SRO Tutorial: Prostate Cancer Treatment Options May 7th, 2010 Daniel M. Aebersold Klinik und Poliklinik für Radio-Onkologie Universität Bern, Inselspital
Is cure necessary in those in whom it may be possible, and is cure possible in those in whom it is necessary? W.F. Whitmore Jr. Urol Clin North Am 1990; 17: 689
Watchful waiting vs. Prostatectomy Bill-Axelson 2005 NEJM
Watchful waiting vs. Prostatectomy Bill-Axelson 2005 NEJM
Radical radiation for localized prostate cancer 100 Distant metastasis free survival by local disease status. metastasis-free survival (%) 80 60 40 20 p<0.0001 local control (n=1271) local failure (n=198) 0 0 5 10 15 years J.J. Coen, W.U. Shipley et al., J Clin Oncol 20:3199-3205, 2002
Radical radiation for localized prostate cancer 10 Hazard rate of distant metastasis by local disease status hazard rate of DM (%/yr) 8 6 4 2 local control local failure 0 0-3 3-6 6-9 9-12 years 12-15 J.J. Coen, W.U. Shipley et al., J Clin Oncol 20:3199-3205, 2002
Korrelation LC mit DM?
The Decision Discussion between patient and doctor Thoroughly discuss various options available Thoroughly discuss the procedure Patient should be fully aware of risks and potential complications
Considerations Prior to Treatment Patient s general medical condition and age Tumor Grade (Gleason Score) and serum PSA Disease Stage and the likelihood of the cancer being confined to the prostate gland and thus potentially curable Estimation of outcome compared to other treatments Side effects from various treatments
Goals of Treatment (In Order of Priority) 1. Cancer Control 2. Preservation of Urinary Control (Continence) 3. Preservation of Sexual Function (Potency)
Therapy decision is dependent on: 1. Live expectancy >5y or <5y 2. Clinical stage 3. PSA 4. Gleason-Score UROLOGY 2003; 61: 14-24 www.nccn.com
Asymptomatic, Gleason 7 watchful waiting (ww) High risk factors (impending hydronephrosis or metastasis): bulky T3-4, Gleason 8-9 TAB oder palliative RT
Why Wait? PSA and DRE can detect prostate cancer at a very early stage Average doubling time of a prostate tumor is quite slow (2-4 years) Immediate radical therapy may constitute overtreatment and an introduce unnecessary urinary and potency risks May be appropriate if the patient is elderly and/ or in poor health, and will live out their life spans without the cancer causing problems May also be appropriate for a younger patient who is willing to be vigilant and accept the risk of the cancer spreading
Primary Androgen Ablation Nobel Prize Testosterone necessary for the growth and development of prostate cancer Removal of testosterone results in apoptosis of stromal and epithelial cells
Primary Androgen Ablation Palliative An active decision not to pursue curative therapy If a man lives long enough he will die from prostate cancer
Results of Androgen Removal Impotence Loss of sexual desire (libido) Hot flashes Weight gain, Increased appetite Fatigue Reduced brain function Loss of muscle and bone mass Some cardiovascular risks Hot flashes Gynecomastia and breast tenderness Bone loss
low risk of recurrence intermediate risk of recurrence high risk of recurrence very high risk of recurrence
Definition: T1-T2a and PSA 10 and Gleason 2-6 Therapy: LE < 10y ww or RT LE 10-20y ww, RT or OP LE > 20y RT or OP RT: 3dRT, IMRT, Brachytherapy (HDR/ LDR)
Definition: T2b T2c or Gleason 7 or PSA 10-20 Therapy: LE < 10y ww, RT oder OP LE > 10y RT oder OP No brachytherapy only
Definition: T3a or Gleason 8-10 or PSA > 20 Therapy: LE <5y ww or TAB LE > 5y TAB (2-3y) + RT RT + 6m (TAB) with only 1 risk actor (OP)
Definition: T3b T4 TAB +/- RT any T, N1 TAB +/- RT any T, any N, M1 TAB
Hormone-Refractory Prostate Cancer (HRPC) = Castration Resistent PC Despite initial response rates of 80-90%, nearly all men with advanced prostate cancer develop hormone-resistant prostate cancer after 18-24 months These hormone-refractory (HR) prostate cancer cells can grow in the absence of androgens The behavior of HR prostate cancers differ widely between patients