Localized prostate cancer management .pptx

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1. Seminar on non surgical management of localized prostate cancer Moderator: Dr Fitsum Solomon (consultant urologist) Presenter: Dr kumlachew.T(UR3) 12/18/2022 Dr Kumlachew.T 1

2. Outline of presentation Introduction Staging Risk stratification Treatment Summary Reference 12/18/2022 Dr Kumlachew.T 2

3. Introduction In the USA, prostate cancer is the most commonly diagnosed cancer in men ,representing 19% of all newly reported cases with estimated 164,690 cases annually in 2018. It is the 2 nd leading cause of cancer death in men's with estimated death of 39,430 in 2018. 12/18/2022 Dr Kumlachew.T 3

4. After a diagnosis of prostate cancer , the goal of staging is the accurate determination of disease extent and risk for management decisions and prognostication. In addition to PSA level and DRE, the pathologic features on prostate biopsy (grade and volume of cancer) help inform management decisions. Imaging studies also may be used during the staging process to evaluate the locoregional extent of disease and/or to rule out metastases. 12/18/2022 Dr Kumlachew.T 4

5. Staging General Concepts of Staging Clinical staging is the assessment of disease extent using pretreatment parameters (DRE, PSA values, needle biopsy findings, and radiologic imaging), whereas pathologic stage is determined after prostate removal and involves histologic analysis of the prostate, seminal vesicles, and pelvic lymph nodes if lymphadenectomy is performed. Pathologic staging more accurately estimates disease burden and is more useful than clinical staging for outcome prediction. Biochemical recurrence-free survival and cancer-specific survival are both inversely related to the pathologic stage of disease. The most important pathologic criteria that predict prognosis after radical prostatectomy are tumor grade, surgical margin status, extracapsular disease, seminal vesicle invasion, and pelvic lymph node involvement. 12/18/2022 Dr Kumlachew.T 5

6. Staging 12/18/2022 Dr Kumlachew.T 6

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10. Shared decision making Counseling of pts –(evidence level A(strong recommendation) Why? Because of need for shared decision making for selection of management strategy Cancer severity(risk stratification) Patient values and preferences Life expectancy of pt Pretreatment general functional and GU symptoms Expected post treatment functional status Potential salvage treatment (strong recommendation) 12/18/2022 Dr Kumlachew.T 10

11. Estimating life expectancy and health status Prostate cancer is common in older men (median age 68) and diagnoses in men > 65 will result in a 70% increase in annual diagnosis by 2030 in Europe and the USA. B ased on age, expected life expectancy, CCI, risk stratification and patient preference mag’t could be AS watchful waiting RP/RT In localised disease, over 10 years life expectancy is considered mandatory for local treatment to improve the CSS. 12/18/2022 Dr Kumlachew.T 11

12. Watchful waiting is indicated for Older age and worse baseline health status in age <65 years with good performance CSS is high following surgery RP in older age have benefit of 1 reducing metastasis 2 reducing use of ADT External beam RT shows similar cancer control regardless of age, assuming a dose of > 72 Gy when using intensity-modulated or image-guided RT. 12/18/2022 Dr Kumlachew.T 12

13. Gait speed is a good single predictive method of life expectancy (from a standing start, at usual pace, generally over 6 meters). For men at age 75, 10-year survival ranged from 19% < 0.4 m/s to 87%, for >/= 1.4 m/s. 12/18/2022 Dr Kumlachew.T 13

14. CFS CFS is predictor of post surgery 30 days mortality. 12/18/2022 Dr Kumlachew.T 14

15. Co-morbidity is a major predictor of non-cancer-specific death in localized PCa is more important than age Measures for co-morbidity include: Cumulative Illness Score Rating-Geriatrics (CISR-G) Charlson Co-morbidity Index (CCI) 12/18/2022 Dr Kumlachew.T 15

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17. treatment Deferred treatment (active surveillance/watchful waiting) Pts with localized PCA with life expectancy>10 yrs should be treated Pts with CCI>/=2 has high risk of death from co morbidity than PCA 12/18/2022 Dr Kumlachew.T 17

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19. Active surveillance Inclusion criteria all patients with Gleason 6 cancer selected intermediate-risk patients (Gleason 7 or PSA >10) The actual 15-year prostate cancer mortality rate was 5% The rate of intervention is consistently around 25% at 5 years 12/18/2022 Dr Kumlachew.T 19

20. Monitoring of AS Pts should be followed with 1 PSA every 6 months 2 digital rectal examination (annual ) MRI and/or prostate biopsy every 2 to 5 years The finding of Gleason score 7 or higher should, in most cases, prompt intervention. An increase in volume of Gleason 6 cancer prompt targeted biopsy 12/18/2022 Dr Kumlachew.T 20

21. Other interventions while on AS Cessation of smoking Exercise Weight Control Diet Micronutrients(vitamin D and capsiacin )??? 5ARI Statins Metformins 12/18/2022 Dr Kumlachew.T 21

