Prostate Cancer What a GP Needs to Know Dr Manish Patel Urological Cancer Surgeon Sydney Adventist Hospital Westmead Public and Private Hospital Senior Lecturer, University of Sydney

Prostate Cancer What a GP Needs to Know Prostate Cancer Screening What you need to tell your patients. The PSA test When to refer to a urologist. Localised Prostate Cancer What are the newest modalities? Androgen Deprivation Therapy How to monitor these men.

1. Prostate Cancer Screening What you need to tell your patients. Mr J.B. 57 year old. Mild LUTS Hypertension Asks his G.P. whether he needs a test for prostate cancer? What should the G.P discuss with him?

1. Prostate Cancer Screening What you need to tell your patients. PSA Blood test Can detect early Cancer Digital Rectal Exam Important 15% of cancers have “normal” PSA but abnormal DRE.

1. Prostate Cancer Screening What you need to tell your patients. Potential Benefits Potential Harms False positives are common. Indolent cancers are treated inadvertently PSA screening detects cancers earlier. Treating early CaP improves survival. Negative results reduce anxiety Test is easy to administer What we have attempted to show here is a balance between the potential benefits and harms or side effects of screening and early treatment. On the benefits side, evidence appears strong that PSA screening leads to early detection of prostate cancer. There is evidence that treating PSA-detected prostate cancer may be effective in reducing the likelihood that patients will die from the disease, but other evidence makes this uncertain. PSA use may contribute to the decline in U.S. prostate cancer mortality, but the evidence is not consistent. For harms or side effects, false positives are common. Overdiagnosis is a problem, but we are uncertain about the magnitude. Treatment-related side effects are fairly common. The balance of potential benefits and possible side effects is uncertain. This uncertainty leads the clinician to ask the next question. Need to discuss the individual benefits and risks of screening with all male patients 50-70years.

Risk Of Prostate Cancer 2. The PSA Test-When to Refer to a Urologist. Risk of Prostate Cancer in Men with Normal DRE PSA Levels Risk Of Prostate Cancer 1-1.99 17% 2-2.99 24% 3-3.99 27% 4-10 29% 10+ 45%

2. The PSA test When to refer to a urologist. Age Median PSA Normal Range 40-49 0.7ng/ml 0-2.5ng/ml 50-59 0.9ng/ml 0-3.5ng/ml 60-69 1.2ng/ml 0-4.5ng/ml 70+ 1.4ng/ml 0-6.5ng/ml

2. The PSA test- When to refer to a urologist 2. The PSA test- When to refer to a urologist. Free to Total (%) Does Help Specificity.

2. The PSA test- When to refer to a urologist 2. The PSA test- When to refer to a urologist. PSA Velocity is important to calculate Men with PSA below 4.0ng/ml PSA velocity > 10%/yr =30% risk CaP PSA velocity >0.4ng/ml/yr = 45% risk CaP PSA velocity >2.0ng/ml/yr = high risk of death More accurate with multiple measures over time.

2. The PSA test- When to refer to a urologist. Suggested Algorithm

3. Localised Prostate Cancer- Options of Treatment Active Surveillance Radical Prostatectomy Seed Brachytherapy External Beam Radiotherapy +/- hormone deprivation. HDR Brachytherapy HIFU (High Intensity Focused Ultrasound) Watchful Waiting

3. Localised Prostate Cancer- Active Surveillance 99% 8year disease specific survival Advantages: Avoid treatment in 50% of men Only treat men who need treatment Disadvantages Anxiety Possibility of “missing the window of opportunity” Patel et.al. J Urol. 2004;171(4):1520

3. Localised Prostate Cancer- Radical Prostatectomy Advantages: Good cure rate Quick recovery in young men Salvage XRT Prostate NVB Disadvantages Possible incontinence Possible impotence Rectum

3. Localised Prostate Cancer- Robotic or Laparoscopic Radical Prostatectomy Advantages Less blood loss 1 day less hospital stay Disadvantages Unable to palpate the cancer (Positive margin) Poorer continence and potency Learning curve Expensive

3. Localised Prostate Cancer- Brachytherapy Advantages: Minor procedure Disadvantages Only for low risk Urinary symptoms Rectal symptoms Unable to have surgery afterwards Urethra Rectum

3. Localised Prostate Cancer- External Beam Radiotherapy Advantages: Minor procedure Disadvantages 7 weeks treatment May need hormones Urinary symptoms Rectal symptoms Unable to have surgery afterwards

3. Localised Prostate Cancer- HDR Brachytherapy Advantages: Good treatment of high risk disease Disadvantages Need hormones 5 weeks EBRT Urinary symptoms Rectal symptoms Unable to have surgery afterwards

3. Localised Prostate Cancer- HIFU Advantages: Minimally invasive Similar cure to XRT High continence and potency Repeatable procedure Disadvantages Expensive Experimental

4. Androgen Deprivation Therapy How to Monitor These Men. Factor Treatment Osteoporosis Ca, Vit D, Exercise. Annual DEXA scan Lipid profile Regular measurements, cholesterol lowering drugs Weight gain Exercise Loss of muscle mass Cognitive decline Social support, Intellectual stimulation Depression Understanding, Counselling, Exercise, Medication

Summary Prostate Cancer Screening The PSA test Tell your patients all the Pros and Cons. The PSA test Criteria will continue changing Divide in to Definite, Possible and Watch categories. Localised Prostate Cancer Lots of new modalities Androgen Deprivation Therapy Monitor their cardiac and bone health