C. Stephen Farmer, II MD Urology Associates

Transcription

1 C. Stephen Farmer, II MD Urology Associates

2 Benign Prostate Hypertrophy

3 Benign Prostate Hypertrophy Symptoms Hesitancy Intermittency Nocturia Post-void dribbling Dysuria Urgency Frequency Hematuria

4 Benign Prostate Hypertrophy Evaluation Examination PSA Urinalysis urine flow rate post-void residual volume cystoscopy

5 Benign Prostate Hypertrophy Copyright NeoTract, Inc. All Rights Reserved. MAC Rev C

6 SCREEN For Cancer

7 Cancer Screening Prostate to screen or not to screen, that is the question What is screening? Vs Following abnormals? AUA/ACS/HPSTF recommendations - Examination PSA Additional markers fpsa, PCA3, Phi, 4K score Bladder or Renal Symptoms gross hematuria, change in urination, flank pain, family history Urinalysis Testicle Symptoms enlargement or mass Self-examination Target age puberty through early 40 s

8 Prostate Cancer Screening IS NOT PERFECT but cannot be omitted. It needs improvement and tailoring.

9 Prostate Screening is Endangered PLCO (Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial) ERSPC (European Randomized Study of Screening for Prostate Cancer) Göteborg (Göteborg Prostate Cancer Screening Trial) US Preventative Services Task Force May 2012 Issued a D rating to PSA screening, indicating "moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits." The inevitability of overdiagnosis and overtreatment of prostate cancer as a result of screening means that many men will experience the adverse effects of diagnosis and treatment of a disease that would have remained asymptomatic throughout their lives. If we don t fix the overtreatment problem we will lose screening.* Rather than pushing active surveillance (AS) across all AUA low risk patients, we need to optimize AS by further stratifying patients based on another independent tool. Andriole GL, et al. N Engl J Med 2009;360: Chou R, et al. 2011, Annal Int Med; USPSTF website. *Cooperberg MR.

10 There is Both an OVER and UNDER Treatment Problem in Practice Today Patient Subgroup Reality Treatment Paradigm Result without Improved Tools AUA Low Risk Patients Without immediate treatment, less than 5% of Low Risk patients will die of PCa Yet the vast majority are treated upfront AUA Intermediate Risk Patients Overtreatment Problem AUA High Risk Patients More than half will experience BCR with singlemodality treatment alone Yet the majority do not receive multi-modality treatment Undertreatment Problem Wilt et al. Prostate Cancer Intervention versus Observation Trial (PIVOT) Study Group, N Engl J Med. 2012;367: Prostate cancer infolink. (2011). CAPRA-S scores and projection of prostate cancer recurrence post-surgery. Retrieved February 20, 2013 from

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12 Men should have a chance to make an informed decision about whether to be screened for prostate cancer - after getting information about the uncertainties, risks, and potential benefits screening. Men should not be screened unless they have received this information. The discussion about screening should take place at: Age 50 for men who are at average risk of prostate cancer and are expected to live at least 10 more years. Age 45 for men at high risk of developing prostate cancer. This includes African Americans and men who have a first-degree relative (father, brother, or son) diagnosed with prostate cancer at an early age (younger than age 65). Age 40 for men at even higher risk (those with more than one firstdegree relative who had prostate cancer at an early age) IF no cancer is found on the first screening: Men who have a PSA of less than 2.5 ng/ml may only need to be retested every 2 years. Screening should be done yearly for men whose PSA level is 2.5 ng/ml or higher. Last Medical Review: 04/01/2016 Last Revised: 04/14/2016

13 recommends against PSA screening in men under age 40 does not recommend routine screening in men between ages 40 to 54 years at average risk recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man's values and preferences To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening does not recommend routine PSA screening in men age 70+ years or any man with less than a 10 to 15 year life expectancy

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15 NCCN includes a history of BRCA 1/2 in the family history as an indication to screen for prostate cancer NCCN also screens age with selected screening above 75

