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

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 Early diagnosis of Prostate How is Prostate Cancer Cancer diagnosed? • A simple urine test Early diagnosis is important in any cancer Particularly so in Prostate Cancer because of the anatomy: 7 10 Early diagnosis of Prostate How is Prostate Cancer Cancer diagnosed? • PSA blood test Early diagnosis is important in any cancer Particularly so in Prostate Cancer because of the anatomy: There are various different types of prostate cancer – some are more aggressive than others 8 11 How is Prostate Cancer How is Prostate Cancer diagnosed? diagnosed? • PSA blood test There is no single test to diagnose prostate • This is a blood test that measures the total amount of prostate cancer itself specific antigen (PSA) in your blood. SENSITIVITY But your GP can do a few tests to find out if you • PSA is a protein produced by normal cells in the prostate and have a prostate problem. also by prostate cancer cells. SELECTIVITY Problems with prostate health are likely to be • A raised PSA level may show that you have a problem with your prostate, but not necessarily prostate cancer. from another cause and not cancer SPECIFICITY 65 % men with a 15 % men with a raised PSA will normal PSA WILL VARIABILITY NOT have PCa have PCa 9 12 2

23/09/2020 How is Prostate Cancer Am I eligible for a PSA test? diagnosed? • PSA blood test • You have the right to have a PSA test if you’re over 50 and you’ve talked about the pros and • This is a blood test that measures the total amount of prostate specific antigen (PSA) in your blood. cons with your doctor SENSITIVITY • PSA is a protein produced by normal cells in the prostate and You shouldn’t be refused a test if you make this also by prostate cancer cells. SELECTIVITY choice after talking with your doctor. • A raised PSA level may show that you have a problem with your prostate, but not necessarily prostate cancer. SPECIFICITY Other factors can Rate of change of levels is more VARIABILITY raise the PSA important than one absolute value level 13 16 When should I have a PSA What is a ‘NORMAL’ PSA? test? It depends very much on the age of the patient • 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 14 17 National Screening Program for A few important facts… Prostate Cancer • NO National Screening Program for Prostate Cancer based on PSA • PSA based screening is NOT just a test at one time and never again • National Screening Committee are just about to publlish updated opinions • It MUST be a regular test to monitor changes in PSA blood levels 15 18 3

23/09/2020 How is Prostate Cancer A few important facts… diagnosed? The DRE • D igital R ectal E xamination • If your prostate feels larger • PSA based screening trials have reduced than expected this could be mortality by up to 64% a sign of prostate disease – Regular measurement of serial PSA – NOT just one PSA test alone What might suggest prostate cancer? • A prostate gland with hard bumpy areas Does everyone need Hugusson j et al, Scand J Urol 2018;52(1): 27-37 The only way to a rectal examination? Bokhurst LP et al, Eur Urol 2014; 65: 329-36 examine the Alpert PF, Urology 2018; 118: 119-26 prostate is with a DRE 19 22 A few important facts… What’s new in diagnosis? • 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 20 23 What other tests need to be The biggest Game-Changer done? • Multiparametric MRI – ‘Sees inside the prostate’ 21 24 4

23/09/2020 The biggest Game-Changer Prostate biopsy • Should be standard • Trans-Perineal Biopsy practice to scan – Template biopsy before biopsy – Targeted T-P biopsy • Now in the NICE guideline • Biopsy rate reduced by 30% • Targeted biopsy now easier 25 28 A Useful Spin-Off Prostate biopsy • PSA Density • Template biopsy • 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 26 29 Prostate biopsy What’s new in imaging? • Trans-Rectal Ultrasound Guided • Standard CT & MRI Bone scanning – TRUS biopsy – ‘Static’ scans – Standard biopsy for most people – 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 27 30 5

23/09/2020 Improved imaging Improved imaging • PET - P ositron E mission T omography • WB-DWI – Demonstrates cell activity – Whole body diffusion – F 18 FDG weighted MRI  More accurate than bone  fluorodeoxyglucose scanning to assess the response of bone – C 11 choline metastases to therapy  important in making cell walls  Computer software to assist  More sensitive for PCa cells assessment – Not easy to manufacture  May also identify lymph – Occasional supply problems nodes 31 34 Improved imaging What’s new in treatment? PET Scanning • PMSA PET scanning – Ga 68 injection 32 35 Robotic / laparoscopic Improved imaging prostatectemy PET Scanning • Now the norm for • PMSA PET scanning major surgery – Ga 68 injection • Any better than the open operation? – Less bleeding – Less incontinence? – Less E D? – Nerve sparing surgery 33 36 6

23/09/2020 Robotic / laparoscopic External beam RadioTx prostatectemy IG-IMRT • NPCA Audit 2019 (April • Image guided 2017 – March 2018) Intensity modulated Radiotherapy • 7, 018 Radical surgery • CT localisation at the – 85% Robotic time of treatment – 6% Laparoscopic • No need to rely on – 8% Open skin markers alone • Hypofractionation 37 40 External beam RadioTx SpaceOAR • Injectable gel 38 41 External beam RadioTx What’s new in drug therapy? • Linear accelerator 3D-CRT • 3D Conformal RadioTherapy • Accurate beam shaping • Fewer side effects and tissue damage 39 42 7

23/09/2020 Androgen Deprivation Therapy Gene Therapy for PCa • ‘Hormone resistant • This is not about prostate cancer’ physically altering the genes themselves • Abiraterone (2011) – • Concerns the ability of stops body producing testosterone (different action to cells to repair their Zoladex) genes when damaged • Enzalutamide (2012) at cell division – blocks the action of testosterone on cancer cells 43 46 Newer drug therapy Olaparib • ‘Hormone resistant • BRCA 1 & BRCA 2 prostate cancer’ – Commonest genetic defects in PCa – Also associated with breast cancer • Abiraterone (2011) – group stops body producing • Many other genetic abnormalities testosterone (different action to Zoladex) – ATM • Enzalutamide (2012) – 12 others – blocks the action of testosterone on cancer cells 44 47 Gene Therapy for PCa 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 45 48 8

23/09/2020 The Future 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 49 52 The Future..... The Future..... • A diagnostic test that can: • Stop using treatments that act globally and indiscriminately – Identify prostate cancer very selectively – Accurately differentiate between aggressive and non- aggressive prostate cancers • Use highly selective targeted – ? ‘Fluid Biopsy’ - reduction in invasive biopsies? treatments specific for each patient • Earlier diagnosis will lead to earlier treatment – Less recurrence? – Less progression? 50 53 The Future..... Prostate Cancer • Serial monotherapy or better use of multi- modal therapy? – Will this reduce the incidence of progressive recurrent disease? Screening, Diagnosis, Treatment 51 54 9