Prostate cancer update

Suresh GANTAConsultant urological surgeon

Manor Hospital

Agenda

Suspected cancer referral update Management of PSA. What is new about prostate cancer

Prostate cancer management update Primary care management Secondary care management

When to do PSA

After the age of 50 yrs Do earlier (40 yrs) if family history and Afro-Caribbean

descent.

Consider PSA and DRE in patients with

Any LUTS (nocturia/frequency/retention/hesitency/urgency)

ED Visible Hematuria

Suspected cancer referrals: urology NICE 2015

PSA above the age specific range.

Malignant feeling prostate on DRE : refer under 2 week pathway Hard/firm feeling prostate, hard nodule

Prostate cancer

41K new cases of prostate cancer each year in the UK, so a full time GP will diagnose one new person with prostate cancer each year.

134 new cancers /100,000 men. 10K die each year from prostate cancer in UK 5 Yr survival is 80%

Clinical symptoms

Presenting complaints PPV

LUTS (voiding/storage) Hematuria 1.8% ED Disseminated disease. Nocturia + abn DRE 15% Loss of weight + nocturia 12% Loss of weight + BPH on DRE 9.4%

PSA facts

PSA between 3-10 only 20% have cancer on biopsy PSA >10 upto 50% risk of cancer Screening: currently not supported by all organisations

13 year follow up from ERSPC shows a 0.11 reduction of death from caP per 1000 person years. 1 caP death averted in 781 screened and 27 additional caP detected.

Other PSA related parameters

PSA density (prostate volume) PSA velocity. PSA doubling time.

Baseline PSA at 40-45 yrs

Early PSA between 40 and 45yrs has a potential to predict risk of advanced caP 30 yrs later.

If the PSA is <1 then low risk and only repeat 8yrs later.

PSA >1.4 to monitor more closely.

What is new in the diagnosis of prostate cancer

TRUS biopsy of the prostate :

Multiparametric MRI of the prostate to identify lesions more accurately. Increased characterization of the lesions PIRAD scoring system Improved accuracy of biopsy targeting using fusion

software.

Background

Peripheral zone 70 % Central zone 25% Transitional zone 5%

TRUS vs transperineal biopsy prostate

Accessing peripheral zone. Misses 12-15% of cancer. Only targeting through

ultrasound and hence ‘blind’.

NICE guidance CG 175

Magnetic resonance imaging for rebiopsy

Consider multiparametric MRI (using T2- and diffusion-weighted imaging) for men with a negative transrectal ultrasound 10–12 core biopsy to determine whether another biopsy is needed. [new 2014]

Do not offer another biopsy if the multiparametric MRI (using T2- and diffusion-weighted imaging) is negative, unless any of the risk factors listed in recommendation 1.2.5 are present. [new 2014]

Risk factors in patients with negative TRUS biopsy.

Men who have had a negative first prostate biopsy still has a risk that prostate cancer is present and

the risk is slightly higher if any of the following risk factors are present:

The biopsy showed high-grade prostatic intra-epithelial neoplasia (HGPIN)

The biopsy showed atypical small acinar proliferation (ASAP)

Abnormal digital rectal examination. [new 2014]

MRI pre biopsy

263 consecutive patients with suspicion of prostate cancer were investigated.

All had 3-T multiparametric MRI (mpMRI) applying the European Society of Urogenital Radiology criteria.

All patients underwent MRI/US-fusion biopsy transperineally (mean nine cores) and additionally a systematic transrectal biopsy (mean 12 cores).

Benefit of MRI to target

Abnormality on MRI is common.

Significant abnormality is in central and ventral area NOT accessible by TRUS.

45% (69/154) peripheral zone

37% (57/154) central zone

18% (28/154) ventral zone of the prostate

AllWithout previous biopsy

Repeat biopsy

Number of patients 263 68 195

Lesions, n 531 131 400

PI-RADS on mpMRI, n (%)

PI-RADS < 2 86 (18.9) 22 (20) 64 (18.6)

PI-RADS 3 183 (40.3) 31 (28.2) 152 (44.2)

PI-RADS 4 135 (29.8) 44 (40) 91 (26.4)

PI-RADS 5 50 (11.0) 13 (11.8) 37 (10.8)

Benefit of MRI to target

AllWithout previous biopsy

Repeat biopsy

Number of patients 263 68 195

Lesions, n 531 131 400

Men with proven prostate cancer, n (%)Overall 137 (52) 35 (52) 102 (52)Targeted biopsy 116 (44) 31 (46) 85 (44)

Systematic biopsy 91 (34) 29 (43) 62 (32)

More lesions noted per patient

More cancers in targeted transperineal biopsy 44% vs standard TRUS biopsy34%.

We may have to do both to be able to get best outcomes.

First biopsy the difference is small.

MRI/US-fusion biopsy detected significantly more cancer than systematic prostate biopsy (44% [116/263] vs 35% [91/263]; P = 0.002).

In first biopsy, the detection rate was 46% (31/68) in targeted and 43% (29/68) in systematic biopsy (P = 0.527).

Treatment of prostate cancer.

Localised prostate cancer: Active surveillance Radical retropubic prostatectomy

Robotic Laparoscopic Open.

Radical radiotherapy Brachy therapy

Locally advanced prostate cancer Metastatic prostate cancer. Management of hormone resistant prostate cancer.

When to do active surveillance

Level of risk PSA Gleason

scoreClinical stage

Low risk <10 ng/ml

≤6 T1–T2a

Intermediate risk

10–20 ng/ml

7 T2b

High risk1

>20 ng/ml

8–10 ≥T2c

Timing Tests 1

At enrolment in active surveillance Multiparametric MRI if not previously performed

Every 3–4 months: measure PSA2

Throughout active surveillance: monitor PSA kinetics3

Every 6–12 months: DRE4

At 12 months: prostate rebiopsy

Every 3–6 months: measure PSA2

Throughout active surveillance: monitor PSA kinetics3

Every 6–12 months: DRE4

Every 6 months: measure PSA2

Throughout active surveillance: monitor PSA kinetics3

Every 12 months: DRE4

4 Should be performed by a healthcare professional with expertise and confidence in performing DRE.

Year 1 of active surveillance

Years 2–4 of active surveillance

Year 5 and every year thereafter until active surveillance ends

1 If there is concern about clinical or PSA changes at any time during active surveillance, reassess with multiparametric MRI and/or rebiopsy.

2 May be carried out in primary care if there are agreed shared-care protocols and recall systems.

3 May include PSA doubling time and velocity.

Management of prostate cancer in primary care

Raised PSA and negative prostate biopsy: Active surveillance Stable prostate cancer in metastatic prostate cancer.

Stable metastatic prostate cancer

Hormone treatment Zoladex/ prostap/

Intermittent hormone treatment. Monitor PSA Q 3 mo Restart if PSA >10

Summary

PSA remains the marker of choice. PPV increases with loss of weight, abnormal DRE +/- LUTS MRI helps to identify areas of the prostate that are

suspicious and allows targeted biopsy and may influence treatment.

Active surveillance is a suitable option in low risk prostate cancer.

Primary care management of patients with stable metastatic prostate cancer on hormone treatment .

Questions please?