Prostate Cancer: Evaluation & New Treatments Christopher L. Coogan, M.D.

Document technical information

Format pdf
Size 1.8 MB
First found Jun 9, 2017

Document content analysis

Language
English
Type
not defined
Concepts
no text concepts found

Persons

Organizations

Places

Transcript

Prostate Cancer:
Evaluation & New
Treatments
Christopher L. Coogan, M.D.
Charles F. McKiel, M.D.
Kalyan C. Latchamsetty, M.D.
©2007 RUSH University Medical Center
What is the prostate?
• Male sexual gland
• Adds nutrients and
fluids for sperm
• This fluid is added to
sperm during
ejaculation
• Urethra (urine channel)
runs through the middle
of the prostate
• Weight ~ 20 – 30gms
©2007 RUSH University Medical Center
Anatomy
• 1 = Peripheral Zone
– 75% of CA
• 2 = Central Zone
– 5% of CA
• 3 = Transitional Zone
– 20% of CA
• 4 = Anterior Fibromuscular Zone
– CA rare
©2007 RUSH University Medical Center
What is prostate cancer?
• Abnormal cells growing without
regulation
• Spreads and invades local tissues
• Prostate Cancer…
– Begins with a small tumor in the gland
– First spreads to the local lymph nodes
– Then spreads to the bony skeleton and other
areas of the body
©2007 RUSH University Medical Center
Introduction
• CAP  most commonly diagnosed (non-skin)
cancer in American ♂
• 2nd most common cause of ♂ cancer death
• ~ 217,730 new cases of CAP in 2010
• American Cancer Society
• ~ 32,050 deaths in 2010 in the U.S.
©2007 RUSH University Medical Center
Incidence of prostate cancer
©2007 RUSH University Medical Center
What are the symptoms of prostate cancer?
• You might not have any at all!
– Often there are none, or they are not recognized
• Major symptoms:
–
–
–
–
–
–
Urinary frequency
Slow urinary flow
Painful urination
Blood in urine or semen
Impotence
Lower back or thigh pain
©2007 RUSH University Medical Center
How Significant Is Prostate Cancer?
• In the USA, 217,730 men will be diagnosed with
prostate cancer in 2010. That is one man
diagnosed every 3 minutes
• Prostate cancer deaths are estimated at 32,050 in
2010. That is one death every 18 minutes
• In Illinois, 8,730 men were diagnosed in 2010
• 1,420 men died of prostate cancer during 2010 in
Illinois
Source: Cancer Facts and Figures –2006- American Cancer Society
©2007 RUSH University Medical Center
Prostate cancer risk factors:
 Age: The risk increases with age, but 25% of
diagnoses are made under age 65.
 Race: African-Americans have a rate of incidence
double that of Caucasian men
 Family history of prostate cancer: Men with a
family history have two- to three-fold increase in the
risk of prostate cancer
 Diet: A diet high in saturated animal fat can double
the risk of developing prostate cancer.
©2007 RUSH University Medical Center
Risk Factors - Age
AGE
0 - 39:
40 – 59 :
60 – 69 :
70 – 79 :
0 - Death :
RISK
1 per 10149
1 per 38
1 per 14
1 per 7
1 per 6
Source: ACS 2000 to 2002
©2007 RUSH University Medical Center
Risk Factors - Race
Race
Afr.-Am.
Cauc.
Hisp.
Asian
Incidence
272.0
169.0
141.9
101.4
Death
68.1
27.7
23.0
12.1
Source:
Rates per 100,000 and age-adjusted. SEER incidence and U.S. cancer death rates, 1975-2002,
in (SEER = NCI Surveillance, Epidemiology, and End-Results Program
©2007 RUSH University Medical Center
RACE
• Prostate cancer is almost twice
as common in AfricanAmerican men than in
Caucasian men
• African Americans are more
than twice as likely to die
when diagnosed than
Caucasian men
• Why? Uncertain.
–
–
–
–
Socioeconomic
Diet
Genetic
???
©2007 RUSH University Medical Center
Risk Factors – Family History
FAMILY HISTORY
2.4 times increased risk for men with a firstdegree relative
All blood relatives need to be screened
starting at the age of 40
(Spitz, et al, “Familial patterns of prostate cancer: A case-control analysis”, J Urol,
1991, 146:1305-1307)
©2007 RUSH University Medical Center
Risk Factors - Diet
Eating red meat increases the risk of developing prostate
cancer 2.64 times

Red meat and dairy products are high in saturated fat
rich in arachidonic acid (a fatty acid)

Vegetable oil is rich in alpha linolenic acid (a fatty
acid)

