PrimaryCareManagementof StableProstateCancer

ByMarcLaniadoMDFEBUFRCS(Urol)

marc.laniado@nhs.netBASE1Dec,2015

EasthampsteadParkConferenceCentre

181,000menlivingwithprostatecancer

Manymenwithprostatecancerwhowon’tdie

NICECG175OFFERFOLLOWUPOUTSIDEHOSPITAL

Learningmoreaboutprostatecancerfor1°care

Ifwedon'tmakechanges….

Benefits for all• Patients

• care closer to home

• ↓appointment burden

• NHS

• ↑efficiency

• ↓ 2° care tariffs

• Optimisation of LHRH injections, PSA testing & follow ups

Primarycaremanagementofprostatecancer

Prostate examination▪ Prostate

▪ Size

▪ Normal – golf ball

▪ > 50 cm3 – tennis ball

– Consistency

▪ Nodule/asymmetric? Cancer

– Anatomical limits

▪ Should be able to feel median sulcus, lateral and cranial borders

▪ Seminal vesicles impalpable

– Normal anal tone and sensation

T1: feels benign T2: hard but mobile T3: hard, not mobile T4: fixed

DRE unnecessary if PSA normal for age in watchful waiting

Age Range PSA Threshold

40 to 49 years 2

50 to 59 years 3

60 to 69 years 4

Over 70 years 5

PSA varies by 15% & affected by many factors - best to avoid them

Naturalhistoryofprostatecancer

YearsaZerdiagnosis

Deadfromprostatecancer

Deadfromothercauses

4%chanceofdyingaZer10yforlowriskdiseaseinPSAerain65yearold

ContainsGleasonpa^ern3only

12345

40%chanceofdyingat10yearsforhighriskdiseaseinPSAeraina65yearold

YearsaZerdiagnosis

Deadfromprostatecancer

Deadfromotherreasons

Gleasonpa^ern4or5

12345

CG175 NICE risk stratification

Low risk cancers are about 50% of new cancer diagnoses

HighIntermediate/high

Intermediate

Low

Manyfeaturesdiscriminatelowandhighriskprostatecancer

• Cancercharacteristics• Gleasonscore• PSAabsolutelevel• Clinicalstage• Tumourvolume

• Patientcharacteristics• Biologicalmorethanchronologicalage

• MultiparametricmpMRI• restricteddiffusion

Clinicalcluesindicateprogressionpossible

• Deterioratingurinarysymptoms• IPSS/incontinence/haematuria/UTI

• Progressivechangesondigitalrectalexamination• Loinpain• Bonepain• IncreaseduseofNSAIDs/analgesics

• Weightloss• Newonsetneurology/spinalcordcompression• PSArising• FallingeGFR

Stableprostatecanceriswhatwewant!

“Stable”ProstateCancercanbehandedovertoprimarycare(NICECG175)

ActiveSurveillance/monitoring?-SHAREDCARE-

WatchfulWaiting

radicalprostatectomy/brachytherapy/externalbeam/Androgendeprivationagonists

UnsuitablePatients-relapsingafterlocaltreatment&castrateresistant

WatchfulWaiting=delayedpalliativeinterventionwithnointentiontocure

• Idealcandidate:earlyinterventionwon’treducemorbidity

• Assess• 4monthsx1yr,then6mox1yr,thenannually• PSAatleastannuallyforlife(NICE)• IfUTI,cipro/nitrof.for4weeks,thenrepeat• NODREunlessPSA>age-specific

• Indicationsforreferralto secondarycare• PSA>15-20ordoublingevery6months• DeterioratingLUTSorIPSS>20/35• Bonepain/weightloss/neurology

PSA 15% normal variation

024681012141618

PSA

PSA1

ActiveSurveillance=delayedselectiveinterventionwithintentiontocure

• Idealcandidate:earlyinterventionmaybeunnecessarybutcanreducemorbidity/mortalitysoneedscarefulwatching

