Thomas A. Kollmorgen, M.D. Oregon Urology Institute

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1 Thomas A. Kollmorgen, M.D. Oregon Urology Institute

2 None

3 240,000 new diagnosis per year, and an estimated 28,100 deaths (2012) 2 nd leading cause of death from cancer in U.S.A. Approximately 1 in 6 men will develop prostate cancer in their lifetime

4 Few men present with symptoms and those that do are more likely to have advanced disease Pattern of prostate cancer growth varies among men like no other cancer Can be indolent or can be virulent Only organ-confined disease is potentially curable, although late stage disease can be treated Therefore, the objective is to identify early

5 History and Physical Exam DRE is important! Risk Factors: Family History, Race Screening: PSA testing

6 Screening and PSA testing controversy PSA test received a D rating from United States Preventative Services Task Force Why? Not enough reduction in mortality Doesn t differential indolent vs. aggressive cancer High rate of over diagnosis and treatment (clinically insignificant cancers) 90% of screened cancers treated Harmful risks of diagnostic tests (biopsy) and treatment

7 The PLCO trial lasted 7 years (76,693 men - US). Prior to the study about 44% of entering pts had already been screened with at least one PSA. 52% of the usual care pts in the control arm had at least one PSA. In the PSA screening arm only 85% were compliant. So the PLCO compared 52% screening (control) with 85% screening (treatment) in a population of which 44% had already been screened prior to the study. This is not a very "clean" study and as a result showed no benefit The ERSPC study compared 162,243 men from 50 to 74 who where screened every 4 years vs. no screening. Unlike the PLCO, there was a very low contamination rate of prior PSA screening. Overall prostate ca mortality was 20% lower in the screening arm after 9 years. They used active surveillance in low grade prostate ca. The Goeborg Sweden study looked at 20,000 men btwn 50 and 64 who were screened every two years. This showed 41% decrease in advanced ca and 44% reduction in prostate cancer mortality after 14 years. NNS = 293, NNT =12 to prevent one prostate cancer death. This compares favorably with other ca screening. Longer studies w/less PSA contamination in younger men suggests benefit

8 In addition, there has been a 40% reduction in prostate cancer mortality since the introduction of PSA screening Waiting for symptoms usually results in late diagnosis Lack of other tests to detect early prostate cancer No current cure for metastatic disease

9 How can we improve? Be selective on which patients to screen Those with +FH, African American Those who are young enough and healthy enough to benefit from treatment (physiologic age vs. chronologic age) Use age-adjusted PSA, PSA velocity, F/T PSA Use biopsy data to determine risk level (low, intermediate, high) PSA alone not predictive Select appropriate treatment depending on level of risk. Continue to search for more accurate screening tests

10 Discuss pros and cons of screening. Initial screening at age 40 with repeat testing every 2 years ( 1 year for those with +FH or African American) Annual screening starting at age 50 May stop screening men with previously normal PSA at age 75.

11 Using these more selective criteria, we can decrease the chances of over diagnosis and treatment. At OUI Our +biopsy rate is 65% (National Avg. 33%) 27% of our patients are currently on active surveillance ( National Avg. ~15%)

12 Pts can be placed into risk categories based on clinical stage, Gleason grade, and PSA level Low risk Stage T1-2a, PSA<10, GG =6 or below Intermediate risk- Stage T2b-c, PSA 10-20, GG=7 High risk- Stage T3, PSA>20, GG=8 or higher. Very High risk-staget3b-t4

13 Low and intermediate risk with life expectancy >10 years High risk patients without evidence of distant metastatic disease Many of these pts will need adjuvant therapy with radiation +/- hormone deprivation therapy

14 Potential cure excellent survival for organ confined low and intermediate risk cancer Provide definitive pathology Debulk locally invasive cancer Prevent future morbidity (Bladder outlet obstruction, ureteral obstruction, gross hematuria) Does not preclude the use of additional local therapy (i.e. IMRT) Post-op follow up more precise (PSA<0.2)

15 Recovery ( activity restrictions, catheter, healing time) Complications: Blood loss, Infection, Bowel injury, Bladder neck contracture and perioperative risks (DVT, MI, etc.) Urinary Incontinence Erectile Dysfunction

16 Eradicate all tumor if possible (negative margins) Maintain Urinary Continence (meticulous urethral dissection and preservation) Preserve Erectile function (Nerve-sparing) Not all pts are potent pre-op! Not all potent patients are candidates for nervesparing procedures

17 Open Radical Retropubic Prostatectomy (RRP) has been the gold standard Robotic Assisted Laparoscopic Prostatectomy (RALP) has increasingly been used. Currently, > 60% of Prostatectomies are done robotically is US. Perineal Approach has essentially gone away

18 Smaller incisions Excellent visualization Less blood loss Quicker recovery Shorter hospital stay +/-

19 Less operative time Tactile feedback Retropubic approach rather than intraabdominal Lower intra operative complication rate No need to Convert Cheaper

20 Currant long-term data shows no significant difference in outcomes regarding: Cancer control Urinary continence Preservation of Erectile function Data shows that Experience and Surgical skill determine outcomes regardless of technique

21 No bowel prep Same day admit Early post-op feeding and Ambulation Low dose Narcotics Toradol Discharge in 24 to 48 hrs for 90% of cases Foley Catheter for 7-14 days 4-6 weeks until regular activity Follow up 3months with PSA unless adverse pathology

22 Early rehabilitation for return of Erectile function. PDI s, Vacuum, injection Tx Pelvic Floor strengthening and Biofeedback for early, lasting continence Quality of life Questionnaire and Satisfaction Survey

23 Currently building a database to track outcomes Less than 5% experience complete incontinence 80% return of erection at 1 year post-op (with nerve-sparing), but may require PDI Quality of life rated 4.3 out of possible 5 Decision Voiding function Sexual function Met expectations