22. The Protect trial Classified localized prostatic ca pt in to active treatment with either RP or EBRT active monitoring (AM) Risk stratification Low risk and intermediate risk group are involved After 10 years of follow-up, CSS was the same between those actively treated and those on AM (99% and 98.8%, respectively), as was the OS . Cost is higher in AM group because of Regular follow up Repeated imaging Rebiopsy 12/18/2022 Dr Kumlachew.T 22

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24. Watchful Waiting Inclusion criteria Localized prostatic ca(low and intermediate risk) on elderly or co morbid condition harm of treatment outweighs the benefit Follow up is with clinical ass’t and PSA Rebiopsy and imaging is not necessary Treatment is indicated for symptomatic progression 12/18/2022 Dr Kumlachew.T 24

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27. Treatment of intermediate-risk disease favorable ISUP 2 cancer (PSA < 10 ng/mL, clinical stage < cT2a and a low number of positive systematic cores) should also be considered for deferred treatment with AS. re-biopsy within 6 to 12 months to exclude sampling error is mandatory. ISUP 3 disease should not be considered for AS. 12/18/2022 Dr Kumlachew.T 27

28. Recommended IMRT/VMAT for intermediate-risk PCa Patients suitable for ADT can be given combined IMRT/VMAT with short-term ADT (4–6 months ). For patients unsuitable (e.g., due to co-morbidities) or unwilling to accept ADT (e.g. to preserve their sexual health) the recommended treatment is IMRT/VMAT (76–78 Gy ) or a combination of IMRT/VMAT and brachytherapy. 12/18/2022 Dr Kumlachew.T 28

29. Rx of intermediate risk prostate ca 12/18/2022 Dr Kumlachew.T 29

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32. radiotherapy the primary mechanism for the effect of radiographs on tissues was via ionization and production of DNA damage, either directly or via free radical production. Intensity-modulated RT (IMRT) or volumetric arc radiation therapy (VMAT) with image-guided RT (IGRT) is currently widely recognised as the best available approach for EBRT. Several relevant considerations exist when delivering therapeutic radiation, particularly in a relatively deep-seated internal organ such as the prostate: 1. Need for tissue penetration of beams with minimal energy deposition to superficial structures to reduce skin and tissue toxicity 2. Proximity of and need for sparing of adjacent normal tissues such as the rectum, bladder, and femoral heads 3. Minimizing the potential for targeting errors resulting from organ motion and tissue deformation 12/18/2022 Dr Kumlachew.T 32

33. Image-Guided Radiation Therapy Advantage of IGRT is Target the area of target on real time Decrease damage to surrounding area Increase chance of radiation to the target 12/18/2022 Dr Kumlachew.T 33

34. CT-Based Treatment Planning and Three- Dimensional Conformal Radiotherapy Allows increased dose to the target Reduce radiation to the surrounding normal tissue 12/18/2022 Dr Kumlachew.T 34

35. Intensity-Modulated Radiation Therapy Unlike 3D-RT, IMRT allows to modulate the dose both to the target and surrounding area. Disadvantage 1 increased treatment time 2 increased number of monitor units Above disadvantage is overcomed by using VMAT 12/18/2022 Dr Kumlachew.T 35

36. External beam radiation therapy VMAT and IMRT over 3D-CRT significantly reduced acute and late grade > 2 genito -urinary (GU) and gastro-intestinal (GI) toxicity. PSA relapse free survival is comparable with 3D-CRT 12/18/2022 Dr Kumlachew.T 36

37. Brachytherapy Low-dose rate brachytherapy uses radioactive seeds permanently implanted into the prostate. Indicated for low- or favorable intermediate-risk and good urinary function For pts with obstructive LUTS minimal channel TURP can be done Dose D90% with>140GY For those with unfavorable intermediate and high risk pt 1 adding LD brachytherapy with EBRT(46GY) complication is high with grade 3 GU toxicity 12/18/2022 Dr Kumlachew.T 37

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39. Complication of brachytherapy and EBRT Comparing brachytherapy with EBRT EBRT has high GU and GI toxicity Brachytherapy has high GU toxicity than GI General side effects like fatigue are common Acute side effects are common than late complication 12/18/2022 Dr Kumlachew.T 39

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41. Post treatment follow up PSA every 3 to 6 months for 1 st 2 years Every 6 months for 2 to 5 years Annually after 5 years After 10 years with undetectable PSA is shared decision 12/18/2022 Dr Kumlachew.T 41

42. summary prostate cancer is one of common cancer with indolent course Localized prostate cancer is cancer that is only inside your prostate gland and has not spread to other parts of your body . Pts with localized prostate cancer should be carefully stratified based on risk stratification, comorbidity and age for decision making Decision regarding choice of treatment should be shared decision 12/18/2022 Dr Kumlachew.T 42

43. Reference Campbell 12 th edition EAU guideline 2022 NCCN guideline 2020 12/18/2022 Dr Kumlachew.T 43

44. Thank you 12/18/2022 Dr Kumlachew.T 44