• Complexarea-butimprovingrapidly• AssessmentofPSA,multiparametric

MRI,MRI-targetedprostatebiopsyinhospitalallowbetterselectionofpatients

At 5 and 10 years, 24% and 36% have come off active surveillance

26 Klotz 2015 JCO

Enhanced mpMRI can “see” prostate cancer that cannot

be felt or hit by transrectal biopsy

The same part of the prostate examined by MRI in different ways (“multiparametric MRI”) exposes cancer

Cancer in prostate

Bladder

Rectum

Anus

Active Surveillance better now with mpMRI & template biopsies

Back

Front

Prostate

Cancer Transrectal biopsies many problems

Back

Front

Prostate

Cancer``

``

Transperineal biopsies hits the significant cancer Unlikely to miss important cancer

Mulitparametric MRI: restricted diffusion predicts failure of active surveillance

Henderson 2015 Eur Urol

Follow up 12 years

n=86

MRI results not available to investigators

Postradicalprostatectomy:PSAverysensitiveindicatorofrecurrence

• NICE:“…after2years,menwithstablePSAandnosignificanttreatmentcomplications…”

• AssessPSAannuallyatleast,IPSS,eGFR

• DREunnecessary• Indicationsforreferralto

secondarycare• PSArising• ≥0.06ng/mlorconsultantthreshold

• DeterioratingLUTS/incontinence/UTI• Bonepain/weightloss/neurology/loinpain

Postbrachytherapy/radiotherapy:canbemoretrickytodetermineifnecessarytoreferback

• NICE:“…after2years,menwithstablePSAandnosignificanttreatmentcomplications…”

• AssessPSAannuallyatleast,IPSS,eGFR• NoDREunlessPSA>age-specificPSA• Indicationsforreferralto

secondarycare• PSArising• 2ng/mlabovenadirorspecifiedconsultant

threshold• DeterioratingLUTSorbowelsymptoms• Bonepain/weightloss/neurology/loinpain

Posthormonaltherapy:

• NICE:“…after2years,menwithstablePSAandnosignificanttreatmentcomplications…”

• AssessPSAannuallyatleast,IPSS,eGFR• Indicationsforreferralto

secondarycare• PSArising• specifiedconsultantthresholdordoubling

every6months• DeterioratingLUTSorbowelsymptoms• Bonepain/weightloss/neurology/loinpain/

spinalcordcompression

Hot flushes on androgen deprivation therapy

• Medroxyprogesterone

• 20 mg per day

• for 10 weeks, [new 2014]

• Cyproterone acetate

• 50 mg bd for 4 weeks [new 2014]

• no good-quality evidence for the use of complementary therapies to treat troublesome hot flushes. [new 2014]

Exercise to fight fatigue from androgen deprivation

• supervised resistance and aerobic exercise

• at least twice a week

• 12 weeks [new 2014]

Transferringfromsecondarytoprimarycare

Identifying patients to transfer

Hospital Clinic Medical Records EMIS codes B46

Welcome Letter: introduces man to 1° care management• Indicates date of check up

• Support information

• symptoms to look out for

• list of local support services

• definition of commonly used terms

• holistic care plan

Holistic Care Plan to be completed before GP/nurse appointment

Stable prostate cancer PSA appointment

Reporting Tool

iQudos system facilitates stable prostate cancer management in primary care

Protocolrequireshand-overletterwithclinicalinformationandGPtoconfirmacceptanceinwriting

PatientAssessedStable

Consultant

ConsultantsendsdischargelettertoGPpracticeincludingcontactdetailsandsharedcareprotocolfordischargedpatients

Practicedoesnotagreetotakeonpatient

GPhas4weekstoagreetotakeonpatient

GPacceptsandsignsagreementtotakeonpatientGPsendsthisalongwithcontactdetailstoConsultantandinformsUrologyCNSorPSN

GPhasChoicediscussionwithpatient

GP

ShardCareProtocolforfollowupchecks

RecordingandsharingofpatientfollowupsbetweenPSNandGP

MechanismforalertingGP’sPSN,Consultantoverconcerns

NewreferralfaxedtoConsultant’soffice

PatientneedstoreturntosecondarycarePatientremainsstable

PSN

PatientdischargedtoPrimaryCare

SecondarytoPrimaryCareReferralFormclinicaldetailsintophalf

SecondarytoPrimaryCareReferralForm:Replybacksoweknowyouaccept

Primarybacktosecondarycare:use2weekwaitorgiveusacall!

