaRadiation OncologyFranceSteven JoniauUrologyBelgiumTheodor van der KwastPathologyCanadaMalcom MasonRadiation OncologyUKVeseled MatveevUrologyRussiaNicolas MottetUrologyFranceHans Peter SchmidUrologySwitzerlandThomas WiegelRadiation OncologyGermanyFrancesco ZattoniUrologyItaly

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

ScreeningRisk adapted early detection

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

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

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

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

Adjuvant Radiation TherapyEORTC 22911

RadiationW & SR076.2%67.4%R177.6%48.5%*

R0 + RadR1 + RadHR0.870.38Benefit88/1000291/1000

Adjuvant Radiation Therapy72%54%ARO/AUO German Study

Adjuvant Radiation TherapyARO/AUO German Study5 year F-up: 25% benefit for progression-free survivalpT3aR1

SWOG 8794Survellance adj. Radiation Adjuvant Radiation Therapy

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%

Adjuvant Radiation Therapy

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

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

Intermittend Androgen DeprivationCalais da Silva FEC et al. ; Eur Urol 2009

Intermittend Androgen DeprivationEC507: IHT does not affect progression-free survivalTunn U. BJU Int 2007;99(Suppl 1)

Intermittend Androgen Deprivation

Follow-up: local

Follow-up: ADT

Follow-up: ADTCAVE: Diabetes mellitusMetabolic SyndromCholesterine, TriglycerideCholesterine/HDL - RatioFollow-up: cancer specific: PSA, Tendocrinologicmetaboliccardiovascular