Controversies in

Prostate DiseasesEuropa Uomo Masterclass

L. DenisKrakow, February 6, 2009

Understanding Prostate Diseases

Prostate Cancer is a chronic Disease

Purpose of this Chat Session

1. Highlight the uncertainty in prostate diseases.

2. Address overdetection / overtreatment.

3. Address undertreatment

OCA 2009

Europa Uomo Strategy and Aims

1. Protect the patient with focus on quality of life & solidarity.

2. Inform and educate evidence based care and values our business.

3. Collaborate and understand optimal medical care.

OCA 2009

The Way Forward

1. Individual prevention and treatment according to optimal treatment and care.

2. Reduce over- and undertreatment.

OCA 2009

The lost patient

Tsunami information (Professionals, media, friends)

The medical labyrinth

EBM GuidelinesNomograms

Loss of personality

Outcome resultsStatistics

PANIC

OCA 2009

Request of a Patient

• Professional expertise specialist

• Expertise and guidance general practitioner

• Support from his environment

Cure or ControlQuality of Life

We want our place in Society

OCA 2009

Uncertainties Prostate Cancer

• Early prostate cancer has no symptoms

• DRE not much help

• PSA non specific, variable

• Imaging TRUS, MRI not perfect

• Biopsy techniques / pathology reports

• Treatment choice

We need: - Marker for Progression

- % of trifectaOCA 2009

Uncertainty with the Doctor

1. Limits of knowledge & training

2. Feels secure in his own specialty

3. Never enough time to communicate with the patient

OCA 2009

Localized Prostate Cancer

Preferred RXAll

Replies (%)

U.S. Physicians

R.O. (%)

Urol. (%)

M.O. (%)

Radiotherapy 40 92 8 46

Prostatectomy 40 8 80 42

Other RX 20 0 12 12

Do we have time for a secure diagnosis / find rest with the idea.

1. PCa begins at age 30, present in half of men age 50 and increasing with age.

2. These cancers need 20 year (38 doublings) to be detected.

3. From diagnosis to death 15 years. With PSA 5 year survival obsolete.

OCA 2009

Relativity of Prostate Cancer in Belgium KCE (knowledge)

Of 100 Belgian men before 75 years of age

- 64 have latent cancer

- 2 to 6 are diagnosed

- 1 died of PCA

OCA 2009

Overdetection is a fact

Men PCa Women Bra

Inc. Mortality Inc. Mortality

2004 202,1 68,2 275,1 88,4

2006 301,5 67,8 319,985,3

Europa 25 * thousands, IARC

Incidence en Mortality 2004 - 2006

PSA ng/ml Number of men

Number (%) with prostate cancer

Number (% of cancer) withhigh-grade prostate cancer

< 0.5 486 32 (6.6) 4 (12.5)0.6 – 1.0 791 80 (10.1) 8 (10.0)1.1 – 2.0 998 170 (17.0) 20 (11.8)2.1 – 3.0 482 115 (23.9) 22 (19.1)3.1 – 4.0 193 52 (26.9) 13 (25.0)Total 2950 449 (15.2) 67 (14.9)

Indolent Cancer is a FactPCa and HGca (>7 Gleason) by PSA level (>4 ng/ml) in the Prostate Cancer Prevention Trial study.

Bowery Series: Arbitrary Open BiopsyAge, frequency, and diagnosis of prostatic disease in

300 patients

Age BPH Ca % Ca

30 – 39 2 --- ---

40 – 49 46 2 4.2

50 – 59 116 17 12.9

60 – 69 82 17 16.1

70 – 79 14 3 16.9

80 – 89 1 --- ---

Total: 261 39

P. Hudson, Cancer 1954

Primary Treatment according to Specialist Consult (N-85.088)

Specialty RP % XRT % Hormones % A.S.

Urology (N = 42,309)65-69 (N = 12,248) 70 5 7 18

70-74 (N = 10,751) 40 8 17 31

75+ (N = 19,310) 5 4 45 46

Urology / Medical Oncology (N = 2,329)65-69 (N = 601) 53 17 14 16

70-74 (N = 657) 38 22 17 23

75+ (N = 1,071) 5 15 46 34

T. Jang, NCI, 2007

Primary Treatment according to Specialist Consult (N-85.088)

Specialty RP % XRT % Hormones % A.S.

Urology / Radiation Oncology (N = 37,540)65-69 (N = 10,604) 15 78 3 470-74 (N = 14,058) 7 85 4 475+ (N = 12,878) 2 85 7 6

Urology, Radiation & Medical Oncology (N = 2,910)65-69 (N = 890) 19 70 6 570-74 (N = 1,037) 8 80 7 5

75+ (N = 983) 2 79 12 7

T. Jang, NCI, 2007

Active Surveillance vs. Watchful Waiting

Fit Patient Co-Morbidity

Low risk Cancer High risk Cancer

PSA dynamics define treatment

(+ biopsies)

Symptoms define treatment

Option: Cure Option: PalliationOCA, 2008

Mismatch

• Organ dysfunction increases toxicity / side-effects

• Out of 438 patients, 389 (89%) with known dysfunction.

• More than 1/3 received inappropriate treatment

• Communication problems ?

Chen 2008

New Technology

1. Not the necessity but availability defines frequent use.

2. Good treatment not supported by industry fails.

3. Replacement ‘old’ treatments by new ones.

4. The learning curve of technology.

W. Oosterlinck 2008

Choice of Curative Treatment

1. Surgery: Anatomic Prostatectomy in T1, T2 and T3 cases

2. Radiatation: EBRT / Brachytherapy

in T1, T2 well and intermediate risk

in T3 combination hormones

3. Active Surveillance

OCA 2009

Avoid Undertreatment

1. Treatment decision based on SIOG evaluation

2. Salvage treatment after RP (ECE, rising PSA) EBRT or reverse

3. A double negation in watchful waiting (no symptoms, less than calculated life expectancy)

OCA 2009

Castration Resistant Prostate Cancer

1. About 20% of diagnosed, advanced PCa has diminished lowering PSA below 4 ng/ml

2. After secondary hormonal treatment:

AA withdrawal – DES – MAB – Abiraterone seen as resistant

3. Docetaxel & combinations first choice

4. Experimental: Immunotherapy, growth factors, gen therapy

5. Lifestyle in all casesOCA 2009

Close Communication Problems

Knowledge Reality

Prevention Treatment

Rich Poor

Collaboration Olympic stand

Transparant ObscureOCA, 2009

Life Expectancy

• Age

• Health

• Activity

• Address

• Social Status

OCA 2009

Partnerships Europa Uomo

EPPOSI OECI ESU ESOP – ESMO

EAU – EONS – ECCO

ECPC Eurocan+Plus Europa Donna PROCABIO

WWPCC TRANSMARK

Europa Uomo - ESO

Europa Uomo 2009

Thank you for not sleeping.

Don’t shoot the pianist.

OCA, 2009