How do I control (monitor) patients receiving TRT after prostate cancer treatment

Transcription

1 How do I control (monitor) patients receiving TRT after prostate cancer treatment Anthony J. Bella MD, FRCSC Greta and John Hansen Chair in Men s Health Research Division of Urology, Department of Surgery University of Ottawa

2 ACKNOWLEDGEMENTS Research Funding Prostate Cancer Research Foundation of Canada Canadian Male Sexual Health Council Canadian Foundation for Innovation Grant Northeastern Section of the AUA American Medical Systems PROPPER Study (ClinicalTrials.gov Identifier: NCT ) Greta and John Hansen Chair in Men s Health Research Speakers Bureau/Honoraria/Consulting Fees: Eli Lilly Inc, Pfizer, Abbott, American Medical Systems, Coloplast, Actavis Specialty Pharmaceuticals

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8 POST-RADICAL PROSTATECTOMY TREATMENT WITH TESTOSTERONE

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11 BACKGROUND

12 White Paper Position Statement

13 White Paper Position Statement

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15 PSA velocity (PSAV) was calculated using linear regression of three of more measured serum PSA levels obtained during at least a 12 month period

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20 BRACHYTHERAPY AND TREATMENT WITH TESTOSTERONE

21 BJU Int Jul;114(1): Long-acting testosterone injections for treatment of testosterone deficiency after brachytherapy for prostate cancer. Balbontin FG, Moreno SA, Bley E, Chacon R, Silva A, Morgentaler A. Serum PSA and testosterone concentrations were recorded monthly for 3 months, then every 3 months for the first year, every 6 months for the second year, and annually then after.

22 BJU Int Jul;114(1): Long-acting testosterone injections for treatment of testosterone deficiency after brachytherapy for prostate cancer. Balbontin FG, Moreno SA, Bley E, Chacon R, Silva A, Morgentaler A. Serum PSA and testosterone concentrations were recorded monthly for 3 months, then every 3 months for the first year, every 6 months for the second year, and annually then after. CONCLUSIONS: With a median of 31-months follow-up, long-acting testosterone injections in men with prostate cancer treated with brachytherapy produced significant clinical benefits. There were no cases of rising serum PSA, prostate cancer progression or recurrence.

23 ACTIVE SURVEILLANCE AND TREATMENT WITH TESTOSTERONE

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25 CONCLUSIONS

26 CLINICAL SCENARIO

27 CLINICAL SCENARIO Symptomatic hypogonadism treat or not treat?

28 SO HERE WE GO Symptomatic hypogonadism treat. How to follow if decide to treat?

29 CLINICAL SCENARIO - MONITORING There is no consensus on careful monitoring of our patients There are no specific differentiators for vigorous surveillance protocol We use 1,1,1 then 3,3 then 6 month intervals including PSA, measure of T levels, and HCT/HGb

30 CLINICAL SCENARIO FOLLOW-UP

31 CLINICAL SCENARIO 1 PREVIOUS ADT

32 CONCLUSIONS POST RP We use 1,1,1 then 3,3 then 6 month intervals including PSA, measure of T levels, and HCT/HGb Post RP pts receive TST/TRT if organ confined disease (negative margins, no SV invasion, Gleason less than 8) and undetectable PSA (<0.04) PSA rise to over 0.2 triggers oncologic assessment

33 CONCLUSIONS ACTIVE SURVEILLANCE For active surveillance, biopsy at 6 12 months includes anterior directed cores (CCO PEBC Guidelines first authored by my colleague Prof. Chris Morash) If continues on AS, biospy q3 5 yrs until age 80 If young age, more than 2 cores, more than 50% any core q2 yr biopsy Multiparametric MRI for discordant findings (PSA increase with no Gleason change or volume on bx) used for fusion targeted biopsy To come off TST/TRT increase in Gleason score or concerning rise in PSA (no clear guide here)

34 CONCLUSIONS ACTIVE SURVEILLANCE For active surveillance, biopsy at 6 12 months includes anterior directed cores (CCO PEBC Guidelines first authored by my colleague Prof. Chris Morash) If continues on AS, biospy q3 5 yrs until age 80 If young age, more than 2 cores, more than 50% any core q2 yr biopsy Multiparametric MRI for discordant findings (PSA increase with no Gleason change or volume on bx) used for fusion targeted biopsy To come off TST/TRT increase in Gleason score or concerning rise in PSA (no clear guide here)

35 How do I control (monitor) patients receiving TRT after prostate cancer treatment Anthony J. Bella MD, FRCSC Greta and John Hansen Chair in Men s Health Research Division of Urology, Department of Surgery University of Ottawa