16:30-18:30 WS #67: Urology Forum - Prostate Cancer, Stones, Renal Tumours, Voiding Dysfunction (120 minutes, not repeated) -

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1 Dr Anna Lawrence Urologist Auckland Dr Andrew Williams Urologist Auckland Madhu Koya Urologist Auckland Andrew Lienert Urologist Auckland Dr Louise Tomlinson Consultant Gynaecologist Auckland 16:30-18:30 WS #67: Urology Forum - Prostate Cancer, Stones, Renal Tumours, Voiding Dysfunction (120 minutes, not repeated) -

2 PROSTATE CANCER MOH WORKFORCE AND NZ GUIDELINES ANDREW WILLIAMS UROLOGIST ADHB, CMDHB AND 161 GILLIES AVE

3 MY BACKGROUND Subspecialty in Urological Oncology A PSA debate moderate. Member of MOH Prostate Cancer Workforce Specialist Committee Public and Private Urologist Urology Fellowship Examiner for RACS. Medical Advisor for Prostate Cancer Foundation. I have no financial relationship with any drug or equipment companies.

4 WHY THE DILEMMA? Prostate Cancer is the most diagnosed cancer in NZ men. Early detection tests are available PSA, DRE, PCA-3 etc But. Only 1 in 5 men diagnosed with prostate cancer will die from it. Overtreatment has been rife particularly in privately based medical systems (eg USA)

5 6 7 8+

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7 INTERNATIONAL PROSTATE CANCER MORTALILTY RATES

8 BACKGROUND MOH Prostate Cancer workforce formed to establish standards of care in the treatment of men with prostate cancer. MOH AQIP Implementing the recommendations of the Prostate Cancer Workforce. Standardisation of the care of prostate cancer. National guidelines Referral Investigation Management

9 SUITE OF PATIENT CARE Patient Education GP Education PSA Testing Referral Specialist Care Consistency is required at all levels

10 REFERRAL GUIDELINES Designed to simplify and standardise care of prostate cancer patients nationally. Will be built into an online referral tool with risk stratification that will be rolled out nationally and will be the basis for referral to public hospitals. Reality is that PSA is a bad test and even after complicating things it is still a bad test. Pragmatic levels have been set at which clinical review is initiated.

11 POTENTIAL PSA DERIVATIVES THROWN AT GP S PSA Age standardised >4 Free PSA PSA/Free PSA ratio PSA Density PSA Velocity

12 CRITERIA FOR REFERRAL Age <70 years PSA >4 leads to referral for review. Age years PSA >10 leads to review Little (many would say no) evidence of survival benefit for treatment of early prostate cancer in patients >70yrs. Age >75 years PSA >20 As patients >75 years are not candidates for radical treatment PSA threshold is significantly higher, i.e at a level that androgen deprivation would be considered. All patients with abnormal DRE or other clinical concern

13 WE ARE AWARE These levels aren t perfect, but what is? These levels are simplistic, however most GP s do not spend hours discussing the role of PSA dynamics or density and it has to be simple. A 68 year old with a PSA of 4.1 probably has a normal PSA, it is therefore the role of the Urologist to not investigate, making the issue more complicated for GP s will not help.

14 QUESTIONS WE ARE ALWAYS ASKED Do we recommend population based screening. No but patients should have access to appropriate decision making tools to decide if they would like to have a PSA test. When should we check PSA No clear answer Either at 50 and then yearly following or 40 and then yearly if >1 or at 45 and 50 followed by yearly if <1. Do we recommend a DRE Yes but if this is a barrier to the patient the second best option is a PSA test alone.

15 PROSTATE CANCER MANAGEMENT NEW ADVANCES AND TECHNOLOGIES

16 PROSTATE CANCER The quandary in prostate cancer: Is cure necessary in those for whom it is possible, and is cure possible in those for whom it is necessary? Willet Whitmore

17 MR P 80 year old Hypertension, overweight. Had a brother that got prostate cancer at 80 (still alive) Presents requesting a prostate check and a PSA

18 MR P Actuarial expected survival 88.3 years Therefore life expectancy is 8.3 years No data exists for purely hormone treated prostate cancer. Post Radiation with recurrence of prostate cancer expected survival 13 years.

19 POST RADIATION, POST SALVAGE TREATMENT SURVIVAL % % Surviving Overall Survival Disease Free Survival Time (Months)

20 SIDE EFFECTS OF TREATMENT Surgery Would not usually be offered. Incontinence rates circa 5% Perioperative major morbidity 5% Perioperative Mortality 1% Radiation treatment Rectal bleeding 5% Haematuria 5% Urinary retention 1-3%

21 DON T DO IT A PSA should only be used in the over 75 patient to rule out metastatic disease. A PSA >20 would be required to trigger intervention. A reassuring check of PSA mildly raised PSA Prostate biopsy (1% risk of ICU admission) A diagnosis of prostate cancer (30% of >65yrs have it) I have to have something done Intervention and side effects of treatment

22 BALANCE THE RISK - BENEFIT Patient read it was a good idea on the internet Side effects Invasive treatments. Psychological effects No evidence of survival benefit

23 MR B 50 Year old man. Fit and well. Would like a prostate screening check. Brother had prostate cancer at 54. Mother died of Breast Cancer at 45.

24 Life expectancy is 81.2 years 31.2 years remaining Lower Morbidity More likely to be offered surgery with fewer long term effects

25 WHAT S THE NEWEST AND GREATEST ADVANCE IN PROSTATE CANCER? Active Surveillance The primary treatment option for men with low risk prostate cancer. No Treatment and regular follow up to make sure that the initially investigations did not underestimate the disease.

26 HOW TO RADICALLY TREAT PROSTATE CANCER There is no evidence for superiority of any treatment over another in either chances of cure or morbidity. Outcome are related to surgical or radiotherapist expertise. Patient factors, preference and the need or not for sequential treatment guide decisions. Radiation leads to more bowel side effects, surgery leads to more urinary side effects QOL studies are equivalent. Open vs Laparoscopic vs Robotic series have shown no evidence for benefit of one treatment over another.

27 RADICAL PROSTATECTOMY Can be performed open, laparoscopically or robotically. Usually a 2-3 night stay Minimal blood loss Continence is rarely a long term issue Potency remains a challenge Incontinence rates (>1 pad/day approx. 5%) Transfusion rate <5%

28 RADIOTHERAPY

29 CASE EXAMPLE 1 52 year old PSA 12 Biopsy shows High volume, High grade Cancer (Gleason 9). Staging shows no distant disease but possibly invading periprostatic fat bilaterally. Patient is potent and is worried about erections.

30 TREATMENT OPTIONS Erections will be a bonus, this guy has life threatening cancer. Surgery vs EBRT Surgery can be offered following EBRT but not vice versa. Options are Surgery followed by Radiotherapy of hormonal therapy for 2 years with Radiotherapy.

31 CASE EXAMPLE 2 52 year old PSA 4 Biopsy shows low volume, low grade Cancer (Gleason 6). No staging required due to low risk nature. Patient is potent and is worried about erections.

32 Best treatment is no treatment Is cure necessary in those for whom it is possible? 7 8 Active Surveillance 9-10

33 QUESTIONS OR DISCUSSION?