Update on Prostate Cancer and BPH Gary Das MS, FRCS, FRCS (Urol) Lead Cancer Urologist, Croydon University Hospital Pelvic Cancer Surgeon, St George’s Hospital Introduction Function of the prostate PSA Prostate Cancer Incidence Symptoms Management BPH (Benign Prostatic Hypertrophy) Incidence Symptoms Management What is the prostate? Walnut sized gland in pelvis Prostate produces about 30% of seminal fluid Nourishes and activates sperm PSA Blood test for protein produced by prostate cells May be elevated in benign conditions or cancer May be raised in benign prostatic enlargement, retention, prostatitis, urological instrumentation, sexual activity, cycling Rises with age Elevated PSA Not specific for prostate cancer Decision to investigate also depends on prostate size, digital rectal examination, general health, patient’s wishes NICE guidelines Key priority: PSA 6630 male volunteers over 50 years old PSA (ng/ml) <4 N (%) 5647 (85%) Cancer / biopsy 4-10 >10 809 (12%) 174 (3%) 143/548 (26%) 73/138 (53%) J Urol 1994; 151:1287 Prostate Cancer Most common male cancer in UK 35,000 new cases / year 10,000 deaths / year Cancer Research UK Incidence & mortality rates Cancer Research UK Mortality stable since 1990s Cancer Research UK Age distribution Cancer Research UK UK does favourably compared to Western World Cancer Research UK Patients are surviving longer Cancer Research UK Risk factors Hereditary Early age onset Double risk if one first-line relative Environmental Risk increases in Japanese men moving to USA Diet Good: lycopenes (tomatoes), vitamin pomegranate, pumpkin seeds Bad: red meat, dietary fat Social Class E, selenium, Symptoms Often asymptomatic Lower Urinary Tract Symptoms Bone pain (pelvis / vertebral) Lower Urinary Tract Symptoms Sensation of incomplete emptying of bladder Frequency – urinating every 2 hours or less Intermittency – stop/start stream Hesitancy Urgency – difficult to postpone urination Nocturia – number of times urinating at night Weak stream Straining Diagnosis Digital rectal examination Nodular Firm Loss of median sulcus PSA TRUS and prostate biopsy TRUS and prostate biopsy Antibiotic prophylaxis Risk of bleeding, infection and septicaemia (1 in 1000) Require hospitalisation if rigors or fever post procedure If first set of biopsies negative 10-35% detection rate in second set Detection biopsies rate extremely low after three negative Imaging MRI of pelvis Bone scan Gleason score Grading Sum system of two most common patterns (grade 1-5) Most cancers are 6 or more Multidisciplinary meeting To discuss histology, imaging and management Urologists, oncologists, pathologists, radiologists, specialist nurses Local and regional Recruitment To to clinical trials improve and standardise patient care and increase patient choice Treatment Few comparative studies between the different treatments exist No randomised trials between radical prostatectomy and radiotherapy for localised prostate cancer exist Treatment Organ confined Men with a life expectancy of greater than 10-15 years should be treated with curative intent Active Surveillance Radical Prostatectomy External beam radiotherapy Brachytherapy Cryotherapy HIFU Treatment Locally advanced Watchful waiting Hormones Radical prostatectomy and radiotherapy / hormones Radiotherapy and hormones Metastatic Hormones Oestrogens & corticosteroids for hormone refractory disease Chemotherapy – docetaxel, mitoxantrone & steroids Active surveillance Well-informed asymptomatic patients with small volume disease with a low Gleason score Reduces over-treatment and morbidity by selecting out patients with significant cancers who would benefit from curative treatments Choo R et al. J Urol 2002; 167: 1664-9 Parker C. BJU Int 2003; 92: 2-3 Active surveillance Closely monitor PSA every 3 months Repeat prostate biopsies within 2 years Radical treatment if PSA progression (doubling time <2 years, histological progression (primary Gleason 4 or 5) or clinical progression. Radical