prostate cancer · ipss
TRANSCRIPT
22/05/2013
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Mr Ben Challacombe MS FRCS Consultant Urological Surgeon
& Honorary Senior Lecturer Guy's Hospital and KCL, London, UK
Prostate Cancer Masterclass Prostate Cancer UK March 2013
Active Surveillance
Radical Prostatectomy
Brachytherapy
External Beam Radiotherapy + hormones
Brachytherapy + EBRT (no hormones)
Alternatives:
HIFU?
Cryotherapy
Focal Therapy
Risk of death from prostate cancer or other causes after RP
By Gleason grade in the RP specimen for men age 60-69 From Eggener S et al. Cancer-specific mortality after RP: a collaborative study (n=23,910)
0.2
.4.6
.81
Dea
th R
ate
0.2
.4.6
.81
Su
rviv
al
0 5 10 15 20Years After Surgery
PC Death Non-PC Death
Survival
Age 60-69, Gleason 6
0.2
.4.6
.81
Dea
th R
ate
0.2
.4.6
.81
Su
rviv
al
0 5 10 15 20Years After Surgery
PC Death Non-PC Death
Survival
Age 60-69, Gleason 7
0.2
.4.6
.81
Dea
th R
ate
0.2
.4.6
.81
Su
rviv
al
0 5 10 15 20Years After Surgery
PC Death Non-PC Death
Survival
Age 60-69, Gleason 8 -10
20 yr PCSM 0.2% 20 yr PCSM 12%
20 yr PCSM 39%
Low Risk
PSA <10, clinical stage T1c, Gleason ≤6
Intermediate Risk
PSA 10-20, clinical stage T2a-c, Gleason ≥7 (3+4, 4+3)
High Risk
PSA >20, clinical stage T3, Gleason ≥ 8 (4+4, 4+5, 3+5)
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Avoids (or postpones) side effects of therapy
Retains quality of life
Maintains normal activities and work schedule
Minimizes over treatment of indolent cancers
Risks under treatment –
Cancer may progress and become incurable before it is treated
Later treatment may entail greater morbidity
Increases anxiety of living with untreated cancer
Requires frequent assessment, repeat biopsies with uncertain side effects
Uncertain long-term (> 10 yrs) natural history of cancer
Advantages Disadvantages
A t r is k :
2 6 1 15 8 8 1 39 2 2
0.0
00
.25
0.5
00
.75
1.0
0
Pro
po
rtio
n o
f m
en
0 20 4 0 60 8 0
T i m e s in c e ac t iv e s u rv e illa n c e ( m on th s )
A c tu a r ia l E st im a te o f R e m a in in g o n A c t iv e S u rve il la n c e
100%
50%
75%
25%
0%
Two-year: 91% Five-year: 75%
Eggener et al. J Urol, 2009
Fre
e fr
om
act
ive
trea
tmen
t
Suitable low risk, low volume, T1c, ≤2/12 cores Gleason 3+3, <50% core involvement. <75yrs?
PSA & DRE 6 monthly
Re biopsy 12-18/12
2nd Re-biopsy 3-5 years
Stop AS if upgraded, Up-staged, up- volume, pt choice/anxiety
Entry Biopsy usually TRUS
Low Risk Disease identified
All pts have multi parametric MRI
Early Trans-perineal biopsy
Repeat MRI and TP Bx 12-18 months
Guy’s Tran-perineal Sector
Biopsy Format
d d c c b b a a base
a b c d
d
d
d c
c
c
b
b
b
a
a
a
basal end of
core inked
anterior
midgland
posterior
a
a
a b
b
b c
c
c d
d
d
d c b a
basal end of
core inked
4
1
2
3
5
6
Cores placed on sponges medial to lateral with medial inked at basal end, placed in cassette and placed in labelled
numbered formalin pots as below
1 – Right Anterior 2 – Right Middle 3 – Right Posterior
4 – Left Posterior 5 – Left Middle 6 – Left Anterior
7 – Left base 8 – Right base
Trans-Perineal Biopsies
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Low/Intermediate risk
IPSS <15
FR/RV
Small gland <60mls
No prev pelvic DXT
Single session
No catheter
Day case
Safe with minimal side effect profile
Bad for basal disease, high risk?, significant LUTS, very large prostates, caution in younger patients.
