Covid is changing everything 27,000 fewer men referred to a - - PDF document

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Covid is changing everything 27,000 fewer men referred to a - - PDF document

Oct 10, 2022 174 likes •270 views

23/09/2020 Prostate Cancer Screening, Diagnosis, Treatment 1 4 2 5 Covid is changing everything 27,000 fewer men referred to a specialist Up to 3,500 men with potential high risk disease have not yet been diagnosed 3 6 1 23/09/2020

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23/09/2020 1

Prostate Cancer

Screening, Diagnosis, Treatment

Covid is changing everything

27,000 fewer men referred to a specialist Up to 3,500 men with potential high risk disease have not yet been diagnosed 1 2 3 4 5 6

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23/09/2020 2

Early diagnosis is important in any cancer Particularly so in Prostate Cancer because of the anatomy:

Early diagnosis of Prostate Cancer

Early diagnosis is important in any cancer Particularly so in Prostate Cancer because of the anatomy:

Early diagnosis of Prostate Cancer

There are various different types of prostate cancer – some are more aggressive than others

There is no single test to diagnose prostate cancer itself But your GP can do a few tests to find out if you have a prostate problem. Problems with prostate health are likely to be from another cause and not cancer

How is Prostate Cancer diagnosed? How is Prostate Cancer diagnosed?

  • A simple urine test

How is Prostate Cancer diagnosed?

  • PSA blood test

How is Prostate Cancer diagnosed?

  • PSA blood test
  • This is a blood test that measures the total amount of prostate

specific antigen (PSA) in your blood.

  • PSA is a protein produced by normal cells in the prostate and

also by prostate cancer cells.

  • A raised PSA level may show that you have a problem with

your prostate, but not necessarily prostate cancer.

SENSITIVITY SELECTIVITY SPECIFICITY 65 % men with a raised PSA will NOT have PCa 15 % men with a normal PSA WILL have PCa VARIABILITY

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How is Prostate Cancer diagnosed?

  • PSA blood test
  • This is a blood test that measures the total amount of prostate

specific antigen (PSA) in your blood.

  • PSA is a protein produced by normal cells in the prostate and

also by prostate cancer cells.

  • A raised PSA level may show that you have a problem with

your prostate, but not necessarily prostate cancer.

SENSITIVITY SELECTIVITY SPECIFICITY Other factors can raise the PSA level VARIABILITY Rate of change of levels is more important than one absolute value

What is a ‘NORMAL’ PSA?

It depends very much on the age of the patient

National Screening Program for Prostate Cancer

  • NO National Screening Program for

Prostate Cancer based on PSA

  • National Screening Committee are just

about to publlish updated opinions

Am I eligible for a PSA test?

  • You have the right to have a PSA test if you’re
  • ver 50 and you’ve talked about the pros and

cons with your doctor You shouldn’t be refused a test if you make this choice after talking with your doctor.

When should I have a PSA test?

  • If you are over 50 yrs old

– ? 45 yrs if you have a strong family history

 Many are found on routine health screening

checks

  • If you have recurrent urinary symptoms
  • If you’re in a high risk group

– African-Caribbean men – Family history of breast cancer

A few important facts…

  • PSA based screening is NOT just a test at
  • ne time and never again
  • It MUST be a regular test to monitor

changes in PSA blood levels 13 14 15 16 17 18

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A few important facts…

  • PSA based screening trials have reduced

mortality by up to 64%

– Regular measurement of serial PSA – NOT just one PSA test alone

Hugusson j et al, Scand J Urol 2018;52(1): 27-37 Bokhurst LP et al, Eur Urol 2014; 65: 329-36 Alpert PF, Urology 2018; 118: 119-26

A few important facts…

  • Early measurement of PSA in a man’s 40’s

can predict lifetime rise of dying from PCa.

– Low risk men with consistently low PSAs (<1ng/ml) can stop screening in their 60’s

 Subsequent risk of death is only 0.2% Vickers AJ et al, BMJ 2010; 341: C4521

What other tests need to be done?

The DRE

  • Digital Rectal Examination
  • If your prostate feels larger

than expected this could be a sign of prostate disease

The only way to examine the prostate is with a DRE

What might suggest prostate cancer?

  • A prostate gland with hard

bumpy areas Does everyone need a rectal examination?

