1. Prostate Cancer David Eedes 11 May 2013

2. Prostate Cancer Definition: Prostate cancer is a disease in which cells in the prostate gland become abnormal and start to grow uncontrollably, forming tumours. Histology: Adenocarcinoma

3. Prostate Cancer Symptoms: (similar to benign prostatic hypertrophy) - frequency - nocturia - hesitancy/poor stream - haematuria - dysuria. Bone pain in advanced metastatic disease.

4. Prostate Cancer Risk Factors: The primary risk factors are obesity, age and family history. First degree family = 2x Certain genetic risks or oncogenes have been identified

5. Prostate Cancer - Screening Goals of screening: – Finds cancer before symptoms appear – Screens for a cancer that is easier to treat and cure when found early – Has few false-negative test results and false- positive test results – Decreases the chance of dying from cancer Stats: 1410 screened/48 treated/1 death prevented

6. Prostate Cancer - Screening Problems of screening: -over diagnosis -over treatment "The real impact and tragedy of prostate cancer screening is the doubling of the lifetime risk of a diagnosis of prostate cancer with little if any decrease in the risk of dying from this disease.” Screening recommendations: Promote awareness in patients; discuss pros and cons of regular PSA/DRE

7. Prostate Cancer Screening Prostatic Specific Antigen - PSA

8. Prostate Cancer - screening Ref: The United States Preventive Services Task Force. 2012 JCO

9. Prostate Cancer – Screening/Diagnosis 1.DRE 2.PSA – affected by prostatitis, ejaculation/medicines (5 alpha reductase inhibitors) Age to do screening: 50 – 75 (depends on life expectancy) Referral pathways

10. Prostate Cancer – Screening/Diagnosis 1. Digital Rectal Examination - DRE Method Abnormal DRE to Urologist

11. Prostate Cancer – Screening/Diagnosis 2. Prostatic Specific Antigen - PSA

12. Prostate Cancer - Diagnosis Transrectal ultrasound guided prostate biopsy

13. Prostate Cancer - Diagnosis Transrectal ultrasound guided prostate biopsy

14. Prostate Cancer - Diagnosis Histology looks at: Grade - Gleason score A + B

15. Prostate Cancer - Diagnosis Histology looks at: Grade Volume of disease Peri-neural infiltration (Capsular or seminal vesicle infiltration)

16. Prostate Cancer - Staging Stage I Incidental Stage II Palpable/PSA Stage III Seminal vesicle or through capsule Stage IV into glands other organs/distant mets

17. Prostate Cancer Incidence: 150/100 000 Mortality rates 23/100 000/year Survival by Stage:

18. Prostate Cancer - Treatment Watchful Waiting Active Surveillance Radical Prostatectomy External Beam Radiotherapy (EBRT) Prostate Implant Brachytherapy Hormonal therapy - LHRH agonists - Anti-androgens - Castration

19. Prostate Implant Brachytherapy

20. Iodine-125 and Palladium-103 (Gold – 198; Cesium -131

21. Prostate EBRT

22. Prostate External Beam Radiation Therapy (EBRT)

23. Prostate EBRT

25. Radical Prostatectomy Types: - Radical retropubic - Radical perineal - Suprapubic transvesical - Laparoscopic radical - Computer-assisted laparoscopic radical (robotic)

26. Prostate Hormonal therapy Neo-adjuvant Adjuvant - LHRH agonists -goserelin -leuprolide -buserelin - anti-androgens -bicalutamide -flutamide -cyproterone (steroidal)

27. Prostate Cancer - Follow up Aims: - identify recurrence - PSA (DRE) - identify and manage complications (inform patients what to look out for) - psycho-social support - measure outcomes PSA – 6 weeks then 3 monthly for 2 years then 6 monthly x 2 years; annually

28. Prostate Cancer – Side effects Side effects: Acute vs Late - Skin - Urinary - Rectal - Erectile dysfunction - Relapse

29. Prostate Cancer – Relapse Relapse: Biochemical Failure - Post RT - Post Sx Treatment post relapse depends on: 1.primary Rx. 2.local or distant metastases

30. Prostate Cancer – Relapse Treatment Local relapse – treatment depends on primary treatment Metastases – bone Hormones Chemotherapy GP’s role

31. Advanced Prostate Cancer – Palliative Management Palliation vs terminal care Active palliation – disease; side effects; psycho- social Goals: -Functional independence -Symptom control -family support

32. Advanced Prostate Cancer – Terminal Care ECOG Performance Status (PS) 0; 1; 2; 3; 4; (5) Terminal care goals: - manage symptoms - manage psycho-social issues

33. Pathways of Care Standardization – reduces variability Also measures outcomes Shown to improve outcomes Multidisciplinary or Cross functional approach Team member have defined roles Focuses on the patient ‘journey’ - patient-centric

34. Key Principles of NHI Equity Access Social Solidarity Appropriate- ness Efficiency Effectiveness Affordability

35. The Tavistock Principles 1.Health care is a human right. 2.The care of the individual is at the center of health care, but the whole system needs to work to improve the health of populations. 3. The health care system must treat illness, alleviate suffering and disability, and promote health. 4. Cooperation (with each other, those served, and those in other sectors) is essential for all that work in health care. 5. All who provide health care must work to improve it. 6. Do no harm.

36. Cancer in South Africa – the Reality Expected annual cases 2012 – 75 000 Public sector only have capacity to care for 30% of population (37 EBRT machines) Private sector only caring for 16 % of that market Total expenditure on health as % of GDP (2006): 8.4% (UK – 8.7%; Aus – 8.3%;) Best case scenario 40% of patients - NO access to care

37. Cost of Cancer Care CRISIS or?

38. CHALLENGE

39. Thank you!