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6th ESMO Patient Seminar ESMO CONFERENCE LUGANO ECLU

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Natural History, Screening, Early Diagnosis. No Diagnosis without Prognosis. ... 3. Level A evidence (probability for cure) surgery, EBRT, brachytherapy. 4. New HIFU. ... – PowerPoint PPT presentation

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Title: 6th ESMO Patient Seminar ESMO CONFERENCE LUGANO ECLU


1
6th ESMO Patient SeminarESMO CONFERENCE LUGANO
(ECLU)
  • The Prostate Continuum
  • Louis Denis
  • Europa Uomo
  • July 7, 2007

2
The Prostate Cancer ContinuumFive Important Steps
  • Natural History, Screening, Early Diagnosis.
  • No Diagnosis without Prognosis.
  • Localized Cancer Cure vs. Control.
  • Locally Advanced Relapse
  • Metastatic HRPC.

OCA, 2007
3
Prostate Cancer an Endemic Disease
  • Incidence and Mortality 2004-2006 in thousands
  • European Union (25)

IARC, 2004-2006
4
Finding Latent PCa at Autopsy
Sakr WA, et al. Eur Urol 199630138-144
5
Facts of Natural History
  • It takes 38 doublings (20 y.) for a latent PC to
    be detected by biopsy (0,5 cc).
  • PSA driven biopsies may detect PC in up to 30 of
    males age 65.
  • 3. Clinical PC (symptoms) develops in 10 of all
    males leading to death in 15 years (2-4)
  • QoL is as important as survival (EU).

OCA, 2007
6
(No Transcript)
7
What the facts/figures tell us ?
  • There is a consistent overdetection especially
    over 65 y of age (ERSPC).
  • Early diagnosis brings uncertainty.
  • a. When should we stop screening for PC (70
    y.) ?
  • b. When and how to use curative treatment
    options ?

OCA, 2007
8
Where do we stand on Screening ?
  • 1. ERPSC 1994 2007 (270.000 men)
  • Too few events on mortality.
  • Overdetection 50 (indolent PC)
  • Failed curative attempt 30
  • All diagnostic tools carry uncertain
  • 2. PLCO 1994 - 2008 (28.000 men)
  • We have no tomatoes today (PC vs. lycopene in
    serum)

OCA, 2007
9
Primary Prevention Prostate Cancer
  • Fact Physical activity, vegetables, fruits,
    obesity.
  • Nutrition Circumstantial Evidence
  • Caution vitamins/supplements
  • Calcium vit.D3
  • Chemo Finasteride (PCPT trial)

OCA, 2007
10
Early Diagnosis Tailored to Patient
  • Informed patient on PSA screening, biopsy and
    active surveillance.
  • Age 50 standard but earlier detection advised in
    high risk groups race, history, anxious request
    after consensus professionals and civil society.
  • (PROCABIO HP7 Europe)

OCA, 2007
11
  • Overdetection may lead to Overtreatment. The
    case for Active Surveillance.
  • Delayed curative treatment facing indolent
    cancer Volume 0.5cc
  • cT1T2 No Mo
  • Gleason score 33
  • Biopsy cores 1-2
  • PCA lt 10 ng/ml
  • New markers PCA3 EOCA2

PRIAS www.prias-project.org, 2006
12
Prostate Cancer Diagnosis and Prognosis
  • Based on histology/cytology.
  • All diagnostic tools carry uncertainty
  • PSA and derivatives (cut-off)
  • DRE (inefficient)
  • TRUS (inefficient)
  • TRUS directed biopsies (number)
  • TNM stage (understaged)
  • Cancer Volume (indirect)
  • CT scan (inefficient)
  • Prognosis Gleason score low vs. high
    risk. Age vs. Co-morbidity
  • Access to expertise

OCA, 2007
13
Doctors facing Uncertainty
  • Cause Incomplete knowledge
  • Limitations in medical knowledge
  • Combination
  • Preference Move into action in their own
    discipline, overconfidence
  • Solution Consider angles, respect other
    opinions, open communication

How Doctors Think, J. Groopman, 2007
14
The lost male facing prostate disease
Contradictory information (doctor, media,
networking)
A lot of experts Lack of empathy ?
Statistics ? Outcomes ?
?
Inflexible guidelines Evidence Based Medicine
Loss of personality Body language
EMHF, June 7, 2007
15
Options Primary Treatment
  • No rush in a slow growing tumor.
  • 2. Include Active Surveillance
  • (deferred curative treatment)
  • Watchful Waiting
  • (palliative treatment)
  • 3. Level A evidence (probability for cure)
    surgery, EBRT, brachytherapy.
  • 4. New HIFU.

OCA, 2007
16
No cure without side-effectsThe Patients Story
  • Treated Norm
  • Incontinence urine 23 48 vs 4
  • Incontinence bowel 5 14 vs 2
  • Erectile dysfunction 40 74 vs 18

Thesis F. Mols, 2007
17
The Complexity of Relapse (15-30)
  • Meticulous review of prognostic factors low risk
    vs. high risk.
  • Monitor PSA (velocity) DT
  • Salvage EBRT or RP vs. WW
  • HIFU
  • Adjuvant ADT
  • Bisphosphonates (CA Vit.D)
  • 5. Need New Markers

OCA, 2007
18
Metastatic Prostate CancerClassic Treatment
Algorithm in systemic Prostate Cancer
  • Hormonal Treatment (LHRH A)
  • Maximal Androgen Blockade (MAB)
  • Anti-Androgen Withdrawal (switch)
  • Alternative Hormonal Treatment
  • Bisphosphonates Chemotherapy
  • Experimental Immuno - Gentherapy

OCA, 2007
19
Hormonal Treatment
  • Androgen Deplete ex. LHRH A
  • Block ex. Bicalutamide
  • Immediate vs. Delayed
  • gt PSA DT lt 12 months
  • PSA gt 50 ng/ml
  • Intermittent vs. Continuous
  • Monitoring Side-effects
  • Serum T

OCA, 2007
20
Side-effects Androgen Depletion
  • Hot Flashes Gynecomastia
  • Depression Anemia
  • ED Libido Obesitas
  • Fatigue Osteoporosis
  • Muscle Wasting Metabolic Syndrome
  • Diabetes/C.V.

OCA, 2007
21
HRPC Treatment
  • 1996 Mitoxantrone Prednisone
  • 29 palliation QoL
  • 2004 Docetaxel Prednison 3y. 18 increase
    overall survival
  • 2007 Second line Satraplatin
  • Access to CRT

OCA, 2007
22
Take Home Message 2007Prostate Cancer Diagnosis
and Treatment.
  • Seek balance optimal treatment vs. patient
    centered care.
  • Active Surveillance Watchful Waiting.
  • What good is for the heart is OK for the
    prostate.
  • PSA kinetics may help decision in uncertainty.
  • Access to RCT in HRPC.
  • Need for New Markers (PROCABIO).

OCA, 2007
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