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Published: November 5, 2018

CONTROVERSIES IN PROSTATE CANCER MANAGEMENT

CaP

  • Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. Not all tumors are cancerous; benign tumors do not spread to other parts of the body.

WHAT IS ESTABLISHED

  • slow growing cancer
  • most men do get it at an advanced age
  • a lot of men don't even need to know about it let alone treat it
  • it can kill
  • no one established modality of treatment is considered the best!
  • So prostate cancer does fit the bill…but it doesn't behave life most cancers.
  • Thus managing it is an art and not just nearly following guidelines and algorithms, and its unlikely AI will replace a clinician atleast for this cancer!

The controversies in investigating..

  • PSA: simple blood test but with PV of only maybe 10-15% depending on how high the pSA is.
  • Then you need histological proof which entails a transrectal or transperineal biopsy which may risk e-coli septicaemia.
  • The biopsy itself is not 100% accurate as its almost blind thus has a pick up rate is about 60-70% only. Thus we still can miss unto 30% of cancers!

So the biopsy is negative…

  • What next?
  • Repeat biopsies
  • MRI
  • Watch and see

CaP-Screening controversy

  • Because prostate cancer often grows slowly, men without symptoms of prostate cancer who do not have a 10-year life expectancy should not be offered testing since they are not likely to benefit. Overall health status, and not age alone, is important when making decisions about screening.
  • Even after a decision about testing has been made, the discussion about the pros and cons of testing should be repeated as new information about the benefits and risks of testing becomes available. Further discussions are also needed to take into account changes in a man’s health, values, and preferences.
  • The main summary of findings from literature published on PCa screening is the Cochrane review published in 2013 . This review was based on an up-to-date systematic literature search until November 2012 and is an update of a 2010 paper with the same methodology. Its findings are as follows
  • Screening was associated with an increased diagnosis of PCa (RR: 1.3; 95% CI: 1.02-1.65).
  • Screening was associated with more localised disease (RR: 1.79; 95% CI: 1.19-2.70) and less advanced PCa (T3-4, N1, M1) (RR: 0.80; 95% CI: 0.73-0.87).
  • From the results of five RCTs, representing more than 341,000 randomised men, no PCa-specific survival benefit was observed (RR: 1.00; 95% CI: 0.86-1.17). This was the main objective of all the large trials.
  • From the results of four available RCTs, no overall survival followed by (OS) benefit was observed (RR: 1.00; 95% CI:0.96-1.03).
  • Moreover, screening was associated with minor and major harms such as overdiagnosis and overtreatment.

The numbers..

PSA TESTING CONTROVERSY

  • So even doing a PSA is controversial and YOU MUST ENSURE THE PATIENT UNDERSTANDS THE CONSEQUENCES OF A RAISED PSA…The consequence is merely the risk of prostate cancer bearing in mind the need to proceed with sleepless nights, a potentially fatal procedure(septicemia) etc

So its prostate cancer…now what

  • Treatment modalities, which are all validated, range from
    • Watchful waiting
    • Active survaillance
    • Surgery
    • Radiotherapy
    • Hormonal therapy in combination or alone
    • Cryotherapy
    • High Intensity Frequency Ultrasound treatment
    • Chemotherapy
    • Targeted therapy
    • Vaccines

To treat or not to treat controversy

  • ProtecT trial in the UK
  • At a median follow-up of 10 years, the ProtecT trial showed that mortality from prostate cancer was low, irrespective of treatment assignment. Prostatectomy and radiotherapy were associated with lower rates of disease progression than active monitoring; however, 44% of the patients who were assigned to active monitoring did not receive radical treatment and avoided side effects.

Ok lets treat….To cure or not to cure controversy

  • Curative options will involve radical surgery or radiotherapy with all their potential side effects
  • Treatment modalities to calm and keep the cancer under some control are an option but for whom?

Curative option: Which is better controversy

  • Both have the same overall survival and overall cancer free survival rates
  • Both have almost the same complication portfolio
  • One is urology based and one is oncologist based
  • Who to trust and why?

Why CUT?

  • There is a psychological benefit of removing the cancer
  • You potentially can avoid being andropaused!
  • Of course having the patholology can predict future progress and recurrence to a certain extent

What to offer…

  • Consider the Age
  • Life expectancy based on national census
  • Cost to the patient
  • Expertise available
  • Remember that in prostate cancer sometimes noting is everything!

80 year old asian gentlemen.

  • Maybe best NOT to do anything

80 year old caucasian who is one of richest people on the planet and is still working

  • But if its this man then what?

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