PSA & Prostate Cancer Dan Burke Consultant Urological Surgeon Uro-Oncology & Complex Laparoscopic Surgery

Incidence of Prostate Cancer 2008 37 051 new cases in UK 10 168 deaths from Ca Prostate 101 men diagnosed every day One new diagnosis every 15 minutes Accounts for 3% of male mortality daniel.burke@cmft.nhs.uk

Incidence daniel.burke@cmft.nhs.uk

Age at diagnosis daniel.burke@cmft.nhs.uk

PSA

2 raised readings - beware UTI’s, LUTS(acute), big prostates PSA – relative risk Age related <50 ?? 50-60 <2.5 60-70 <3.5 70-80 <6.0 0ver 80 – abnormal DRE 2 raised readings - beware UTI’s, LUTS(acute), big prostates PSA Velocity >0.75 / year Low readings <0.7 Reassurance daniel.burke@cmft.nhs.uk

PSA velocity / density >0.75 per year Doubling time Patterns over time (fluctuating PSA’s with large prostates) Accept higher PSA levels with larger prostates – but obtain a predicted PSA with TRUSS Changes of PSA with dutasteride / finasteride daniel.burke@cmft.nhs.uk

DRE daniel.burke@cmft.nhs.uk

Prostate Cancer Risk Calculator daniel.burke@cmft.nhs.uk

daniel.burke@cmft.nhs.uk

0.9 13.2% 1% 12 57.8% 22.1% Same man different PSA PSA Chances of detecting a cancer Chances of detecting a high grade cancer 0.9 13.2% 1% 12 57.8% 22.1% daniel.burke@cmft.nhs.uk

Same man different history Chances of detecting a cancer Chances of detecting a high grade cancer Abnormal DRE & FH PSA 3.2 59% 12.3 PSA 12 >75% 43% daniel.burke@cmft.nhs.uk

Screening daniel.burke@cmft.nhs.uk

Prostate cancer screening could see every man over 50 tested March 2009 Prostate cancer screening could see every man over 50 tested All men over the age of 50 could be tested for prostate cancer after the largest international study ever conducted suggested that screening could save thousands of lives a year in Britain. daniel.burke@cmft.nhs.uk

Mortality Results from a Randomized Prostate-Cancer Screening Trial The Evidence Screening and Prostate-Cancer Mortality in a Randomized European Study Published at www.nejm.org March 18, 2009 (10.1056/NEJMoa0810084) 182,000 men Mortality Results from a Randomized Prostate-Cancer Screening Trial Published at www.nejm.org March 18, 2009 (10.1056/NEJMoa0810696) 76,693 men daniel.burke@cmft.nhs.uk

The Facts 820 / 10,000 Carcinoma of the Prostate diagnosed in screened arm vs 480 / 10,000 diagnosed in control arm daniel.burke@cmft.nhs.uk

The Facts 73,000 men screened 17,000 biopsies daniel.burke@cmft.nhs.uk

The Facts 227/10,000 radical prostatectomies performed in screened arm Vs 100/10,000 in control arm daniel.burke@cmft.nhs.uk

214 / 10,000 Deaths due to prostate cancer (Screened arm) Vs 326 / 10,000 (unscreened arm) daniel.burke@cmft.nhs.uk

1410 people screened 48 treated 1life saved Over a 10 year period The Facts 1410 people screened 48 treated 1life saved Over a 10 year period daniel.burke@cmft.nhs.uk

The conclusion! European Study – Screening has its place Based on improved rate of cancer deaths American Study – No role for screening Risk of over treating too many for a small gain BUT NEITHER STUDY WAS CONCLUSIVE daniel.burke@cmft.nhs.uk

Who to screen – risk factors for clinically significant prostate cancer Afro-Caribbean men – 3x and diagnosed younger 1st degree relative diagnosed at a young age – 3x increase risk Strong family history – 5x increase risk The concerned informed patient daniel.burke@cmft.nhs.uk

The HSC205 referral ?early prostate CA YES NO Young men Family history Afro-caribean rising PSA Age related PSA Symptomatic / advanced CaP <10year life expectancy Over 80 with normal DRE Raised PSA with UTI daniel.burke@cmft.nhs.uk

Average life expectancy in years Current age daniel.burke@cmft.nhs.uk

New Headlines daniel.burke@cmft.nhs.uk

10:00PM BST 16 Apr 2012 New treatment for prostate cancer gives 'perfect results' for nine in ten men: research A study has found that focal HIFU, high-intensity focused ultrasound, provides the 'perfect' outcome of no major side effects and free of cancer 12 months after treatment, in nine out of ten cases. Study of 41 patients. daniel.burke@cmft.nhs.uk

High Intensity Focused Ultrasound daniel.burke@cmft.nhs.uk

Prostate biopsy / prostate mapping Standard Template daniel.burke@cmft.nhs.uk

Study raises doubts over treatment for prostate cancer Saturday 28 April 2012 Study raises doubts over treatment for prostate cancer Experts shaken by verdict suggesting thousands of men go through painful treatment for nothing USA study of an older age group average age 67, many low grade disease that would not have been offered surgery in the UK daniel.burke@cmft.nhs.uk

