Prostate cancer Risk stratification and choice of initial treatment final.pptx

Prostate cancer Risk stratification and choice of initial treatment final

1. Ahmed Eliwa M.D. Lecturer of urology Zagazig University Prostate cancer: Risk stratification

2. Objectives The student by the end of this session will be able to : Describe the role of risk stratification models in management of prostate cancer patients Apply commonly used risk stratifications models in management of prostate cancer patients Plan and coordinate a multidisciplinary approach in pre and postoperative care for prostate cancer patients

3. Organ confined disease Locally advanced disease PSA relapse after definitive therapy PSA persistently high after definitive therapy Metastatic disease Castrate resistant disease WW AS RP RTx ADT CTx OTHER

4. RISK STRATIFICATION separating patient populations into high-risk , low-risk, and the ever-important rising-risk groups key to the success of any population health management initiative .

5. enables providers to identify the right level of care and services for distinct subgroups of patients.

6. IN PCa assists in decision-making therapeutic treatment clinical trial design weigh therapeutic options on comparative benefits and risks in domains: life expectancy disease control health-related quality-of life treatment complications

7. Reduction of inconsistent management due to physician bias, or differences in experience and knowledge

8. Risk Models In PCa Pretreatment risk assessment Tumor related Patients related Post-treatment risk assessment

9. Pretreatment risk assessment

10. Tumor related

11. Characterization of the Primary Tumor DRE prostate ultrasound serum PSA data Prostate Health Index The biopsy findings Gleason score/ISUP grouping number of cores containing cancer distribution and volume of cancer in the biopsy cores presence of perineural space invasion, lymphovascular invasion, ductal, signet ring, or neuroendocrine differentiation) Benson et al, 1992; Carter, 1997; Catalona et al, 1998; D’Amico et al, 2004; Thompson et al, 2004; Kundu et al, 2007; Catalona et al, 2011).

12. Prediction tables and algorithms Prediction tables and algorithms Partin et al, 1997, 2001; Makarov et al, 2007; Eifler et al, 2013

13. However, such statistical aids are more useful in groups of patients than in individual patients wide confidence intervals surrounding estimates of outcomes simultaneous assessment of multiple variables in nomograms provides more accurate predictions than do tables for individual patients ( Kattan , 2003).

14. Characterization of the Primary Tumor Evaluation of the Patient

15. Evaluation of the Patient Patients related

16. LIFE EXPECTANCY ESTIMATION critical in prostate cancer early detection and treatment . Life expectancy can be estimated using the Social Security Administration tables (www.ssa.gov/OACT/STATS/table4c6.html) the WHO’s Life Tables by country (http://apps.who.int/gho/data/view.main.60000?lang=en).

17. Comorbidity major predictor of non-cancer-specific death in localised PCa Cumulative Illness Score Rating-Geriatrics (CISR-G)

18. Dependence in daily activities influences survival in senior adults. The Activities of Daily Living (ADL) scale rates Instrumental Activities of Daily Living (IADL ) scale rates activities requiring higher cognition and judgment.

19. The higher the score, the greater the person's abilities score ranges from 0 (low function, dependent ) To 22 (high function, independent

20. Malnutrition associated with increased mortality in senior patients body weight during the previous three months: Good nutritional status < 5% weight loss Risk of malnutrition: 5-10% weight loss Severe malnutrition: > 10% weight loss.

21. Cognitive impairment associated with increased mortality risk in senior adults In patients undergoing major elective surgery, there is an association between baseline cognitive impairment and long-term postoperative complications and mortality Depression

22. mini-COG is the best available tool to evaluate cognitive function

23. G8 (Geriatric 8) health status screening tool The International Society of Geriatric Oncology (SIOG) PCa Working Group (PCWG) Baseline screening using the G8 screening tool recommends that treatment for senior adults should be based on a systematic evaluation of health status

24. Post-primary treatment risk

25. Risk factors for BC-relapse [needing Adjuvant treatment after radical prostatectomy] ISUP score > 2 pT3 pN0 after RP positive margins (highest impact ) capsule rupture and/or invasion of the seminal vesicles [high risk of relapse ] number of removed LNs tumour volume within the LNs LN capsular perforation [ early recurrence] LN density (% of positive LNs in relation to the total number of analysed/removed LNs) over 20% was found to be associated with poor prognosis number of involved LNs major factor for predicting relapse [ 3 positive nodes ]

26. Risk for Persistent PSA after radical prostatectomy Risks of PSA persistence were • higher BMI • higher pre-operative PSA • ISUP grade > 3

27. Survival Risk for Metastatic prostate cancer Prognostic factors for survival number and location of bone metastases visceral metastases ISUP grade PS Initial PSA alkaline phosphatase “ Volume” of disease introduced by CHAARTED

28. Definition of high- and low-volume and risk in CHAARTED and LATITIDE   High Low CHAARTED Chemo-hormonal Therapy versus Androgen Ablation Randomized Trial for Extensive Disease in Prostate Cancer > 4 Bone metastasis including > 1 outside vertebral column or spine OR Visceral metastasis Not high LATITUDE Abiraterone plus prednisone in metastatic, castration-sensitive prostate cancer 2 high-risk features of: • > 3 Bone metastasis • Visceral metastasis • > ISUP grade 4 Not high

29. Prognostic factors based on the SWOG 9346 study PSA after 7 months of ADT Median survival < 0.2 ng/mL 75 months 0.2 < 4 ng/mL 44 month > 4 ng/mL 13 months

30. prognostic factors to stratify the response to Docetaxel Visceral metastases Pain anaemia (Hb < 13 g/dL) bone scan progression Prior estramustine. Patients can be categorised into three risk groups Low risk (0 or 1 factor) Intermediate (2 factors) High risk (3 or 4 factors) Docetaxel The standard first-line chemotherapy is docetaxel

31. New concepts and trends in Risk stratification

32. Novel prognostic factors genetic β- catenin , Androgen CAG repeats receptor CYP3A4 genotype DNA ploidy , vitamin D receptor Ki67, Bcl-2 P53 syndecan-1 CD10 stat5 activation) biochemical acid phosphatase Creatinine PSA related Gleason variants 3+4 vs. 4+3 high grade components Modified Gleason score % biopsy involvement, % cancer in surgical specimen pathological maximum tumor dimension and tumor volume clinical

33. RECIST = Response evaluation criteria in solid tumours : Complete Response ( CR) Partial Response ( PR Progressive Disease (PD ) Stable Disease (SD ) = Prostate Cancer Radiographic Assessments for Detection of Advanced Recurrence Group improve the early detection of metastatic disease RADAR I: IMAGING TRIGGERS RADAR II: THERAPUTIC LAYERING RADAR III: RADIOPHARMACEUTICALS RADAR

34. Artificial Neural Network for Prostate Cancer Risk Prediction and Stratification

35. Home messages Risk stratification of PCa is an integral part of PCa management