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Page 1: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Prostate cancer

Page 2: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Metastatic disease

• 80% will die of prostate cancer

• 5 year survival only 25%• No major advances in cure since 1942

Page 3: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Impact of early prostate cancer from Iversen et al

0

2

4

6

8

10

12

70-80years

60-70years

50-60years

40-50years

Life Years Lost

NNT for all tumours: 19-41

Page 4: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

PSA Isoforms etc• Free/Total PSA, Complex PSA

– Improves 2nd Bx yield– Not assessed versus PSA TZ density

• UPM-3– Urine test, high specificity for cancer– No validation for

• Prostatitis• PSAD• Race

Page 5: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Rebiopsy

• Suspicious focal area• Atypia / AAH• High Grade PIN• ?Atrophy

– Rebiopsy with targeted bx

• Normal, persistently raised PSA– Template Bx under GA

Page 6: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Early Treatment Options

Surgery

Surveillance

Radiotherapy

Page 7: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Racial Elements• PROstate Cancer in Ethnic SubgroupsS

– Black men in UK have RR of 3.2

– Equal in Carribean and African men– Younger age of onset

Page 8: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

New and controversial• Radical Treatment

– Screening

– Prostatectomy techniques– Brachytherapy

– Conformal radiotherapy

• Early hormone therapy• Treatment of bone metastases• Focal Therapy

Page 9: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Screening• PSA screening is best model• Cut off arguable: probably 2.5ug/l• Screening reduces Ca specific mortality in all

studies reported• But NNT not agreed

Page 10: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Radical Treatment• Radical Prostatectomy• External Beam Radiotherapy• Brachytherapy

– Little difference in good risk at 7 years– RP ? better in longer term– RP ? better in high risk– No good RCT’s

Page 11: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Prostatectomy techniques• Nerve sparing• Continence Preserving• Laparoscopic/ “robotic”

Page 12: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Brachytherapy• Radioactive seeds under US control• Good PSA data in good risk patients at 7

years• ED higher than thought (30-70%)• Unsuitable for

– High risk– Obstruction

Page 13: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Conformal radiotherapy• Major advance in EBRT• Allows doses up to 77Gy• Reduced toxicity• Now IMRT

Page 14: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Cryotherapy• Day case general anaesthesia• Urethral warming

• Percutaneous cryoneedles• Rectal protection• Continuous monitoring

• Double freeze/thaw cycle (-40°C)

• Catheter for 1 week

Page 15: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Technique

Page 16: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Technique• Freezing controlled by TRUS and thermocouples

Page 17: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

ED after PC Treatment• High straight after surgery & Cryo• High later after radiation• Equal 5 years after surgery or WW

• “Penile Rehabilitation”

Page 18: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

“Penile Rehabilitation”• Benefit for injections, pumps & PDE5’s

after surgery• Now standard practice in SE Thames

Page 19: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Early or Late Hormone Therapy?• Definite benefits of early treatment in

breast cancer• Original VACURG data showed less

prostate cancer mortality but high CVS mortality

• All recent studies favour Early treatment

Page 20: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Early Treatment?AGAINST• Expense• Trials Flawed

• Side effects– Cognition– Osteoporosis

• Possibility of HRPC developing earlier

FOR� Reduce

complications

� Reduce progression� Reduce PSA

Reduce anxiety� ?? Extend Life

Page 21: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Chemotherapy• Mitoxantrone

– 40% reduction in PSA

– Improvement in wellbeing– Mucositis and lassitude

0

50

100

150

200

250

Mito+

Pred

Pred

Kantoff et al, JCO; 17,1999.

