What’s new in PCA...

Steven Joniau

University Hospitals Leuven, Belgium

EAU Guidelines 2010 update

PCA Guideline Panel

Axel Heidenreich (Chairman) Urology Germany

Joacqim Bellmunt Medical Oncology Spain

Michel Bolla Radiation Oncology France

Steven Joniau Urology Belgium

Theodor van der Kwast Pathology Canada

Malcom Mason Radiation Oncology UK

Veseled Matveev Urology Russia

Nicolas Mottet Urology France

Hans Peter Schmid UrologySwitzerland

Thomas Wiegel Radiation Oncology Germany

Francesco Zattoni Urology Italy

Screening

Schröder et al.New Engl J Med 2009

Andriole et al.New Engl J Med 2009

Risk reduction 27%Numbers needed to screen 1410Numbers needed to treat 48 No significant difference

Screening

Risk adapted early detection

Active Surveillance

• Active Surveillance• close follow-up examinations under strict rules of

guidelines• Purpose: Identification & treatment of significant

PCA, curative intent

• Watchful Waiting• withhold treatment until development of disease-

specific symptoms• Purpose: symptom-based therapy, palliative intent

Active Surveillance: why?

Because it• avoids overtreatment with insignificant or slowly

proliferating prostate cancer

• avoids unnecessary impairment of quality of life

• Is a viable alternative for elderly and co morbid patients who harbour a higher mortality risk from non-cancer specific causes

Active Surveillance

Inclusion Criteria• PSA ≤ 10 ng/ml• Biopsy Gleason Score ≤ 6• ≤ 2 positive biopsies• ≤ 50% cancer per biopsy• cT1c – cT2a

Intervention required• Biopsy Gleason Score > 6• PSA-DT < 3 years• cancer volume • patient’s preference

Adjuvant Radiation Therapy

• Bolla et al.• EORTC 22911: 60 Gy vs Wait-and-See • pT3a, pT3b, pTxpR1 independent on postop. PSA

• Wiegel et al.• ARO 96-02: 60 Gy vs Wait-and-See• pT3a-bpN0, PSA negative !

• Swanson et al.• SWOG 8794: 60-64 Gy vs Wait-and-See• pT3a, pT3b, pTxpR1 independent on postop. PSA

Adjuvant Radiation Therapy

Radiation W & S

R0 76.2% 67.4%

R1 77.6% 48.5%*

R0 + Rad R1 + Rad

HR 0.87 0.38

Benefit 88/1000 291/1000

EORTC 22911

Adjuvant Radiation Therapy

72%

54%

ARO/AUO – German Study

Adjuvant Radiation Therapy

ARO/AUO – German Study

5 year F-up: 25% benefit for progression-free survival

pT3aR1

SWOG 8794

Survellance Survellance adj. Radiationadj. Radiation

Adjuvant Radiation Therapy

SWOG 8794

Wait-and-See Radiation

PSA ≤ 0.2 0.21 – 1.0 ≤ 0.2 0.21 – 1.0

PSA 59% 23% 77% 34%

Local relapse

20% 25% 7% 9%

Metastases 12% 16% 4% 12%

Adjuvant Radiation Therapy

Adjuvant Radiation Therapy

Intermittend Androgen Deprivation

Cyclic therapy

• On-treatment period

• Off-treatment period

IHT aims to

• Minimise adverse events / improve quality of life (QoL)

• Delay progression to hormone resistant Pca

• Reduce costs of care

Intermittend Androgen Deprivation

Trial Population # patients randomised

NCIC/PR7 PSA relapse after RT ±300

EC 507 PSA relapse after RP 201

ICELAND PSA relapse/locally advanced ±700

SEUG Advanced PCa 626

Japan Locally advanced 188

AP 17/95 Advanced PCa and M+ 335

SWOG 9346 M+ PCa (PSA > 5 ng/mL) 1,345

EC 210 M+ PCa (PSA > 20 ng/mL) 194

Europe Advanced PCa (90% T3) 914

Intermittend Androgen Deprivation

Calais da Silva FEC et al. ; Eur Urol 2009

Intermittend Androgen Deprivation

EC507: IHT does not affect progression-free survival

Tunn U. BJU Int 2007;99(Suppl 1)

Intermittend Androgen Deprivation

Follow-up: local

Follow-up: ADT

Follow-up: ADT

CAVE: Diabetes mellitusMetabolic SyndromCholesterine, TriglycerideCholesterine/HDL - Ratio

Follow-up: cancer specific: PSA, Tendocrinologicmetaboliccardiovascular