16 Other than skin cancer, prostate cancer is the most common cancer in American men. The American Cancer Society s estimates for prostate cancer in the United States for 2016 are: About 180,890 new cases of prostate cancer About 26,120 deaths from prostate cancer About 1 man in 7 will be diagnosed with prostate cancer during his lifetime Prostate cancer is the second leading cause of cancer death in American men, behind only lung cancer. About 1 man in 39 will die of prostate cancer Currently there are nearly 2.8 million American men living with the disease roughly equal to the population of Chicago

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19 Or is the TREATMENT IMPROVING? WE MUST BE DOING SOMETHING RIGHT

20 Web page from 8/21/16 review underway.

21 Prostate Cancer Diagnosis Transrectal biopsy ultrasound guided MRI without or with fusion ultrasound-guided transrectal biopsy Transperineal saturation biopsy Risks Prostatitis or sepsis prevalence of resistance rectally colonized organisms Cancer stratification by grading and staging Genetic evaluation Prolaris, Oncotype Dx, Decipher

22 Genomic Testing Decipher - genomic test that was co-developed by GenomeDx Biosciences (Vancouver, BC, Canada) and the Mayo Clinic to assess the post RP risk of developing recurrence or metastatic disease of prostate cancer patients. This test is based on the RNA expression of 22 genes involved in cell adhesion, migration, tumor motility, immune system modulation, cell cycle control, and some genes with unknown or non-coding function. This test provides a percentage risk of metastases at 5 years. Oncotype Dx - diagnostic test that has been developed by Genomic Health (Redwood City, California). By analyzing the expression of 17 genes (includes 5 housekeeping genes) on biopsies, it has been shown to enhance the ability to predict adverse pathology (upgrading and/or upstaging) at RP in patients diagnosed with NCCN very-low, low, and low-intermediate disease. Prolaris - diagnostic test that has been developed by Myriad Genetics (Wakara Way, Salt Lake City, UT based on evaluation of the expression of 31 cell cycle progression genes and 15 housekeeping genes. It was designed to evaluate patients with low-risk prostate cancer who may be candidates for active surveillance as well as patients who are at high risk for metastasis and who may benefit from closer monitoring or additional therapy after curative intended treatment. PTEN/ERG - Promark- For patients with atypical/hgpin diagnoses, and those with biopsy Gleason Scores 3+3 and 3+4, PTEN/TMPRSS2:ERG molecular testing or Promark protein-based testing can help predict prostate cancer aggressiveness, providing additional information to make informed treatment decisions by Metamark Genetics

23 Prostate Cancer Treatment Radiation therapy External beam IGRT, IMRT Brachytherapy radioactive seed implant Active surveillance Hormonal manipulation LHRH agonists- leuprolide (Lupron, Eligard ), goserelin (Zoladex ), triptorelin (Trelstar ), histrelin (Vantas ) LHRH antagonists - Degarelix (Firmagon ) Antiandrogen flutamide (Eulexin ), bicalutamide (Casodex ), nilutamide (Nilandron ), Enzalutamide (Xtandi ) CYP17 antagonist - Abiraterone (Zytiga ) Estrogens, ketoconazole, orchiectomy Chemotherapy Docetaxel (Taxotere ), Cabazitaxel (Jevtana ), Mitoxantrone (Novantrone ), Estramustine (Emcyt ), Doxorubicin (Adriamycin ), Etoposide (VP-16), Vinblastine (Velban ), Paclitaxel (Taxol ), Carboplatin (Paraplatin ), Vinorelbine (Navelbine ) Immunotherapy Sipuleucel-T (Provenge )

24 Prostate Cancer Treatment Surgery open vs robotic radical prostatectomy

25 DaVinci Robot System

26 Recently Approved by FDA HIFU High intensity focused ultrasound Uses ultrasound to localize and to treat by thermal energy Previously difficult to target due to lack of unique ultrasonic signature of prostate cancer in most cases Future possibility of using MRI fusion technology to target the higher grade prostate cancers Can be repeated Is a focal therapy Reportedly fewer adverse effects Although FDA approved, is not yet Medicare or insurance approved

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