Prostate Cancer Treatment: What’s Best For You?

Rajesh G. Laungani, MDDirector, Robotic Urology

Chairman, Prostate Cancer CenterSaint Joseph’s Hospital, Atlanta

Clark Atlanta UniversityCenter for Cancer Research and Therapeutic Development

Prostate Cancer SymposiumJuly 17th, 2010

2008 Estimated US Cancer Cases*

*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.Source: American Cancer Society, 2008.

Men745,180

Women692,000

26% Breast

14% Lung and bronchus

10% Colon and rectum

6% Uterine corpus

4% Non-Hodgkin lymphoma

4% Melanomaof skin

4% Thyroid

3% Ovary

3% Kidney

3% Leukemia

Prostate 25%

Lung and bronchus 15%

Colon and rectum 10%

Urinary bladder 7%

Melanoma of skin 5%

Non-Hodgkin 5%

lymphoma

Kidney 4%

Leukemia 3%

Oral Cavity 3%

Pancreas 3%

JEMAL ET AL. CA CANCER J CLIN 2008

2008 Estimated US Cancer Deaths*

ONS=Other nervous system.Source: American Cancer Society, 2005.

Men294,120

Women271,530

26% Lung and bronchus

15% Breast

9% Colon and rectum

6% Ovary

6% Pancreas

3% Leukemia

3% Non-Hodgkin lymphoma

3% Uterine corpus

2% Liver & IBD

2% Brain/ONS

Lung and bronchus 31%

Prostate 10%

Colon & rectum 8%

Pancreas 6%

Leukemia 4%

Esophagus 4%

Liver and intrahepatic 4%bile duct (IBD)

Non-Hodgkin 3%

Lymphoma

Urinary bladder 3%

Kidney 3%

JEMAL ET AL. CA CANCER J CLIN 2008.

External Beam Radiation

Robotic SurgeryBrachytherapy Watchful Waiting

Open Surgery

Approach To Treatment of Prostate Cancer:

A Multidisciplinary & Individualized Approach

Treatment Options for Prostate Cancer• Active Surveillance

• Radiation Therapy– External Beam– Brachytherapy aka

“seeds”– HDR Therapy– Proton Therapy

• Hormonal Therapy

• Chemotherapy

• Surgery– Robotics– Laparoscopic– Traditional Open

• Retropubic• Perineal

– Cryosurgery– HIFU

“One Size Does NOT Fit All”

• Age• Gleason Grade• Stage• Co-Morbidities• Individual Characteristics

What does a positive biopsy mean?

Gleason Grade

Gleason 6 Gleason 10

LOW GRADE HIGH GRADE

7 8 9

Staging

• Clinical:– DRE– CT Scan– Bone Scan– MRI

• Pathological:– Margins– Lymph nodes– Extracapsular Extension– Seminal Vesical Invasion

STAGE SUB-STAGE DEFINITION T1 Clinically unapparent tumor, not detected by DRE nor visible by imaging T1a Incidental histologic finding; <5% of tissue resected during TURP T1b Incidental histologic finding; >5% of tissue resected during TURP T1c Tumor identified by needle biopsy due to elevated PSA T2 Confined within the prostate (detectable by DRE, not visible on TRUS) T2a Tumor involves half of the lobe or less T2b Tumor involves more than one half of one lobe but not both lobes T2c Tumor involves both lobes T3 Tumor extends through the prostate capsule but has not spread to other organs T3a Unilateral extracapsular extension T3b Bilateral extracapsular extension T3c Tumor invades seminal vesicle(s) T4 Tumor is fixed or invades adjacent structures other than seminal vesicles T4a Tumor invades bladder neck and/or external sphincter and/or rectum T4b Tumor invades levator muscles and/or is fixed to pelvic wall

STAGE SUB-STAGE DEFINITION Node (N) Regional lymph nodes N0 No lymph nodes metastasis N1 Metastasis in single lymph node <2 cm in greatest dimension N2 Metastasis in single lymph node >2cm but <5 cm in greatest dimension, or multiple lymph nodes, none >5 cm N3 Metastasis in lymph node >5 cm in greatest dimension

STAGE SUB-STAGE DEFINITION Metastasis Systemic spread M0 No distant metastasis M1a Non-regional lymph node metastasis M1b Bone metastasis

a) Axial skeleton only b) Extending to peripheral skeleton also

M1c Metastasis at other sites

Robotic Surgery• Decreased Pain

• Shorter Hospital Stay

• Decreased Blood Loss

• Quicker Recovery

• Improved Quality of Life after Surgery

Current Trends

2007 U.S. Radical Prostatectomy (Projected)

dVP

LRP

Open

63%36%

36 247 7662648

8,642

17,582

32,631

48,000

0

10000

20000

30000

40000

50000

60000

70000

80000

2000 2001 2002 2003 2004 2005 2006 2007 2008

U.S. Robotic Prostatectomy Trends

Robotic Prostatectomy

Do Advanced Tools result in Better Outcomes ?

Vision and Control

How do attributes of robotic surgical systems translate into outcomes?

• Operative parameters

• Oncologic parameters

• Quality of life parameters• Potency & continence

Urinary Continence

• Joseph et al. 2006• N=325• Mean age: 60• Method of Assessment: Questionairre• Definition used: No pad• Time of assessment: 6 mos• Continence Rate: 96%

Joseph et al. J Urol 2006

Bilateral Nerve Preservation Technique

“The Veil of Aphrodite”• Menon et al.• N=250• Mean age: 59.9• Method of Assessment: Questionairre• Definition used: Intercourse• Time of Assessment: 6 mos• Potency Rate: 64%

Menon et al. Urol Clin of Amer 2004

Oncologic Efficacy

• Badani et al.• N=2766• Gleason 7 or >: 64%• Median follow up: 22 mos

– PSA recurrence rate: 7.3%

• 5 year biochemical free survival: 84%

Badani et al. Cancer 2007

Robotics vs. Open vs. Laparoscopic

3.53.5 1.21.21.31.3HospitalizationHospitalization

15%15% 5%5%10%10%ComplicationsComplications

1515 5-75-788Catheter(d)Catheter(d)

12%12% 8%8%24%24%Positive MarginsPositive Margins

900900 <100<100380380Blood Loss(ml)Blood Loss(ml)

164164 140140248248Op time (min)Op time (min)

RRPRRP daVPdaVPLRPLRPParameterParameter

How do I choose the best surgeon?

What questions should I ask?

• Training?• Fellowship?• Experience?• How many cases have you done?• Reputation?

• Having a robot and knowing how to do robotic surgery are very different things?

Steady and Experienced Behind the Wheel

Thank You