Prostatectomy Open Laparoscopic Robotic Radical prostatectomy Similar oncological and functional outcomes between techniques 95% 10 year survival Operative time Long-term data awaited for minimally-invasive Open Radical Prostatectomy Complication Peri-operative death Major bleeding Rectal Injury Severe stress incontinence Impotence Urethral stricture Incidence (%) European (EAU) Mayday 0-2.1 0.3 1.0-11.5 0-5.4 Rarely transfuse 1 0-15.4 29-100 1 50% 2.0-9.0 EAU Guidelines 2007 External beam radiotherapy Targeted conformal beam Biochemically free from failure (PSA<1ng/ml) Initial PSA<10 Initial PSA 10-20 Initial PSA >20 75-93% 5 year 60% 5 year 40% 5 year Zelefsky MJ et al. J Clin Oncol 1998; 16: 3380-5 Pollack A et al. Int J Radiat Oncol Biol Phys 2002; 53:1097-1105 External beam radiotherapy Toxicity Cystitis Incidence (%) 5.3 Haematuria Urinary Stricture 4.7 7.1 Urinary Incontinence Overall GU toxicity 5.3 15.9 Proctitis Chronic diarrhoea 8.2 3.7 Small Bowel Obstruction Overall GI toxicity 0.5 9.8 Leg oedema Overall toxicity 1.5 22.8 Potency preservation in up to 50% cases Late toxicity from EORTC trial 22863 Brachytherapy Eligibility criteria Small prostate PSA ≤10 Small volume, low grade cancer (Gleason ≤6) Few LUTS Permanent implants Recurrence-free survival 71-93% (5 year) 65-85% (10 year) EAU Guidelines 2007 Cryotherapy Organ-confined prostate cancer Volume ≤40ml, PSA<20ng/ml, Gleason <7 Sparse long-term outcome data Side-effects Erectile dysfunction 80% Incontinence 4.4% Pelvic pain 1.4% Urinary retention 2% EAU Guidelines 2007 HIFU Limited outcome data Side-effects Urinary retention almost 100% Urinary stress incontinence 12% Impotence 55-70% Watchful waiting Observation with treatment for symptomatic progression Well-informed asymptomatic patients with locally advanced disease Patients unwilling to accept side effects of active treatment Hormones Surgical vs. medical castration LHRH analogues Desensitise anterior pituitary gland resulting in cessation of testosterone production Antiandrogens Block peripheral testosterone receptors Maximal androgen blockade Continuous vs. intermittent BPH Incidence Benign Prostatic Hyperplasia 50% men aged over 60 Moderate to severe lower urinary tract symptoms 15-35% men aged over 60 Neal DE et al http://hcna.radcliffe-oxford.com/urinary.html Lower Urinary Tract Symptoms Sensation of incomplete emptying of bladder Frequency – urinating every 2 hours or less Intermittency – stop/start stream Hesitancy Urgency – difficult to postpone urination Nocturia – number of times urinating at night Weak stream Straining Symptoms Pain on urinating May be due to infection Blood in urine Always seek urgent medical advice Investigations Blood tests U&Es, PSA Urine Dipstick urinalysis MC&S Flow tests and post void residual USS renal tract (possibly) Flow rates www.prostateuk.org Flow rates www.prostateuk.org Flow tests Medical treatment Alpha blockers Relax smooth muscle of prostate Dizziness Reduction in ejaculate 5 alpha-reductase inhibitors Block metabolism of testosterone Cause reduced gland volume and vascularity Impotence TURP Transurethral resection of prostate Established technique Resection of prostate tissue Bleeding Irrigating catheter 3-4 day hospital stay Thulium Laser Prostatectomy Thulium Laser Prostatectomy 2 micron continuous wave Excellent haemostasis & reduced bleeding Tissue vapourisation and clean cuts Useful in anticoagulated patients Faster recovery compared to TURP 23 hour prostatectomy Thulium Laser Prostatectomy First department in South West Thames Access via Choose & Book system Green light laser prostatectomy Green light highly absorbed by oxyhaemaglobin resulting in tissue vapourisation Significantly reduced bleeding compared to TURP Anti-coagulated patients can be treated No irrigation Catheter usually removed next day Overnight hospital stay Green light laser prostatectomy Reduced blood loss Shorter hospital stay Heinrich E et al Eur Urol 2007 52:1632-7 2 GL P To…