THE HISTORY AND EVOLUTION OF PROSTATE CANCER DIAGNOSIS AND TREATMENT BY: DR. ANDREW GROLLMAN ALBUQUERQUE UROLOGY ASSOCIATES

THE HISTORY AND EVOLUTION OF PROSTATE CANCER DIAGNOSIS AND TREATMENT BY: DR. ANDREW GROLLMAN ALBUQUERQUE UROLOGY ASSOCIATES

OVERVIEW Diagnosis Laboratory Tests PSA Free and Total PSA PCA-3 4K Score The Big Question: To screen or not to screen???? Biopsy Techniques TRUS guided Biopsy MRI Guided Biopsy

OVERVIEW Treatment Surgery (Prostatectomy) Perineal Open Retropubic Laparoscopic Robotic Radiation External Beam Radiation X-ray Proton Beam Brachytherapy Active Surveillence

LABORATORY TESTS PSA A protein in the Human Kallikrein family (HK) HK3 is actually PSA First identified in the 1970s Prostate Cancer cells do NOT make more PSA PSA elevation in prostate cancer is due to the disruption of normal cell structure and the leakage of the PSA out of the cell and in to the blood stream PSA elevation can occur in other instances that disrupt the prostate Prostate Trauma Prostate Biopsy Rectal Exam (although not clinically significant)

LAB0RATORY TESTS Free and Total PSA 70% of PSA in the blood is bound to proteins 5% to 35% is free floating (fpsa) Prostate Cancer cells produce PSA that escapes the cleaving process that removes the proteins so more PSA bound and less fpsa Checking free and total PSA seems only to work when PSA is from 4-10.

FREE PSA >25% 5% chance of having prostate cancer 20-25% 10% 15-20% 15% 10-15% 20% 0-10% 60%

PCA-3 (1999) A protein localized to prostatic tissue Found in specimens containing as little as 10% cancer PCA-3 is tested in urine after a prostatic massage Used mainly to decide if someone needs a second biopsy if PSA continues to rise after a first negative biopsy PCA-3 Levels also seem to correlate to Gleason Score. Higher PCA-3 levels = Higher gleason score found on a positive biopsy

4K SCORE (2014) Blood test that measure four different proteins in the Kallikrein family Total PSA Free PSA Intact PSA hk2 Test gives a probability of having aggressive prostate cancer If the risk is very low, one may discuss this with his urologist to decide whether to undergo a biopsy or not

TO SCREEN OR NOT TO SCREEN???? United States Preventative Services Task Force recommends AGAINST screening They feel harms of screening outweigh the benefits This is CRAZINESS!!!

BIOPSY TECHNIQUES TRUS guided biopsy Most commonly used Usually 12 biopsies are done Simple Cheap 1-3% chance of complications Infection Bleeding

MRI GUIDED BIOPSY Less Widely available More expensive Can visualize small areas of suspicion to biopsy

TREATMENT FOR PROSTATE CANCER (SURGICAL) The evolution of the Prostatectomy Perineal (1905) Open Retropubic (1947) Laparoscopic (1991) Robotic (2001)

WHAT IS A PROSTATECTOMY?

PERINEAL VS. RETROPUBIC

LAPAROSCOPIC PROSTATECTOMY

ROBOTIC PROSTATECTOMY (2001)

BENEFITS OF ROBOTIC PROSTATECTOMY Smaller incisions, less pain and quicker recovery compared to Open Laparoscopic 10X Magnification Less Bleeding Better visualization of the Anatomy

WHEN WOULD YOU NOT BE A CANDIDATE FOR THE ROBOT?? Large Prostate (>100grams) Pulmonary Issues Robotic surgery requires patient to be in head down position Difficult for anesthesia to ventilate Previous abdominal surgeries Robotic surgery is intra-abdominal Open surgery is not Scar tissue could make robotic surgery not possible Obese

ACTIVE SURVEILLANCE (AS) Who Benefits Gleason 6 Cancer PSA less than 10 Elderly Multiple medical Issues What is AS? Routine monitoring of the PSA Prostate biopsies yearly No one consensus on the actual Protocol Treatment for the cancer if PSAs or biopsies show progression of the Cancer

NON-SURGICAL TREATMENTS External Beam Radiation X-Rays (Used to treat cancer short after discovery of x-rays in 1895) Proton Beam (First used to treat cancer in 1946) Brachytherapy (1903-1950 was the first use for prostate cancer)

BRACHYTHERAPY What is it? Placement of Radioactive seeds inside the prostate tissue Requires a surgical procedure Placement of the seeds is calculated depending on complicated algorithms based on the patient s specific anatomy of his prostate and location of the cancer in the biopsy specimen

EXTERNAL BEAM RADIATION (EBR) Why is it done? Primary Treatment in patients who can not or don t want to have surgery After surgery, to reduce the risk of prostate cancer recurrence After surgery if there is evidence the cancer may have recurred To treat symptoms of pain from prostate cancer that has spread outide the prostate to the bone

EBR How is it done? Planning Before the radiation, marker seeds will be placed in to the prostate by a radiologist to locate your prostate during the radiation treatment CT scans are done by the radiation team to determine the exact area of the body to be treated The treatment Varies in time but usually takes about 6 weeks

X-RAYS VS PROTON BEAM Proton Beam has a more narrow and specific area of effective treatment This reduces the side effects of radiation damage to areas around the prostate Bladder Rectum

QUESTIONS????