WHY SURGERY? 'Currently, radical prostatectomy is the only treatment for localised prostate cancer that has shown a cancer-specific survival benefit...in a prospective, randomized trial.' European Association of Urologists Guidelines on Prostate Cancer, 2008. daniel.burke@cmft.nhs.uk

Manchester Royal Infirmary surgeons first to use 3D 2 April 2012 Manchester Royal Infirmary surgeons first to use 3D Surgeons at Manchester Royal Infirmary claim to be the first in the UK to use a full 3D projection during an operation. During the operation, a high definition screen carried a 3D image of a hand-held robotic arm developed to carry out intricate surgical techniques daniel.burke@cmft.nhs.uk

New Medicines daniel.burke@cmft.nhs.uk

Aberatirone Mean survival 3 months Cost approx £3000 for 30 days NICE approved 1g a day single dose 4x250mg tablets daniel.burke@cmft.nhs.uk

Prostate Cancer Follow-Up daniel.burke@cmft.nhs.uk

Should we be concerned? Prostate Cancer patients have a worse experience of care including after care than other cancer patients Department of Health - 2005 daniel.burke@cmft.nhs.uk

What’s the evidence / guidelines Who should do it? Who should have it? What’s the evidence / guidelines daniel.burke@cmft.nhs.uk

Nice guidelines 2008 Post Radical Treatment PSA at the earliest 6 weeks post treatment PSA at least every 6 months for the next 2 years PSA then at least once a year thereafter daniel.burke@cmft.nhs.uk

Nice guidelines 2008 After 2 years Stable PSA and no complications then follow up should be offered outside the hospital Telephone follow up Primary care Electronic communications daniel.burke@cmft.nhs.uk

Nice guidelines 2008 DRE (changed from 2002) Now NOT recommended in men with localised prostate cancer while PSA remains stable Warren KS, McFarlane JP J Urol 2007 Jul:178(1):11-9 daniel.burke@cmft.nhs.uk

Nice guidelines 2008 Follow-up Watchful waiting Should normally be followed up in primary care in accordance with protocols agreed by the local MDT PSA should be measured at least once a year daniel.burke@cmft.nhs.uk

Metastatic Patients NICE Sweden Canada Primary care manage day to day complications Sweden More regular PSA testing Canada Less regular PSA testing daniel.burke@cmft.nhs.uk

My Practice Post Laparoscopic Radical Prostatectomy 8/52 post op PSA & Clinical assessment 3/12 for 1 year 6/12 for 1-2 years Discharged to Primary Care Exceptions: Gleason 8/9/10 and/or positive margins and/or BCR daniel.burke@cmft.nhs.uk

My Practice Active Surveillance 3/12 PSA 1 year repeat TRUSS + biopsy 6/12 PSA for 2 years Primary care follow up Exceptions: unstable/fluctuating PSA, Age <65, patient request daniel.burke@cmft.nhs.uk

My Practice Watchful waiting 3/12 PSA for 1 year 6/12 PSA for 1 year Primary Care follow up Exceptions: GP or patient request daniel.burke@cmft.nhs.uk

My Practice Metastatic disease 3/12 PSA initially Symptomatic management Patient specific follow-up daniel.burke@cmft.nhs.uk

Communication with Primary Care Agreed pathways Avoids ‘double’ tests Avoids unnecessary re-referrals Patient copied into communications Agreements on costings of follow-up / new appointments daniel.burke@cmft.nhs.uk

Prostate Cancer Pathways daniel.burke@cmft.nhs.uk

Post Radical Surgery PROPOSED PSA PATHWAY CMFT 2 years post surgery   Post Radical Surgery 2 years post surgery No functional problems PSA Unrecordable Discharge for primary care follow-up 6 monthly PSA PSA unrecordable detectable PSA Continue PSA referral back tertiary care daniel.burke@cmft.nhs.uk

Post Radical Radiotherapy   2 years post radiotherapy (+/- hormonal treatment) No functional Problems + PSA Stable Discharge for primary care follow up With instructions on length of hormonal treatment 6 monthly PSA PSA <2.0 + asympotomatic PSA >2.0 or symptomatic 6 monthly PSA Referral to Urologist or Oncologist daniel.burke@cmft.nhs.uk

Hormonal Treatment PSA Stable for 2 years or satisfactory PSA response   PSA Stable for 2 years or satisfactory PSA response Asymptomatic Discharge to primary care Individual follow-up plan PSA every 3 / 6 or 12 months as directed PSA above designated level PSA stable  or patient symptomatic patient asymptomatic Referral back to Urologist Continue PSA follow-up as directed daniel.burke@cmft.nhs.uk

Active Survaillence Watchful waiting   To remain under consultant care Watchful waiting PSA stable for 1 year Patient asymptomatic Discharge to primary care for follow-up 3/6 or 12 monthly PSA as directed at discharge PSA below recommended level PSA above commended level Patient asymptomatic or patient symptomatic Remain under primary care referred back to urologist daniel.burke@cmft.nhs.uk

And Finally PSA PATHWAY NO DIAGNOSIS OF CA PROSTATE Individual follow up Patient specific Clear discharge letter daniel.burke@cmft.nhs.uk

‘The definition of insanity is doing the same thing over and over and expecting different results’ daniel.burke@cmft.nhs.uk