Difficult to do after TURP
From: Bill-Axelson A et al for the SPCGSN4. Radical prostatectomy versus watchful waiting in localized
prostate cancer: the Scandinavian Prostate Cancer Group-4 Randomized Trial. JNCI, 2008;. 100:1144
26%
19%
p=.03
HR 0.65
18%
13%
40%
33% p=.006
HR 0.65
P=.09
HR 0.82
Radical Prostatectomy Issues Cancer control- Margins and PSA Continence Potency Complications Return to normal activity/ general wellbeing- quality of life
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©Scardino PT and Kelman J: The Prostate Book, Avery, 2010.
5/22/2013
MSKCC
Time from RP (years)
20151050
1.0
.8
.6
.4
.2
0.0
100%
99%
96%
94%
99%
96%
88%
83%
pT2N0
pT3aN0
95%
98%
pT3bN0
pT1-3 N+
71%
74%
pT2N0
pT3aN0
pT3bN0
pT1-3 N+
Time from RP (years)
20151050
1.0
.8
.6
.4
.2
0.0
91%
16%
73%
38%
pT2N0
pT3aN0
69%
91%
pT3bN0
pT1-3 N+
Probability of Cancer Control (PSA) & Cancer Specific Survival: by pathologic stage
PSA Progression-Free Probability Cancer Specific Survival
Risk of dying after RP
• 12,677 men treated at 4 institutions (MSKCC, Baylor, Cleveland Clinic and U. Michigan, with RP in the PSA era (1987-2005)
• Neither PSA velocity nor BMI added to the accuracy of the prediction model.
• Only 17% had a predicted 15-year PCSM rate >5% and 4% had a probability >30%.
CI 0.82
15 yr mortality rate: other causes 26% prostate cancer 12%
Gold standard
Is it MORBID??
Mortality <1%
Blood transfusion 20-30%
Complications 9-30%
Hospital stay 6.4 days
Incontinence <10%
Erectile dysfunction 14-44%
Judge et al. BJUi 2007 Catalona et al. J Urol 2004 Walsh et al. Urology 2000
Graefen et al Eur Urol 2006
1999 2000 2001 2002 2003 2004
Alaska
2005
Hawaii
2006 2007 2008 2009
Puerto Rico
2010
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876337 Rev B
7/1
2
Portugal
Spain
France
Belgium
UK Netherlands
Irish
Republic
Germany
Denmark
Norway
Sweden
Finland
Estonia
Latvia
Lithuania
Poland
Belarus
Switzerland
Italy
Czech Republic
Slovakia
Austria
Ukraine
Moldova
Slovenia Croatia
Hungary Romania
Bosnia &
Herzegovina Serbia &
Montenegro Bulgaria
Macedonia
Albania
Greece
Turkey 1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011 2012
da Vinci ® European Cumulative Installs 1999 – 2012
876337 Rev B
7/1
2
Europe
400
USA
1,789
Australia 27
Japan 70 South Korea 36
India 21 China 21
Taiwan 12 Thailand 7
Singapore 5 Malaysia 4
Indonesia 1 Philippines 1
Portugal 1 Slovenia 1
Cyprus 1 Monaco 1
da Vinci Installs by Country and Region
Saudi Arabia 11
Israel 6 Qatar 4
Pakistan 2 Egypt 1
Kuwait 1 Lebanon 1
Middle
East
26
Brazil 5 Argentina 4
Chile 4 Venezuela 3
Mexico 3 Colombia 2
Panama 1 Uruguay 1
Latin
America
23
Sweden 15 Denmark 11
Norway 9 Finland 5
Austria 4 Ireland 3
Distribution Italy 62
Spain 25 Turkey 16
Czech Rep 12
Direct Germany 60
France 59 Belgium 28
UK 27 Switzerland 18
Netherlands 16
Asia
178
Canada 19
Russia 10 Greece 8
Romania 6 Bulgaria 1
Poland 1
876337 Rev B
7/1
2
Tyrone
Deny Antrim
Down Armagh
Fermanagh
BELFAST
NORTHERN
IRELAND
Waterford Cork
Kerry
Limerick Tipperary Kilkenny
Wexford
Carlow
Laois
Kildare
Dublin
Meath
Offaly
Westmeath Galway
Mayo Roscommon
Longford
Cavan
Sligo
Leitrim
Donegal
Monaghan
Louth
Clare Wicklow
DUBLIN
IRELAND
Dyfed
Powys
West
Glamorgan
Mid
Glamorgan
Gwent
South
