Prostate Cancer Treatment: What’s Best For You? Clark Atlanta University Center for Cancer Research and Therapeutic Development Prostate Cancer Symposium July 17th, 2010 Prostate Cancer Treatment: What’s Best For You? Rajesh G. Laungani, MD Director, Robotic Urology Chairman, Prostate Cancer Center Saint Joseph’s Hospital, Atlanta

2008 Estimated US Cancer Cases* Men 745,180 Women 692,000 Prostate 25% Lung and bronchus 15% Colon and rectum 10% Urinary bladder 7% Melanoma of skin 5% Non-Hodgkin 5% lymphoma Kidney 4% Leukemia 3% Oral Cavity 3% Pancreas 3% 26% Breast 14% Lung and bronchus 10% Colon and rectum 6% Uterine corpus 4% Non-Hodgkin lymphoma 4% Melanoma of skin 4% Thyroid 3% Ovary 3% Kidney 3% Leukemia Now we will turn our attention to the number of new cancers anticipated in the US this year. It is estimated that 1.37 million new cases of cancer will be diagnosed in 2005. Cancers of the prostate and breast will be the most frequently diagnosed cancers in men and women, respectively, followed by lung and colorectal cancers both in men and in women. *Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder. Source: American Cancer Society, 2008. JEMAL ET AL. CA CANCER J CLIN 2008 2

2008 Estimated US Cancer Deaths* Men 294,120 Women 271,530 26% Lung and bronchus 15% Breast 9% Colon and rectum 6% Ovary 6% Pancreas 3% Leukemia 3% Non-Hodgkin lymphoma 3% Uterine corpus 2% Liver & IBD 2% Brain/ONS Lung and bronchus 31% Prostate 10% Colon & rectum 8% Pancreas 6% Leukemia 4% Esophagus 4% Liver and intrahepatic 4% bile duct (IBD) Non-Hodgkin 3% Lymphoma Urinary bladder 3% Kidney 3% Lung cancer is the most common fatal cancer in men (31%), followed by prostate cancer (10%), and colon & rectum cancer (10%). In women, lung (27%), breast (15%), and colon & rectum (10%) are the leading sites of cancer death. ONS=Other nervous system. Source: American Cancer Society, 2005. JEMAL ET AL. CA CANCER J CLIN 2008. 3

Approach To Treatment of Prostate Cancer: A Multidisciplinary & Individualized Approach External Beam Radiation Open Surgery Good morning Our study is directed towards finding accurate predictions of treatment related outcomes in patients with prostate cancer. Watchful Waiting Brachytherapy Robotic Surgery 4

Treatment Options for Prostate Cancer Active Surveillance Radiation Therapy External Beam Brachytherapy aka “seeds” HDR Therapy Proton Therapy Hormonal Therapy Chemotherapy Surgery Robotics Laparoscopic Traditional Open Retropubic Perineal Cryosurgery HIFU

“One Size Does NOT Fit All” Age Gleason Grade Stage Co-Morbidities Individual Characteristics

What does a positive biopsy mean? Gleason Grade Gleason 6 Gleason 10 7 8 9 LOW GRADE HIGH GRADE

Staging Clinical: Pathological: DRE CT Scan Bone Scan MRI Margins Lymph nodes Extracapsular Extension Seminal Vesical Invasion

STAGE SUB-STAGE DEFINITION T1   Clinically unapparent tumor, not detected by DRE nor visible by imaging T1a Incidental histologic finding; <5% of tissue resected during TURP T1b Incidental histologic finding; >5% of tissue resected during TURP T1c Tumor identified by needle biopsy due to elevated PSA T2 Confined within the prostate (detectable by DRE, not visible on TRUS) T2a Tumor involves half of the lobe or less T2b Tumor involves more than one half of one lobe but not both lobes T2c Tumor involves both lobes T3 Tumor extends through the prostate capsule but has not spread to other organs T3a Unilateral extracapsular extension T3b Bilateral extracapsular extension T3c Tumor invades seminal vesicle(s) T4 Tumor is fixed or invades adjacent structures other than seminal vesicles T4a Tumor invades bladder neck and/or external sphincter and/or rectum T4b Tumor invades levator muscles and/or is fixed to pelvic wall Node (N) Regional lymph nodes N0 No lymph nodes metastasis N1 Metastasis in single lymph node <2 cm in greatest dimension N2 Metastasis in single lymph node >2cm but <5 cm in greatest dimension, or multiple lymph nodes, none >5 cm N3 Metastasis in lymph node >5 cm in greatest dimension Metastasis Systemic spread M0 No distant metastasis M1a Non-regional lymph node metastasis M1b Bone metastasis      a) Axial skeleton only      b) Extending to peripheral skeleton also M1c Metastasis at other sites

Robotic Surgery Decreased Pain Shorter Hospital Stay Decreased Blood Loss Quicker Recovery Improved Quality of Life after Surgery

Current Trends 36% 63%

Robotic Prostatectomy

Do Advanced Tools result in Better Outcomes ?

Vision and Control

How do attributes of robotic surgical systems translate into outcomes? Operative parameters Oncologic parameters Quality of life parameters Potency & continence

Urinary Continence Joseph et al. 2006 N=325 Mean age: 60 Method of Assessment: Questionairre Definition used: No pad Time of assessment: 6 mos Continence Rate: 96% Joseph et al. J Urol 2006

Bilateral Nerve Preservation Technique “The Veil of Aphrodite” Menon et al. N=250 Mean age: 59.9 Method of Assessment: Questionairre Definition used: Intercourse Time of Assessment: 6 mos Potency Rate: 64% Menon et al. Urol Clin of Amer 2004

Oncologic Efficacy Badani et al. N=2766 Gleason 7 or >: 64% Median follow up: 22 mos PSA recurrence rate: 7.3% 5 year biochemical free survival: 84% Badani et al. Cancer 2007

Robotics vs. Open vs. Laparoscopic RRP daVP LRP Parameter 164 140 248 Op time (min) 900 <100 380 Blood Loss(ml) 12% 8% 24% Positive Margins 15% 5% 10% Complications 15 5-7 8 Catheter(d) 3.5 1.2 1.3 Hospitalization

How do I choose the best surgeon?

What questions should I ask? Training? Fellowship? Experience? How many cases have you done? Reputation? Having a robot and knowing how to do robotic surgery are very different things?

Steady and Experienced Behind the Wheel

Thank You