How is Prostate Cancer diagnosed? What’s new in diagnosis? The biggest Game-Changer

  • Multiparametric

MRI

– ‘Sees inside the prostate’

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The biggest Game-Changer

  • Should be standard

practice to scan before biopsy

  • Now in the NICE

guideline

  • Biopsy rate

reduced by 30%

  • Targeted biopsy

now easier

A Useful Spin-Off

  • PSA Density
  • mpMRI can now accurately measure

prostate volume

  • PSA and prostate volume ratio computed

High PSA and large prostate volume – Low PD Mildly raised PSA and moderate prostate volume – Normal PD High PSA and low prostate volume – High PD PSA Density may be as useful as Gleason score – particularly in PSA range 4 – 10ng/ml

Prostate biopsy

  • Trans-Rectal Ultrasound Guided

– TRUS biopsy – Standard biopsy for most people

Prostate biopsy

  • Trans-Perineal Biopsy

– Template biopsy – Targeted T-P biopsy

Prostate biopsy

  • Template biopsy

What’s new in imaging?

  • Standard CT & MRI Bone scanning

– ‘Static’ scans – Show anatomy only – Very useful in initial diagnosis

  • Diagnosis of secondary spread

– Needs a ‘dynamic’ scan – To show activity of cells – Cancer cells more active than ‘normal’ ones

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Improved imaging

  • PET - Positron Emission Tomography

– Demonstrates cell activity – F18 FDG

 fluorodeoxyglucose

– C11 choline

 important in making cell walls  More sensitive for PCa cells

– Not easy to manufacture – Occasional supply problems

Improved imaging

PET Scanning

  • PMSA PET scanning

– Ga 68 injection

Improved imaging

PET Scanning

  • PMSA PET scanning

– Ga 68 injection

Improved imaging

  • WB-DWI

– Whole body diffusion weighted MRI

 More accurate than bone

scanning to assess the response of bone metastases to therapy

 Computer software to assist

assessment

 May also identify lymph

nodes

What’s new in treatment? Robotic / laparoscopic prostatectemy

  • Now the norm for

major surgery

  • Any better than the
  • pen operation?

– Less bleeding – Less incontinence? – Less E D? – Nerve sparing surgery

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Robotic / laparoscopic prostatectemy

  • NPCA Audit 2019 (April

2017 – March 2018)

  • 7, 018 Radical surgery

– 85% Robotic – 6% Laparoscopic – 8% Open

External beam RadioTx External beam RadioTx

  • Linear accelerator 3D-CRT
  • 3D Conformal RadioTherapy
  • Accurate beam

shaping

  • Fewer side effects

and tissue damage

External beam RadioTx

IG-IMRT

  • Image guided

Intensity modulated Radiotherapy

  • CT localisation at the

time of treatment

  • No need to rely on

skin markers alone

  • Hypofractionation

SpaceOAR

  • Injectable gel

What’s new in drug therapy?

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Androgen Deprivation Therapy

  • ‘Hormone resistant

prostate cancer’

  • Abiraterone (2011) –

stops body producing testosterone (different action to Zoladex)

  • Enzalutamide (2012)

– blocks the action of testosterone

  • n cancer cells

Newer drug therapy

  • ‘Hormone resistant

prostate cancer’

  • Abiraterone (2011) –

stops body producing testosterone (different action to Zoladex)

  • Enzalutamide (2012)

– blocks the action of testosterone

  • n cancer cells

group

Gene Therapy for PCa Gene Therapy for PCa

  • This is not about

physically altering the genes themselves

  • Concerns the ability of

cells to repair their genes when damaged at cell division

Olaparib

  • BRCA 1 & BRCA 2

– Commonest genetic defects in PCa – Also associated with breast cancer

  • Many other genetic abnormalities

– ATM – 12 others

Olaparib

  • Olaparib is effective in prolonging survival in

men with BRCA 1&2, ATM genetic abnormalities

– BRCA 2 is the most common abnormality – Some evidence of benefit in other genetic abnormalities. – Waiting for NICE approval

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The Future The Future.....

  • A diagnostic test that can:

– Identify prostate cancer very selectively – Accurately differentiate between aggressive and non- aggressive prostate cancers – ? ‘Fluid Biopsy’ - reduction in invasive biopsies?

  • Earlier diagnosis will lead to earlier

treatment

– Less recurrence? – Less progression?

The Future.....

  • Serial monotherapy or better use of multi-

modal therapy?

– Will this reduce the incidence of progressive recurrent disease?

The Future.....

  • Can we get better ADT – without side

effects

– ? Selective testosterone blockade on prostate cancer cells – Reduce the need for total reduction of testosterone and associated side effects recurrent side effects?

  • Targeted gene therapy
  • Genetic testing

The Future.....

  • Stop using treatments that act globally

and indiscriminately

  • Use highly selective targeted

treatments specific for each patient

Prostate Cancer

Screening, Diagnosis, Treatment

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