By-products of these fats promote the growth and
seriousness of prostate cancer


Eating a diet high in fats also lowers the body’s defenses
©2007 RUSH University Medical Center
Trends in Obesity* Prevalence (%), By Gender, Adults
Aged 20 to 74, US, 1960-2002
45
40
33
Prevalence
35
30
28
30
26
23
25
21
20
15
17
16 17
15
13 15
11
12 13
10
5
0
Both sexes
NHES I (1960-62)
NHANES III (1988-94)
Men
Women
NHANES I (1971-74)
NHANES 1999-2002
NHANES II (1976-80)
*Obesity is defined as a body mass index of 30 kg/m2 or greater.
Source: National Health Examination Survey 1960-1962, National Health and Nutrition Examination Survey, 19711974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and
Prevention, 2002, 2004.
©2007 RUSH University Medical Center
Trends in Overweight* Prevalence (%), Adults 18
and Older, US, 1992-2003
1992
Less than 50%
50 to 55%
More than 55%
State did not participate in survey
*Body mass index of 25.0 kg/m2or greater
Source: Behavioral Risk Factor Surveillance System, CD-ROM (1984-1995, 1998) and Public Use Data Tape (2003),
National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention,
1997, 2000, 2004.
©2007 RUSH University Medical Center
Trends in Overweight* Prevalence (%), Adults 18
and Older, US, 1992-2003
1995
Less than 50%
50 to 55%
More than 55%
State did not participate in survey
*Body mass index of 25.0 kg/m2or greater
Source: Behavioral Risk Factor Surveillance System, CD-ROM (1984-1995, 1998) and Public Use Data Tape (2003),
National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention,
1997, 2000, 2004.
©2007 RUSH University Medical Center
Trends in Overweight* Prevalence (%), Adults
18 and Older, US, 1992-2003
1998
Less than 50%
50 to 55%
More than 55%
State did not participate in survey
©2007 RUSH University Medical Center
Trends in Overweight* Prevalence (%), Adults
18 and Older, US, 1992-2003
2003
Less than 50%
50 to 55%
More than 55%
State did not participate in survey
©2007 RUSH University Medical Center
So what CAN I eat?
• A balanced diet rich in fruits
and vegetables!
(5 servings/day)
• Lower your intake of red
meat, processed and fried
foods. Eat more plant-based
food like soy protein.
• Watch portion sizes
(3 oz meat/serving)
• Eat foods with lycopene
(tomatoes, watermelon
and red grapefruit) which
may be associated with a
decreased risk of prostate
cancer
©2007 RUSH University Medical Center
Can we prevent prostate cancer?
• Prostate Cancer Prevention Trial (PCPT):
18,882 men randomized:
– 25% Reduction in Cancer, BUT
– 14-25% increase in high grade cancer
• REDUCE Trial: 22% decreased
– 8200 men, randomized, ? increase high grade
– Dutasteride (Avodart)
– FDA WARNING
• SELECT Trial: 35,533 men
– Vitamin E vs Selenium: no change
©2007 RUSH University Medical Center
Screening
• American Urological Association
screening recommendations:
• Digital Rectal Examination & PSA
1.All males over the age of 40 – annually
– ?45 or 50
2.All African American males over age of 40 –
annually
3.All pts with family hx (1st degree relative)
starting at age 40 – annually
• ACS: 50
– 45 if 1st degree or AA
©2007 RUSH University Medical Center
Anatomy - DRE
©2007 RUSH University Medical Center
DRE not always accurate!
©2007 RUSH University Medical Center
Screening
• Only 15% of prostate cancers are
detected through this examination
• Many men with abnormal DREs do NOT
have prostate cancer
• Many men with normal DREs DO have
prostate cancer
©2007 RUSH University Medical Center
PSA
• Prostate specific antigen
• Protein produced by the cells of the prostate
• responsible for liquefying semen
immediately following ejaculation
– Increases motility of sperm cells
– Aids in fertilization
• Initially discovered in the late ‘70s, but wasn’t
used for screening for CAP
• Was used mainly by forensics in rape cases
• In 1985, the FDA approved PSA test for use
in humans
©2007 RUSH University Medical Center
PSA
• Can be elevated with benign conditions i.e.
prostatitis, BPH, UTIs, urinary retention
• Normal range: 0 - 4 ng/ml (0 - 2.5)
• PSA rises as we age
– PSA level of 3.0 in a 30 y/o male is abnormal
– PSA level of 3.0 in a 70 y/o male is nl
• PSA Velocity (>0.75/year)
©2007 RUSH University Medical Center
PSA Screening
• Most significant and controversial development in prostate cancer
control over the last 20 years
• Initial studies:
– PSA markedly elevated in men with prostate cancer (but, also
elevated with benign conditions: UTI, BPH, prostatitis, urinary
retention)
– PSA screening resulted in dramatic shift in stage of disease
• Conclusive evidence of efficacy is still lacking! But, it’s the best
test we have.
• In late 1980s, PSA screening in US exploded
©2007 RUSH University Medical Center
©2007 RUSH University Medical Center
SCIENCE TIMES, April 9 2002
©2007 RUSH University Medical Center
Prostate Cancer Screening
• Tyrol Study: 54% reduction in mortality
