6th ESMO Patient Seminar ESMO CONFERENCE LUGANO ECLU

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6th ESMO Patient SeminarESMO CONFERENCE LUGANO
(ECLU)

• The Prostate Continuum
• Louis Denis
• Europa Uomo
• July 7, 2007

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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
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Prostate Cancer an Endemic Disease

• Incidence and Mortality 2004-2006 in thousands
• European Union (25)

IARC, 2004-2006
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Finding Latent PCa at Autopsy
Sakr WA, et al. Eur Urol 199630138-144
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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
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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
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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
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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
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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)

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• 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
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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
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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
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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
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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
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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
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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
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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
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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
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Side-effects Androgen Depletion

• Hot Flashes Gynecomastia
• Depression Anemia
• ED Libido Obesitas
• Fatigue Osteoporosis
• Muscle Wasting Metabolic Syndrome
• Diabetes/C.V.

OCA, 2007
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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
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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