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

2. Incidence of Prostate Cancer
2008
new cases in UK
deaths from Ca Prostate
101 men diagnosed every day
One new diagnosis every 15 minutes
Accounts for 3% of male mortality

3. Incidence

4. Age at diagnosis

5. PSA

6. 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

7. 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

8. DRE

9. Prostate Cancer Risk Calculator

11. 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%

12. 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%

13. Screening

14. 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.

15. Mortality Results from a Randomized Prostate-Cancer Screening Trial
The Evidence
Screening and Prostate-Cancer Mortality in a Randomized European Study
Published at March 18, 2009 ( /NEJMoa )
182,000 men
Mortality Results from a Randomized Prostate-Cancer Screening Trial
Published at March 18, 2009 ( /NEJMoa )
76,693 men

16. The Facts
820 / 10,000 Carcinoma of the Prostate diagnosed in screened arm vs 480 / 10,000 diagnosed in control arm

17. The Facts
73,000 men screened 17,000 biopsies

18. The Facts
227/10,000 radical prostatectomies performed in screened arm Vs 100/10,000 in control arm

19. 214 / 10,000 Deaths due to prostate cancer (Screened arm) Vs 326 / 10,000 (unscreened arm)

20. 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

21. 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

22. 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

23. 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

24. Average life expectancy in years
Current age

25. New Headlines

26. 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.

27. High Intensity Focused Ultrasound

28. Prostate biopsy / prostate mapping
Standard
Template

29. 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

30. 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.

31. 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

32. New Medicines

33. Aberatirone Mean survival 3 months Cost approx £3000 for 30 days
NICE approved
1g a day single dose 4x250mg tablets

34. Prostate Cancer Follow-Up

35. Should we be concerned?
Prostate Cancer patients have a worse experience of care including after care than other cancer patients
Department of Health

36. What’s the evidence / guidelines
Who should do it?
Who should have it?
What’s the evidence / guidelines

37. 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

38. 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

39. 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

40. 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

41. Metastatic Patients NICE Sweden Canada
Primary care manage day to day complications
Sweden
More regular PSA testing
Canada
Less regular PSA testing

42. 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

43. 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

44. 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

45. My Practice Metastatic disease 3/12 PSA initially
Symptomatic management
Patient specific follow-up

46. 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

47. Prostate Cancer Pathways

48. 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

49. 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

50. 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

51. 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

52. And Finally
PSA PATHWAY NO DIAGNOSIS OF CA PROSTATE Individual follow up Patient specific Clear discharge letter

53. ‘The definition of insanity is doing the same thing over and over and expecting different results’