�Taxanes�50% reduction in PSA

�? Survival benefit

�Significant toxicity

�Possible synergy with Estracyt

�Other agents show negligible benefit over corticoids

Page 22: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

• Osteoclast inhibitors: – may be toxic to prostate cancer cells

• Pamidronate, Clodronate, Zoledronate– Oral or IV

• Rapid relief of bone pain in 40-75%• Reduction in development of new sites• Possible reduction in bony progression

in high risk patients

Biphosphonates

Page 23: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Focal Therapy• Many prostate ca unilateral• Focal therapy has low side effects

– Cryotherapy

– HIFU– PDT

Page 24: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y
Page 25: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

The Metabolic Syndrome

Page 26: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

The Metabolic Syndrome: Constellation of CHD Risk Factors

• Abdominal obesity*• Atherogenic dyslipidemia• Elevated blood pressure

• Insulin resistance ±±±± glucose intolerance

• Prothrombotic state: increased fibrinogen, and PAI-1• Proinflammatory state: increased CRP

NCEP ATP III. Circulation. 2002;106:3143-3421.

Reusch JEB. Am J Cardiol. 2002;90(suppl):19G-26G.

*Abdominal obesity: men >>>> 102 cm; women >>>> 88 cm

Page 27: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

The Metabolic Syndrome

• Incidence is rapidly increasing in the US and other countries; related to increasing obesity

• The metabolic syndrome enhances the risk for CHD at any given LDL-cholesterol level

• Has been compared to cigarette smoking as an equal partner to premature CHD

NCEP ATP III. Circulation. 2002;106:3143-3421.

Page 28: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Coronary Heart Disease Mortality

0 2 4 6 8 10 12

0

5

10

15

20

RR (95% CI), 3.77 (1.74-8.17)

Follow-up, Y

Cu

mu

lati

ve H

azar

d (

%)

Yes

No

866

288

852

279

834

234

292

100

Unadjusted Kaplan-Meier Curve

No. at Risk

Metabolic Syndrome

YesMetabolic Syndrome:

0 2 4 6 8 10 12

0

5

10

15

20

RR (95% CI), 3.55 (1.96-6.43)

Follow-up, Y

866

288

852

279

834

234

292

100

0 2 4 6 8 10 12

0

5

10

15

20

RR (95% CI), 2.43 (1.64-3.61)

Follow-up, Y

866

288

852

279

834

234

292

100

Cardiovascular Disease

MortalityAll Cause Mortality

Lakka H-M, et al. JAMA. 2002;288:2709-2716.

No

Page 29: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Increasing Obesity in the US• NHANES (1999) data on overweight and

obesity (BMI ≥≥≥≥ 25 kg/m²) reported

– 61% of adults (aged 20–74 years) are overweight or obese� 34% are overweight (BMI 25–29.9 kg/m²)

� 27% are obese (BMI ≥≥≥≥ 30 kg/m²)

National Health and Nutrition Examination Survey. Available at: http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf. Accessed January 9,

2003.

Page 30: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Causes of The Metabolic Syndrome

• Overweight/obesity• Physical inactivity• Genetics• Closely associated with insulin resistance

− Underlying cause of diabetes− Reduced HDL-C− Elevated triglycerides− Hypertension− Abdominal obesity

NCEP ATP III. Circulation. 2002;106:3143-3421.

Page 31: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Diagnosis of The Metabolic Syndrome

≥≥≥≥ 110 mg/dLFasting glucose

≥≥≥≥ 130/85 mm HgBlood pressure

<<<< 50 mg/dL– Women

<<<< 40 mg/dL– Men

≥≥≥≥ 150 mg/dL

HDL cholesterol

Waist circumference

>>>> 102 cm (>>>> 40 in)

>>>> 88 cm (>>>> 35 in)

Abdominal obesity

– Men

– Women

Defining Level

3 of the following are needed for diagnosis:

NCEP ATP III did not find adequate evidence to recommend routine measurement of insulin

resistance (eg, plasma insulin), proinflammatory state, or prothrombotic state in the diagnosis of the metabolic syndrome.

NCEP ATP III. Circulation. 2002;106:3143-3421.

Triglycerides

Risk Factor

Page 32: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Benefit of Treating The Metabolic Syndrome:Finnish Diabetes Prevention Study

• After 4 years, risk of diabetes reduced by 58%

Tuomilehto J, et al. N Engl J Med. 2001;344:1343-1350.

