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1 2018 Dimensions in Oncology Genitourinary Cancer Disclosures I have no financial or commercial relationships relevant to this presentation. Matthew O Shaughnessy, MD, PhD Director of Urologic Oncology Urology Associates, a division of Minnesota Urology Genitourinary cancers: incidence in US Genitourinary cancers: incidence in US # New diagnoses in 2018 # Deaths in 2018 Lifetime risk Prostate 164,690 29,430 1 in 6 (men) Bladder 81,190 17,240 1 in 43 Kidney 65,340 14,970 1 in 59 Testis 9, in 250 (men) # New diagnoses in 2018 # Deaths in 2018 Lifetime risk Prostate 164,690 29,430 1 in 6 (men) Bladder 81,190 17,240 1 in 43 Kidney 65,340 14,970 1 in 59 Testis 9, in 250 (men) How common is prostate cancer? Who gets prostate cancer? AllinaHealthSystems 1

2 Who dies from prostate cancer? Symptoms of prostate cancer MOST FREQUENTLY NO SYMPTOMS Urinary frequency Difficulty starting or stopping urination Interrupted or weak or slow urinary stream Blood in urine or in semen Intense pain in the low back or hips with prostate cancer spread to other organs Prostate cancer: areas of controversy Screening? Biopsy? Treat or observe? What kind of treatment? Past medical history: none Family history: Grandfather prostate cancer age 70 Urinary function: good stream, nocturia x 1 Erectile function: No difficulty with erections Never had a PSA test Should I have a PSA test? Does prostate cancer screening save lives? Does prostate cancer screening save lives? Follow up Number needed to screen Number needed to diagnose Follow up Number needed to screen Number needed to diagnose 9 years years years *From ERSPC: trial (162,000 men ages 55 69, ) 9 years years years years *1339 Lancet 384(9959): *USPSTF Pooled data, women ages Lancet 384(9959): AllinaHealthSystems 2

3 Who should have Prostate Cancer screening? Men ages No routine screening High risk (strong family history, African American) Men Shared decision making >10 years life expectancy Screen every 1 2 years Men 70+ Not routinely Consider in men with excellent health and >10 15 year life expectancy I m worried about prostate cancer because my grandfather had it I want a PSA test Prostate Cancer Screening Prostate specific antigen blood test (PSA) Digital rectal exam (DRE) I m worried about prostate cancer because my grandfather had it I want a PSA test PSA = 5.0 DRE= slightly enlarged, slightly firm left side of prostate What does this mean? Prostate cancer: areas of controversy Screening? Biopsy? Treat or observe? What kind of treatment? Reasons for elevated PSA Enlarged prostate Prostatitis Recent catheterization/procedure UTI Prostate cancer AllinaHealthSystems 3

4 Normal PSA range increases with age Risk of prostate cancer increases with PSA level *Prostate cancer prevention trial Who should have a prostate biopsy? Abnormal DRE Elevated PSA Rapidly rising PSA Do all of these patients need a biopsy? Biomarkers may predict aggressive prostate cancer 4K score >7.5% All men 4K score <7.5% Prostate Needle Biopsy AllinaHealthSystems 4

5 Prostate needle biopsy: standard template grid Prostate needle biopsy: standard template grid Needle missed the cancer Needle found insignificant cancer Needle missed the most aggressive cancer Use of prostate MRI to improve biopsy targeting Use of prostate MRI to improve biopsy targeting MRI Fusion Prostate Biopsy Gleason 6 (Low risk) prostate cancer AllinaHealthSystems 5

6 New prostate cancer diagnosis: Risk assessment PSA DRE Biopsy score Low risk <10 T1/small T2 6 Intermediate risk Large T2 7 High risk >20 T3 8/10 Gleason 6 (Low risk) prostate cancer I ve heard bad things about prostate cancer treatment. What happens if I don t do anything? Prostate cancer: areas of controversy Screening? Biopsy? Treat or observe? What kind of treatment? Low-risk Prostate Cancer: Active Surveillance 10-year survival for low-risk prostate cancer ~99% Active Surveillance Goal: Defer treatment to preserve quality of life Treatment indication Disease progression (rising PSA, higher biopsy score) Patient choice 40% of men will go on to treatment within 5 years PROTECT Trial. NEJM 375:1415. AllinaHealthSystems 6

7 Active Surveillance Example PSA/DRE every 6 months Prostate MRI every 1 2 years Repeat biopsy every 3 years Gleason 8 (High risk) prostate cancer I ve heard that men die with prostate cancer and not from prostate cancer. What happens if I don t do anything? High-risk Prostate Cancer: Untreated 15-year survival for treated high-risk prostate cancer * 60 y/o Male, PSA 5, Gleason 8, ct2a Gleason 8 (High risk) prostate cancer I want this treated. What is the best way? Prostate cancer: areas of controversy Screening? Biopsy? Treat or observe? What kind of treatment? AllinaHealthSystems 7

8 Treatment options for localized prostate cancer Active Surveillance Surgery Radiation Cryotherapy/thermal ablation Surgery for prostate cancer Remove entire prostate and seminal vesicles Bladder sutured to urethra 1 night in hospital Catheter x 1 week Back to work in 2 weeks Risks Incontinence (10% mild, 1% severe) Erectile dysfunction (40 60%) Surgery: da Vinci Robot Radiation for prostate cancer Outpatient 45 treatments over 9 10 weeks Brachytherapy seeds Cyberknife Risks Bladder and bowel dysfunction Erectile dysfunction Secondary cancer (bladder or rectum) Radiation for prostate cancer Treatment decision for localized prostate cancer Age Comorbidities Baseline urinary symptoms Patient preference Multidisciplinary care for high risk patients Survival equivalent for surgery and radiation AllinaHealthSystems 8

9 Gleason 8 (High risk) prostate cancer My back has been really hurting me lately. Should I be worried this is the cancer? Metastatic prostate cancer: staging Conventional techniques Bone scan CT scan Emerging techniques PSMA PET scan Axumin PET scan Choline PET scan 5% of prostate cancers are metastatic at diagnosis Treatment options for metastatic prostate cancer Hormone treatments (Androgen deprivation) Immunotherapy Chemotherapy Radiation to bone metastasis *Median survival for newly diagnosed metastatic prostate cancer is ~ 48 months. Prostate cancer in 2018 Many gray areas in prostate cancer management Shared decision making critical Prostate cancer risk assessment is critical for diagnosis and treatment planning Biomarkers Novel imaging techniques Genomics AllinaHealthSystems 9