A case of localized Prostate Cancer Marije Hamaker

Disclosure Nothing to disclose

The patient 2014 Born on 1943, worked as police officer, living with wife, with 3 sons. 1,69 mt x 65 Kg Comorbidity: -Hypertension -Cerebrovascular event 1999, mild left emiparesis -Left carotid thromboarterectomy 2000 -Hypercholesterolemia Which is the life expectancy (71 years in 2014)? Whould you adivise for PSA screening in this patient? 3

Urological History The patient undergoes PSA testing in 2014= 3ng/mL (primary care physician's prescription? Wife-induced prescription?) PSA repeated in June 2015: 6.5 without urinary symptoms Urology consultation: Palpable induration in the left prostatic lobe Erectal dysfunction (no interest on the matter) Would you perform prostatic biopsies? 4

Prostatic Biopsy In Oct 2015 the patient undergoes prostatic biopsies and new PSA testing=45. -8 positive cores out of 12 samples -Adenocarcinoma of the prostate Gleason 4+5=9 (GRADE GROUP 5) -Perineural infiltration Would you proceed with radiological staging ? Which radiological exams? 5

Staging with PSA 45 ng/mL Abdomen CT scan: negative (apart from enlarged prostate) Bone scintigraphy: positive on left tibia and several joints …...previous bike fall Would you proceed with PET/CT scan? …...not performed 6

What would you do? Will a Gleason 9 prostate cancer influence life-expectancy of this patient? -Watchful waiting, no further exams until symptoms of metastatic disease or urinary obstruction -Active Surveillance not indicated. -Prostatectomy -Radiotherapy -LH-RH analogue 7

The First Treatment The patient starts LH-RH analogue without Radiotherapy consultation March 2016: PSA 1.3, mild hot-flashes The patient is advised by a friend to have a multidisciplinary consultation at our Institution Are LH-RH analogues safe in this patient? 8

“Multidisciplinary Prostate Clinic” March 2015: First visit at our Radioterapy/Oncology Multidisciplinary Clinic, accompanied by a son. 72 years, lives with wife, KPS=90 Mild gait alteration ABP 125/80 Cholesterol 199 mg/dL No bladder voiding symptoms 9

Full Geriatric Assessment ADL=6, IADL=3 MMSE: 19 BMI=22.7 GDS=8 3 medications: aspirin, ACE inhibitor, atorvastatine (in the past also antidepressant) Worried about “progression of tumor” and “approaching end of life” which will prevent him from seeing his grandchildren Vulnerable for IADL impairment and comorbidity level 10

SIOG GUIDELINES 11

Need for geriatric intervention? Long discussion with the patient concerning the prognosis and therapeutic options for his prostate cancer but ALSO for his current comorbidities and “oncogeriatric” issues SEDENTARY HABITS (walking, but no more bike) DEPRESSIVE ATTITUDES: psycho-oncological support + psychiatric consultation + increase family meetings CARDIOLOGICAL EVALUATION? 12

RADIOTHERAPY The patient has aggressive prostate cancer with high risk of micro-metastatic disease. Surgery is not taken into consideration for this patient (already excluded by urologist) He accepts the proposal of external radiotherapy (already on LH-RH analogues) in order to potentiate local control of disease MRI of the pelvis is requested in order to restage local extension of the tumor after hormonal therapy 13

DISCUSSION POINTS SCREENING for prostate cancer in the elderly: not recommended Hormonal therapy alone may be under-treatment in the elderly with high-risk prostat cancer Treatment choice is still based on first specialist seen by the patient & comorbidies Multidisciplinary Team Discussion should be applied in order for the patient to express his own wishes and concerns 14