– 1993-2005
• PLCO Trial: No benefit to screening
– If PSA <2.0, every 2 years
• European Randomized Study for
Screening for Prostate Cancer (ERSPC)
– 20% reduction mortality, 40% mets, but
– Overdetection?
• FUTURE: Age-adjusted PSA, PSA
velocity, PCA-3
©2007 RUSH University Medical Center
PSA – may rise in presence of CAP
• Drawbacks:
– up to 30 percent of men with prostate cancer have
a normal PSA
– 75 percent of men with an high PSA blood test do
not have prostate cancer
– the PSA blood test cannot determine if the cancer
is a slow-growing or aggressive cancer
– Still is the best test we have
©2007 RUSH University Medical Center
Why do we screen?
To Avoid An Advanced Stage At Diagnosis:
Early detection is the goal for any cancers
Men Assuming Responsibility
for Their Health
PSA
DRE
©2007 RUSH University Medical Center
How does early detection help?
• Survival rate at 5 years is
100.0% for those whose
cancer is still just in the
prostate gland (localized).
• Survival rate at 5 years for
those whose cancer has
spread beyond the gland
(late diagnosis) is only
33.5%
©2007 RUSH University Medical Center
Screening
• American Urological Association
screening recommendations:
• Digital Rectal Examination & PSA
1.All males over the age of 40 – annually
– ?45 or 50
2.All African American males over age of 40 –
annually
3.All pts with family hx (1st degree relative)
starting at age 40 – annually
• ACS: 50
– 45 if 1st degree or AA
©2007 RUSH University Medical Center
Screening
• If PSA or Digital Rectal Examination is
abnormal, then patient needs a prostate
biopsy
©2007 RUSH University Medical Center
©2007 RUSH University Medical Center
©2007 RUSH University Medical Center
Staging of Prostate Cancer
•
•
•
•
•
•
•
PSA
Digital Rectal Exam
Trans Rectal Ultrasound
Gleason Score
Bone Scan
+/- CT scan or MRI
Biopsy and TNM staging system
– Tumor, Nodes, Metastases
©2007 RUSH University Medical Center
Stage I or Stage A Prostate Cancer
• Stage I cancer is
found only in the
prostate and usually
grows slowly
©2007 RUSH University Medical Center
Stage II or Stage B Prostate Cancer
• Stage II cancer has
not spread beyond
the prostate gland,
but involves more
than one part of the
prostate, and may
tend to grow more
quickly
©2007 RUSH University Medical Center
Stage III or Stage C Prostate Cancer
• Stage III cancer has
spread beyond the
outer layer of the
prostate into nearby
tissues or to the
seminal vesicles, the
glands that help
produce semen
©2007 RUSH University Medical Center
Stage IV or Stage D Prostate Cancer
• Stage IV cancer has spread to
other areas of the body such as the
bladder, rectum, bone, liver, lungs,
or lymph nodes
©2007 RUSH University Medical Center
Biopsy Results – Gleason Score
• Gleason Score = sum of the
two most common histologic
patterns (primary and
secondary)
• Range: Gleason 1(well
differentiated) – 5 (poorly
differentiated)
• The higher the Gleason Score,
the more poorly differentiated
the cancer (more aggressive)
• i.e. Gleason 3 + 3 = 6
•
Gleason 4 + 3 = 7
•
Gleason 5 + 4 = 9
• Gleason 3 + 4 ≠ 4 + 3
©2007 RUSH University Medical Center
Gleason Score
• Gleason Score = sum of the two most common
histologic patterns (primary and secondary)
• Range: Gleason 1(well differentiated) – 5 (poorly
differentiated)
• The higher the Gleason Score, the more poorly
differentiated the cancer (more aggressive)
• i.e. Gleason 3 + 3 = 6
•
Gleason 4 + 3 = 7
•
Gleason 5 + 4 = 9
• Gleason 3 + 4 ≠ 4 + 3
©2007 RUSH University Medical Center
Risk Groups
Low
Intermediate
High
Stage
≤ T2a
T2b
T2c or >
Gleason
Score
≤6
7
8-10
PSA
< 10
>10 & < 20
≥ 20
©2007 RUSH University Medical Center
Treatment Options
Dependent upon……
• Stage of disease
• Patient’s age and health
• Patient’s personal preference
©2007 RUSH University Medical Center
Treatment Options (early diagnosis)
 Watchful waiting  Active Surveillance
 Radiation Therapy
 External Beam Radiation Therapy
 Brachytherapy (Radioactive seeds)
 HDR
 Cryosurgery (Freezing prostate)
 Surgery (Radical Prostatectomy)
 Open Surgery
 Conventional Laparoscopic Surgery
 da Vinci™ Prostatectomy (Robotic-Assisted
Laparoscopic Surgery)
©2007 RUSH University Medical Center
Active Surveillance
• Appropriate in patients:
– with a less than 10 year life expectancy
– GS ≤ 6
– Non palpable disease
• DRE, serum PSA q 6 months
• Patients become symptomatic and
require treatment 30-50% of time
©2007 RUSH University Medical Center
Treatment Options (early diagnosis)
 Watchful waiting  Active Surveillance
 Radiation Therapy
 External Beam Radiation Therapy
 Brachytherapy (Radioactive seeds)
 HDR
 Cryosurgery (Freezing prostate)
 Surgery (Radical Prostatectomy)
 Open Surgery
 Conventional Laparoscopic Surgery
 da Vinci™ Prostatectomy (Robotic-Assisted
Laparoscopic Surgery)
©2007 RUSH University Medical Center

Similar documents

×

Report this document