prostate cancer · ipss

9
22/05/2013 1 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 .8 1 Death Rate 0 .2 .4 .6 .8 1 0 5 10 15 20 Years After Surgery Age 60-69, Gleason 6 0 .2 .4 .6 .8 1 Death Rate 0 .2 .4 .6 .8 1 0 5 10 15 20 Years After Surgery Age 60-69, Gleason 7 0 .2 .4 .6 .8 1 Death Rate 0 .2 .4 .6 .8 1 0 5 10 15 20 Years After Surgery 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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Page 1: Prostate Cancer · IPSS

22/05/2013

1

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)

Page 2: Prostate Cancer · IPSS

22/05/2013

2

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

Page 3: Prostate Cancer · IPSS

22/05/2013

3

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

Page 4: Prostate Cancer · IPSS

22/05/2013

4

©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

Page 5: Prostate Cancer · IPSS

22/05/2013

5

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

Page 6: Prostate Cancer · IPSS

22/05/2013

6

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

Page 7: Prostate Cancer · IPSS

22/05/2013

7

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

Page 8: Prostate Cancer · IPSS

22/05/2013

8

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

Page 9: Prostate Cancer · IPSS

22/05/2013

9

Diverse

Variable

Challenging

Exciting