Pleasereferbackusingthe2weekwaitproforma

Case#1• Case1– healthy71-year-oldmantreatedforprostatecancer(Gleasonscore6,PSAlevel9ng/mL,T2)withradicalprostatectomy5.5yearsago.

– PSA0.001to0.7ng/mL,asymptomatic

• Doyouneedtobeconcernedbythisincrease?

Case#2

• 63-year-oldman– brachytherapy4yearsagoforprostatecancer(Gleasonscore6,PSA7ng/mL,T2)

– PSAnadir0.2ng/mL,andPSAvaluestakenevery3monthshavebeen0.7ng/mL,1.0ng/mL,0.8ng/mL,and,mostrecently,0.5ng/mL.

• Whatshouldyoudo?

PSAMonitoring

• RadicalProstatectomy– PSAshouldbeundetectable(<0.2ng/mlwithin3-6wks)– Persistentelevation• suggestiveofresiduallocalordistantdisease,• reflectresidualnormaltissue

– PSAof0.2-0.4ng/mlisconsideredaBCR(BiochemicalRecurrence)

– Whatshouldyoudo?

PSAMonitoring• ExternalBeamRadiotherapy– PSAshouldbe50%itspre-treatmentlevel3monthspost-treatment– PSAshoulddecreaseto0.2-0.5ng/mlwithin36months– PSAbounce

• Transitoryriseof0.4ng/mlor15%ofpreviousPSA• Spontaneouslyresolves• Seenin10-30%ofpeopletreatedwithEBRT• Usuallyoccurswithin9monthsoftreatment• Canoccurafter60months

– PSAfailure:LowestPSA+2.0ng/ml• Brachytherapy:PSAMonitoringunclear– AssumedsimilartoEBRT

Localvs.DistantRecurrence• Factorssuggestiveoflocalrecurrence– Initialpathology:Gleason<7,+vesurgicalmargins,nonodalinvolvement– >1-2yrsaftertreatmenttoPSAfailure– Pre-treatmentPSA<10– PSADT>12months

• Factorssuggestiveofdistantrecurrence– Initialpathology:Gleason>7,extra-prostaticinvolvement,nodal

involvement– <1yraftertreatmenttoBCR– Pre-treatmentPSA>10– PSADT<12months

PatientsWithIncurableDisease

• Visitsq6months– PSAtesting,optionalDRE– BMDq2yrsifonAndrogenDeprivationTherapy(ADT)– BonescanifPSA>20orclinicallyindicated– Evidenceofincreaseddiseaseactivity• PSA>10• PSADT<6mo• Symptomatic• ConsiderADTifnotalreadyreceivingit• ConsidersecondaryhormonaltherapyorchemoifalreadyreceivingADT

Case#1• Case1– healthy71-year-oldmantreatedforprostatecancer(Gleasonscore6,PSAlevel9ng/mL,T2)withradicalprostatectomy5.5yearsago.

– PSA0.001to0.7ng/mL,asymptomatic• Doyouneedtobeconcernedbythisincrease?• Mr.AhasevidenceofBCRandneedsrapidreferralforpotentialsalvagetherapy.

Case#2

• 63-year-oldman– brachytherapy4yearsagoforprostatecancer(Gleasonscore5,PSA7ng/mL,T2)

– PSAnadir0.2ng/mL,andPSAvaluestakenevery3monthshavebeen0.7ng/mL,1.0ng/mL,0.8ng/mL,and,mostrecently,0.5ng/mL.

• Whatshouldyoudo?– PSAbouncelikely– ≠BCR.– MonitorPSAlevels&symptoms.