sro tutorial: prostate cancer treatment options · • psa and dre can detect prostate cancer at a...
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SRO Tutorial: Prostate Cancer
Treatment Options May 7th, 2010
Daniel M. Aebersold
Klinik und Poliklinik für Radio-Onkologie Universität Bern, Inselspital
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„Is cure necessary in those in whom it may be possible, and is cure possible in
those in whom it is necessary?“
W.F. Whitmore Jr.
Urol Clin North Am 1990; 17: 689
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Watchful waiting vs. Prostatectomy
Bill-Axelson 2005 NEJM
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Watchful waiting vs. Prostatectomy
Bill-Axelson 2005 NEJM
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100
0
20
0 15
Radical radiation for localized prostate cancer
5 10
local control (n=1271)
60
40
80
local failure (n=198)
met
asta
sis-
free
surv
ival
(%)
years
J.J. Coen, W.U. Shipley et al., J Clin Oncol 20:3199-3205, 2002
p<0.0001
Distant metastasis free survival by local disease status.
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10
0
2
0-3 9-12
Radical radiation for localized prostate cancer
Hazard rate of distant metastasis by local disease status
3-6 6-9
6
4
8
haza
rd ra
te o
f DM
(%/y
r)
years
J.J. Coen, W.U. Shipley et al., J Clin Oncol 20:3199-3205, 2002
12-15
local control local failure
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Korrelation LC mit DM?
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The Decision
• Discussion between patient and doctor • Thoroughly discuss various options
available • Thoroughly discuss the procedure • Patient should be fully aware of risks
and potential complications
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Considerations Prior to Treatment
• Patient’s general medical condition and age • Tumor Grade (Gleason Score) and serum PSA • Disease Stage and the likelihood of the cancer
being confined to the prostate gland and thus potentially curable
• Estimation of outcome compared to other treatments
• Side effects from various treatments
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Goals of Treatment (In Order of Priority)
1. Cancer Control
2. Preservation of Urinary Control (Continence)
3. Preservation of Sexual Function (Potency)
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Therapy decision is dependent on:
1. Live expectancy >5y or <5y 2. Clinical stage 3. PSA 4. Gleason-Score
UROLOGY 2003; 61: 14-24
www.nccn.com
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Asymptomatic, Gleason ≤ 7 ⇒ watchful waiting (ww)
High risk factors (impending hydronephrosis or metastasis): bulky T3-4, Gleason 8-9 ⇒ TAB oder palliative RT
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Why Wait? • PSA and DRE can detect prostate cancer at a
very early stage • Average doubling time of a prostate tumor is
quite slow (2-4 years) • Immediate radical therapy may constitute over-
treatment and an introduce unnecessary urinary and potency risks
• May be appropriate if the patient is elderly and/or in poor health, and will live out their life spans without the cancer causing problems
• May also be appropriate for a younger patient who is willing to be vigilant and accept the risk of the cancer spreading
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Primary Androgen Ablation
• Nobel Prize • Testosterone necessary for
the growth and development of prostate cancer
• Removal of testosterone results in apoptosis of stromal and epithelial cells
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Primary Androgen Ablation
• Palliative
• An active decision not to pursue curative therapy
• If a man lives long enough he will die from prostate cancer
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Results of Androgen Removal
• Impotence • Loss of sexual desire (libido) • Hot flashes • Weight gain, Increased appetite • Fatigue • Reduced brain function • Loss of muscle and bone mass • Some cardiovascular risks • Hot flashes • Gynecomastia and breast tenderness • Bone loss
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low risk of recurrence
intermediate risk of recurrence
high risk of recurrence
very high risk of recurrence
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Definition: T1-T2a and PSA ≤ 10 and Gleason 2-6
Therapy: LE < 10y ww or RT LE 10-20y ww, RT or OP LE > 20y RT or OP RT: 3dRT, IMRT, Brachytherapy (HDR/LDR)
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Definition: T2b –T2c or Gleason 7 or PSA 10-20
Therapy: LE < 10y ww, RT oder OP LE > 10y RT oder OP
No brachytherapy only
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Definition: T3a or
Gleason 8-10 or
PSA > 20
Therapy: LE <5y ww or TAB LE > 5y TAB (2-3y) + RT RT + 6m (TAB) with only 1 risk actor (OP)
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Definition: T3b – T4 ⇒ TAB +/- RT
any T, N1 ⇒ TAB +/- RT
any T, any N, M1 ⇒ TAB
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Hormone-Refractory Prostate Cancer (HRPC) = Castration Resistent PC
• Despite initial response rates of 80-90%, nearly all men with advanced prostate cancer develop hormone-resistant prostate cancer after 18-24 months
• These “hormone-refractory” (HR) prostate cancer cells can grow in the absence of androgens
• The behavior of HR prostate cancers differ widely between patients