Intervention ControlWith Diabetes (%)

0%

5%

10%

15%

20%

25%

Page 33: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Treatment of The Metabolic Syndrome

• Correct insulin resistance– Weight reduction

– Increased physical activity– Drugs which decrease insulin resistance

have not been proven to reduce CHD risk

• Control diabetes mellitus, if present

NCEP ATP III. Circulation. 2002;106:3143-3421.

Page 34: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Andropause

Page 35: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Andropause: Questions• Does it exist?• If yes, physiologic or pathologic?• Does treatment help?• Harms associated with treatment?• Whom to test?• How to test?• How to treat?

Page 36: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Testosterone and Sexual Function• Sexual dysfunction common in men with

hypogonadism• Non-controlled studies using variety of

Testosterone formulations– Improved sexual activity/satisfaction

– Increased spontaneous erections/duration– Improved sexual performance

Darby E, Anawalt,BD. Treat Endocrinol 2005;4(5):293-309

Page 37: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Testosterone and Libido• Systematic review of randomized control

trials (5 trials)• pts with total testosterone < 300 ng/dl

(longest trial only 6 months)– Inconsistent but overall large improvement in

libido

• Pts with total testosterone > 300 ng/dl– No significant benefit in libido

Bhasin, S et al. J Clin Endocrinol Metab 2007; 91(6):1195-2010

Page 38: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Testosterone and ED• Systematic review of placebo-controlled

trials in pts with total testosterone < 300 ng/dl– Results were inconsistent

– Pooled estimate was not significant

• Pts with total testosterone > 300 ng/dl– Inconsistent results with no significant benefit

on EDBhasin, S et al. J Clin Endocrinol Metab 2007; 91(6):1195-2010

Page 39: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Testosterone and Bone Mineral Density

Page 40: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Copyright ©1999 The Endocrine Society

Snyder, P. J. et al. J Clin Endocrinol Metab 1999;84:1 966-1972

Testosterone and Bone Mineral Density

Page 41: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Copyright ©1999 The Endocrine Society

Snyder, P. J. et al. J Clin Endocrinol Metab 1999;84:2 647-2653

Testosterone and lean body fat

Page 42: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Testosterone and muscle strength

• Muscle strength (knee extension)– No improvement with treatment

– No inverse relation with pretreatment testosterone level

• Physical function – No improvement with treatment– No inverse relation with pretreatment T levels

Snyder, P. J. et al. J Clin Endocrinol Metab1999;84:2647-2653

Page 43: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

ADAM Questionnaire

1. Do you have a decrease in libido (sex drive)?2. Do you have a lack of energy?3. Do you have a decrease in strength and/or endurance?4. Have you lost height?5. Have you noticed a decreased “enjoyment of life”?6. Are you sad and/or grumpy?7. Are your erections less strong?8. Have you noted a recent deterioration in your ability to play

sports?9. Are you falling asleep after dinner?10. Has there been a recent deterioration in your work

performance?

A positive Questionnaire result is defined as a “ye s” to questions 1 or 7 or any 3 other questions

Metabolism, Vol 9, No. 9, Sept 2000. 1239-42

Page 44: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Diagnostic Testing for Androgen Deficiency

• When/How to test?– Morning (before 10 am) total testosterone

level should be initial test

– Low results should be confirmed with at least 1 more morning test

Bhasin, S. et al. J Clin Endocrinol Metab 2006;91:1995

Page 45: Prostate cancer - King's College Hospital - 006.1 - prostate cancer.pdf · Coronary Heart Disease Mortality 0 2 4 6 8 10 12 0 5 10 15 20 RR (95% CI), 3.77 (1.74-8.17) Follow-up, Y

Treatment• Usually therapeutic trial of Testosterone over 3

month period

• Testosterone testing correlating with effect• Options:

– Gel or patches– Short acting injections– Depot injections