Glamorgan
Clwyd
Gwynedd
Anglesey
WALES
Grampian Highland
Shetland Islands
Mull
Skye
Western
Isles
Orkney
Strathclyde
Lothian
Fife
Tayside
Central
Dumfries And
Galloway
Islay
Borders
GLASGOW
SCOTLAND
Arran
Shropshire
LONDON
Cornwall
Devon
Somerset
Avon
Isle of Wight
Dorset
Hampshire
Surrey
Berkshire
Oxfordshire
Gloucestershire
Greater
London
Hertfordshire
Wiltshire
W. Sussex E. Sussex
Kent
Essex
Suffolk
Norfolk
Cambridgeshire North-
Hamptonshire
Lincolnshire
Cumbria
Humberside
Nottinghamshire
Lancashire
Merseyside
Durham
Tyne & Wear
Cleveland
North
Umberland
Isle Of Man
Leichestershire
Hereford & Worcester
West
Midlands
Warwickshire
Bedfordshire
Bucking-
hamshire
Staffordshire
Cheshire Derbyshire
South
Yorkshire
West
Yorkshire
Greater
Manchester
ENGLAND
UNITED KINGDOM
IRELAND
© Copyright Bruce Jones Design Inc. 2003
UK / Ireland da Vinci Installations
Addenbrooke’s Hospital – Cambridge (2)
Broomfield Hospital - Essex
Christies Hospital – Manchester
East Kent Hospital Canterbury
Frimley Park NHS Foundation Trust - Surrey
Guy's Hospital London – London
Lister Hospital – Hertfordshire
Oxford Radcliff Trust - Oxford
Royal Marsden Hospital – London
Royal Berkshire - Reading
Royal Surrey County NHS trust – Guildford
Royal Hospital Liverpool
St. George's Healthcare NHS Trust - London,
St. James’s University Hospital – Leeds
St Mary’s Hospital – School of Medicine – London
South Devon Healthcare NHS Foundation Trust - Devon
The London Clinic – London (2)
The Princess Grace Hospital – London
The Wellington Hospital
Wexham Park Hospital - Berkshire
Exeter
Newcastle
Downsides of RARP
• Cost
• Availability
• Learning Curve
• Training
• Case Volume
• Team
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31
Author N= Mean
PSA
(ng/mL)
Mean
operative
time (m)
Mean
blood
transfusio
n (%)
Mean
hospita
l stay
(d)
Overall
positive
surgical
margins
(pT2
margins
) (%)
Continence
(≤1
pad/day)
(%)
Potency
(%)
Mean
follow-
up
(mo)
BCRFs
(%)
Joseph 325 6.6 130 1.3 1 13(9.9) 96 70 N/R N/R
Patel 1500 6.6 105 0 1.1 9.43(4) N/R N/R 53 N/R
Zorn 300 N/R 282 1.7 1.4 20.9
(15.1)
90.2 80 17.3 93.1
Badani 2766 6.4 154 1.5 1.1 N/R(13) 93 79.2 25.8 92.7
Mottri
e
184 8.7 171 0.5 N/R 15.7(2.5) 95 70 6 94.1
Murph
y
400 8.5 186 1.5 2.5 19.2
(9.6)
91.4 64 23 86.6
Author N= Mean
PSA
(ng/mL)
Mean
operative
time (m)
Mean
blood
transfusio
n (%)
Mean
hospita
l stay
(d)
Overall
positive
surgical
margins
(pT2
margins
) (%)
Continence
(≤1
pad/day)
(%)
Potency
(%)
Mean
follow-
up
(mo)
BCRFs
(%)
Joseph 325 6.6 130 1.3 1 13(9.9) 96 70 N/R N/R
Patel 1500 6.6 105 0 1.1 9.43(4) N/R N/R 53 N/R
Zorn 300 N/R 282 1.7 1.4 20.9
(15.1)
90.2 80 17.3 93.1
Badani 2766 6.4 154 1.5 1.1 N/R(13) 93 79.2 25.8 92.7
Mottri
e
184 8.7 171 0.5 N/R 15.7(2.5) 95 70 6 94.1
Murph
y
400 8.5 186 1.5 2.5 19.2
(9.6)
91.4 64 23 86.6
Author N= Mean
PSA
(ng/mL)
Mean
operative
time (m)
Mean
blood
transfusio
n (%)
Mean
hospita
l stay
(d)
Overall
positive
surgical
margins
(pT2
margins)
(%)
Continence
(≤1
pad/day)
(%)
Potenc
y (%)
Mean
follow-
up
(mo)
BCRFs
(%)
Joseph 325 6.6 130 1.3 1 13(9.9) 96 70 N/R N/R
Patel 1500 6.6 105 0 1.1 9.43(4) N/R N/R 53 N/R
Zorn 300 N/R 282 1.7 1.4 20.9
(15.1)
90.2 80 17.3 93.1
Badani 2766 6.4 154 1.5 1.1 N/R(13
)
93 79.2 25.8 92.7
Mottri
e
