1. 0562/SAH/1112/SAH Dr Max Dias Update on prostate cancer and BPH Robotic, Laparoscopic and General Urological Surgeon

2. Prostate cancer Is prostate cancer a disease worth diagnosing?

3. Prostate cancer Hell Yeah!

4. Cancer Mortality in NSW 1972-2008

5. Metastatic cancer

7. Side effects of androgen deprivation Decreased cognitive function Muscle weakness and increased fat Hot flushes Increased cardiovascular morbidity and death Osteoporosis with fracture Impaired glucose metabolism Decreased libido and impotence

8. PSA Screening studies PLCO – Poor study protocol – 45% entered the trial with a history of screening – Many in control arm continued to be screened – 90% in the control arm had PSA testing ERSPC – PSA naïve patients – 21% reduction in mortality Reevaluating PSA Testing Rates in the PLCO Trial. Shoag et al. N Engl J Med 2016; 374:1795-1796May 5, 2016May 5, 2016

9. Prostate vs Breast Ca screening Trends in Metastatic Breast and Prostate Cancer — Lessons in Cancer Dynamics H. Gilbert Welch, M.D., M.P.H., David H. Gorski, M.D., Ph.D., and Peter C. Albertsen, M.D. N Engl J Med 2015; 373:1685-1687October 29, 2015October 29, 2015

11. NHMRC guidelines

20. Age considerations

21. Shared decision making “In my experience, fear comes from not knowing what to expect and not feeling you have any control over what’s about to happen. When you feel helpless, you’re far more afraid than you would be if you knew the facts.” ― Chris Hadfield, An Astronaut's Guide to Life on EarthChris Hadfield, An Astronaut's Guide to Life on Earth

22. Shared decision making Tell me and I’ll forget. Show me and I may not remember. Involve me and I’ll understand. - Native American Proverb

27. Gallium 68-PSMA – PET Scan Prostate specific membrane antigen

28. Gallium 68-PSMA – PET Scan EUROPEAN UROLOGY 64 (2013) 862–864

29. PSMA – PET Scan

30. Focal therapy Focal Therapy in Prostate Cancer: International Multidisciplinary Consensus on Trial Design Peter T. Scardino European Urology, Volume 65 Issue 6, June 2014, Pages 1078-1083 Peter T. ScardinoVolume 65 Issue 6, June 2014, Pages 1078-1083

31. Focal therapy HIFU Cryotherapy Radiofrequency ablation (RFA) Focal brachytherapy Focal Electroporation Focal laser therapy

32. HIFU

33. Focal therapy Theory: treat part of prostate and minimize side effects. Long term data not available Prostate cancer is a multifocal disease Predominantly used in low risk disease We already have an alternative for low risk disease- active surveillance

34. BPH

35. BPH and risk of PCa and Bladder Ca Meta-analysis of observational studies – PCa 4x higher in men with BPH – Bladder Ca 2.5x in men with BPH – Asian men with BPH had 6x PCa risk Benign Prostatic Hyperplasia and the Risk of Prostate Cancer and Bladder Cancer: A Meta- Analysis of Observational Studies. Medicine (Baltimore). 2016 May;95(18) Dai X1, Fang X, Ma Y, Xianyu J.

36. BPH Alpha blockers – Prazosin, Flomaxtra, Alfuzosin 5 alpha reductase inhibitors – Dutasteride, Finasteride Combined – Duodart – (Anticholinergics, Mirabegron) – Cialis 5mg Surgical treatments – TURP, Laser, Microwave, TUNA, Urolift

37. Urolift

38. Patient selection – Prostate volume <80cc – Patient who cannot tolerate medications or who does not want side effects of medication – Patients not suitable for or not wanting surgery

39. Urolift procedure

41. Urolift BPH-6 and LIFT study presented at this year’s EAU – Data out to 4 years – Preservation of sexual benefits – Significantly better urine flow and IPPS with TURP

42. Prostate artery embolization (PAE) Limitations – Technically challenging – Unilateral embolization associated with 50% clinical success – Ionizing radiation – Potential for severe complications with non-target embolization – Revascularization and regrowth

43. Prostatic artery embolization The National Institute for Health Care Excellence (NICE) in the UK published a procedure guidance of PAE for BPH – recommend that the procedure should only be performed in the context of research and that consideration of the patient should be undertaken by a multidisciplinary team (including an interventional radiologist and urologist).

44. Take home messages Prostate cancer is the second leading cause of cancer disease- It is important! Early detection and cure is the only way to reduce mortality and morbidity Continue performing DRE if comfortable Screen for prostate cancer in those with BPH Urolift and PAE are novel treatments with limited application and deserve further investigation