1. Prostate Cancer James B. Benton,M.D.

2. Prostate Cancer Significant of the clinical problem Early detection/screening Prevention/Management

3. Prostate Cancer 220,000 new case per year in US 380,000 cases projected in 2025 40,000 death per year Second largest cancer killer after lung cancer. Probably #1 in non-smokers.

4. Lifetime risk of diagnosis of prostate cancer is 17% Lifetime risk of death from prostate cancer is 3.4% Autopsy series (22 -55% incidence of prostate cancer)

5. Epidemiology The incidence and mortality of prostate cancer is quite varied among different populations The incidence rate among African Americans is 224/100,000 and American Indians..46/100,000

7. Epidemiology Cont’d African-American men have the highest mortality in the world (54/100,000) A high mortality rate has also been noted in African heritage in Brazil, Jamaica, and in sub-Saharan Africans.

9. Epidemiology Cont’d In 1990, 172,596 cases….33011 deaths 149,631 whites….25,281 deaths 17,417 blacks….5,181 deaths 4,291 Hispanics….727 deaths <400 Orientals….<70 deaths

10. African American (AA) men historically presented with more advanced disease, and an increased death rate. Because of early detection and more aggressive treatments, survival may be equilibrating.

11. Age Specific PSA

12. Age Specific PSA..cont’d

15. Prevention Restrict excessive fat and/or carbohydrates ?Vitamins/Minerals: Selenium and Vitamin E, and Lycopene Annual exam: DRE and PSA at age 40-50 ? Hormonal…ie. Proscar

16. Prostate Cancer Prevention Trial 18,882 men: 55y/o or older: Finasteride(Proscar) or placebo; nl DRE and PSA <3.0: 7 year study (Thompson NEJM…2003) CAP developed in 24% of placebo and 18% proscar (25% reduction) High grade cancers in 22% of placebo and 37% of proscar Side effects: impotence with proscar

17. Prostate Cancer Screening Since introduction of the PSA in the 1980’s, there is evidence that prostate cancer mortality has decreased. In countries not using PSA testing, prostate cancer mortality continues to rise (Denmark, Mexico, and Sweden)

18. American Cancer Society Prostate Cancer Screening Guidelines Beginning at age 50, all men with a ten year life expectancy should be offered both PSA and DRE annually Men in high risk groups, such as African- Americans or those with a family history should start at age 45

19. ACS Guidelines Cont’d Men at an appreciably higher risk due to multiple first- degree relatives who were dx at an early age could begin at age 40 If PSA < 1.0, no more until age 45 If PSA 1.0 – 2.4, annual testing If PSA > 2.4, consider biopsy

20. American Urological Association Guidelines All men 50 or older with a ten year life expectancy Men 40 – 50 with first degree relative with prostate cancer or of African-American heritage background Exams: DRE and PSA

21. PSA Density and Free PSA PSA density(PSAD): PSA value divided by the volume of the prostate gland: >0.15 considered abnormal. Free PSA: unbound PSA divided by bounded PSA: < 25% is considered abnormal Used as factors to determined the need for a biopsy when PSA is 4.0 – 10.0 range

22. Treatment Options Surgery Simultaneous Radiotherapy External Beam Radiotherapy alone Seed Implants alone Cryotherapy Observation Hormonal Ablation ? Vaccines

23. Treatment cont’d Combined Radiation and Tumor-specific vaccine regimen. Chemotherapy: Doxil +/- hormonal therapy

24. Surgery Traditional Radical Prostatectomy Laparoscopic Prostatectomy Robotic Prostatectomy

25. Radiotherapy Simultaneous: Seeds/XRT Sequentially: XRT/Seeds Seeds alone XRT alone: IMRT- Proton/Neutron/Photons

26. Cryotherapy Freezing the prostate Limited experience

27. Hormonal Therapy Chemical Orchiectomy

28. Experienmental Vaccines High energy microwaves therapy

29. Learning How to Count        9 100 99