184 8.7 171 0.5 N/R 15.7(2.5) 95 70 6 94.1
Murph
y
400 8.5 186 1.5 2.5 19.2
(9.6)
91.4 64 23 86.6
Author N= Mean
PSA
(ng/mL)
Mean
operative
time (m)
Mean
blood
transfusio
n (%)
Mean
hospita
l stay
(d)
Overall
positive
surgical
margins
(pT2
margins
) (%)
Continence
(≤1
pad/day)
(%)
Potency
(%)
Mean
follow-
up
(mo)
BCRFs
(%)
Joseph 325 6.6 130 1.3 1 13(9.9) 96 70 N/R N/R
Patel 1500 6.6 105 0 1.1 9.43(4) N/R N/R 53 N/R
Zorn 300 N/R 282 1.7 1.4 20.9
(15.1)
90.2 80 17.3 93.1
Badani 2766 6.4 154 1.5 1.1 N/R(13) 93 79.2 25.8 92.7
Mottri
e
184 8.7 171 0.5 N/R 15.7(2.5) 95 70 6 94.1
Murph
y
400 8.5 186 1.5 2.5 19.2
(9.6)
91.4 64 23 86.6
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Author N= Mean
PSA
(ng/mL)
Mean
operative
time (m)
Mean
blood
transfusio
n (%)
Mean
hospita
l stay
(d)
Overall
positive
surgical
margins
(pT2
margins
) (%)
Continence
(≤1
pad/day)
(%)
Potency
(%)
Mean
follow-
up
(mo)
BCRFs
(%)
Joseph 325 6.6 130 1.3 1 13(9.9) 96 70 N/R N/R
Patel 1500 6.6 105 0 1.1 9.43(4) N/R N/R 53 N/R
Zorn 300 N/R 282 1.7 1.4 20.9
(15.1)
90.2 80 17.3 93.1
Badani 2766 6.4 154 1.5 1.1 N/R(13) 93 79.2 25.8 92.7
Mottri
e
184 8.7 171 0.5 N/R 15.7(2.5) 95 70 6 94.1
Murph
y
400 8.5 186 1.5 2.5 19.2
(9.6)
91.4 64 23 86.6
60 vs 60 pts Italy
No difference in pathology: margins
The continence rate was higher in the RARP group at every time point
3 month 80% RARP, 61.6% LRP (p=0.044)
1 yr 95.0% and 83.3%, respectively (p=0.042).
Among preoperative potent patients treated with nerve-sparing techniques, the rate of erection recovery was 80.0% RARP and 54.2% LRP (p=0.020).
Vickers and Scardino, 2008
Has MIS merely raised the bar for
surgery?
• Refining the anatomy
• Higher volume surgeons and centres
• Better reporting of data
• Removing less able surgeons from the
field.
Case volume is Key
The robot is here to stay
MIS:
Less blood loss/transfusion
Less pain
Earlier Discharge
Faster return to work
? Better oncological and functional results
Choose your surgeon wisely
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Outpatient procedure
20-30 minutes of treatment
5 days a week for 6-7 weeks. 74Gy
Neo-adjuvant hormones 3/12
Intensity-modulated radiotherapy (IMRT),
high doses of radiation precisely
shaped to the individual patient's prostate.
Proton Beam
External Beam Radiotherapy
neoadjuvant and concurrent LHRHa therapy for 3–6 months
– adjuvant LHRH therapy for a minimum of 2 years if Gleason ≥ 8
? pelvic radiotherapy for men with > 15% risk of pelvic lymph node involvement
Radical Prostatectomy if young, fit
As part of multimodal therapy
Complications of surgery and radiotherapy – what to expect
Immediate: Bleeding
Infection
Rectal/Bowel injury
Anastomotic Stricture
Recurrence Salvage DXT, Radicals, WW
Incontinence PFE, Advance sling, AUS
Erectile dysfunction PDE5, vacuum pump, MUSE, Caverject
http://www.mskcc.org/mskcc/html/10088.cfm
Urinary Symptoms
Dysuria, bladder irritation, frequency, urgency
Bowel symptoms
Rectal irritation or discomfort
Diarrhoea and bleeding
Erectile dysfunction: gradually over 6–12/12
Second tumours
slightly higher risk of developing rectal or bladder cancer
Difficult salvage options
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Diverse
Variable
Challenging
Exciting