selecting treatment line for P prostate cancer

2. Prostate cancer: Risk stratification
and choice of initial treatment

4. • RISK STRATIFICATION
• Or
• cancer risk prediction models

5. • Weigh therapeutic options on
comparative benefits and risks in
domains, such as life expectancy, disease
control, health-related quality-of life and
treatment complications.
• Reduction of inconsistent management
due to physician bias, or differences in
experience and knowledge

6. Cancer risk prediction models
• Planning intervention trials
• Assisting in creating benefit–risk indices
• Estimating the cost of the population burden
of disease
• Identifying individuals at high risk
• Designing population prevention strategies
• Improving clinical decision-making (genetic
counseling)

7. Pre-treatment
PSA
clinical T
category
Gleason score
overall survival
disease-free survival
metastasis-free
survival
extracapsular disease
seminal vesicle
involvement
positive margins
lymph node positivity
PSA biochemical-free
failure

10. Prediction tables and algorithms
Prediction tables and algorithms
• Partin et al, 1997, 2001;
• Makarov et al, 2007;
• Eifler et al, 2013

11. • However, such statistical aids are more useful in
groups of patients than in individual patients
• wide confidence intervals surrounding estimates
of outcomes may limit the usefulness of risk
assessment for an individual patient.
• Accordingly, it has been claimed that the
simultaneous assessment of multiple variables in
nomograms provides more accurate predictions
than do tables for individual patients (Kattan,
2003).

14. Prostate Imaging-Data and Reporting System
[PI-RADS]

15. • Characterization of the Primary Tumor
• Evaluation of the Patient

16. Characterization of the Primary
Tumor
• DRE
• prostate ultrasound
• serum PSA data
including the total PSA level, the rate of change of PSA
(PSA velocity and doubling time), the PSA density
(serum PSA divided by prostate volume), the
percentage of PSA in the free or complexed isoforms
• Prostate Health Index are significantly associated with
prostate cancer aggressiveness
• (Benson et al, 1992; Carter, 1997; Catalona et al, 1998;
D’Amico et al, 2004; Thompson et al, 2004; Kundu et al,
2007; Catalona et al, 2011).

17. Characterization of the Primary
Tumor
The biopsy findings
• Gleason score
• number of cores containing cancer
• distribution and volume of cancer in the biopsy cores
• presence of perineural space invasion, lymphovascular
invasion,
• ductal, signet ring, or neuroendocrine differentiation)
also correlate
• with cancer aggressiveness and the likelihood of the
cancer’s being organ confined (Loeb et al, 2010a).

21. • Evaluation of the Patient

23. Evaluating the patients
Evaluation of life expectancy
Health status
• Comorbidity
• dependence in daily activities
• malnutrition
• Cognitive impairment

25. PRINCIPLES OF LIFE EXPECTANCY
ESTIMATION
• critical to informed decision-making in
prostate cancer early detection and
treatment.
• Life expectancy can be estimated using the
• Social Security Administration tables
(www.ssa.gov/OACT/STATS/table4c6.html)
• the WHO’s Life Tables by country
(http://apps.who.int/gho/data/view.main.60
000?lang=en).

26. • Life expectancy can then be adjusted using
the clinician’s assessment of overall health as
follows:
• Best quartile of health - add 50%
• Worst quartile of health - subtract 50%
• Middle two quartiles of health - no
adjustment

28. Comorbidity
• Comorbidity is a major predictor of non-
cancer-specific death in localised Pca
• Cumulative Illness Score Rating-Geriatrics
(CISR-G] is the best tool for assessing mortality
risk unrelated to Pca

34. Dependence in daily activities
• The level of dependence in daily activities
influences survival in senior adults.
• The Activities of Daily Living (ADL) scale rates
accomplishment of basic activities of daily
living, while the Instrumental Activities of
Daily Living (IADL) scale rates activities
requiring higher cognition and judgment.

36. Malnutrition
• Malnutrition is associated with increased
mortality in senior patients
• Nutritional status can be estimated from body
weight during the previous three months:
• • Good nutritional status < 5% weight loss;
• • Risk of malnutrition: 5-10% weight loss;
• • Severe malnutrition: > 10% weight loss.

37. Cognitive impairment
• Cognitive impairment is associated with
increased mortality risk in senior adults
• In patients undergoing major elective surgery,
there is an association between baseline
cognitive impairment and long-term
postoperative complications and mortality
[598].
• Intervention is unlikely to reverse cognitive
impairment, except in depression

38. • The mini-COG is the best available tool to
evaluate cognitive function in order to assess
the patient’s ability to make an informed
decision

41. • Baseline screening using the G8 screening tool
The International Society of Geriatric
Oncology (SIOG) PCa Working Group (PCWG)
recommends that btreatment for senior adults
should be based on a systematic evaluation of
health status

42. • The G8 (Geriatric 8) health status screening
tool is described, the Karnofsky and ECOG
Scores .

48. Definitive
DISEASE MANAGEMENT
• Deferred treatment (active surveillance/watchful
waiting
• Radical prostatectomy
• Definitive radiotherapy
• Options other than surgery and radiotherapy
for the primary treatment of localised prostate
cancer
• Hormonal therapy

49. Active surveillance
• achieve correct timing for curative treatment
in patients with clinically localised PCa, rather
than delay palliative treatment .
• Patients remain under close surveillance, and
treatment is prompted by predefined
thresholds indicative of potentially life-
threatening disease, still potentially curable,
while considering individual life expectancy.

50. Watchful waiting
• known as deferred or symptom-guided
treatment.
• conservative management, until the
development of local or systemic progression
with (imminent) disease-related complaints.
• Patients are then treated according to their
symptoms, in order to maintain QoL.

54. Low-risk PCa
Active surveillance

55. Low-risk PCa
• Radical prostatectomy

56. Low-risk PCa
• Radiotherapy

57. Low-risk PCa

58. Intermediate-risk PCa

59. Intermediate-risk PCa
• Radical prostatectomy

60. Intermediate-risk PCa
• Radiotherapy

61. Intermediate-risk PCa

62. High-risk PCa
• Watchful waiting

63. High-risk PCa
• Active surveillance

64. High-risk PCa
• Radical prostatectomy

66. • Radiotherapy

67. • Androgen suppression monotherapy

68. N1 patients
• cN1

69. • pN1 after extended lymph node dissection
(eLND)

70. Metastatic PCa

71. Metastatic PCa
• Androgen suppression

72. Metastatic PCa

73. Metastatic PCa

74. Metastatic PCa

83. Communicate with your patients

84. External beam radiation therapy Radical prostatectomy
•Effective long-term cancer control with high-
dose treatments
•Very low risk of urinary incontinence
•Wide range of ages and in those with
significant comorbidity
•Combined with hormone therapy treatment,
•eradicate extensions of tumor beyond the
margins of the prostate
•Effective long-term cancer control
•pathologic features in specimen
•Pelvic lymph node dissection is
possible through the same incision
•PSA failure is easy to detect
Brachytherapy Active Observation
•Cancer control rates appear equal to surgery
and EBRT for organ-confined tumors
•Quicker than EBRT (single treatment)
•Risk of incontinence is low in patients
without a previous TURP
•Available for cure of patients over a wide
range of ages and in those with some
comorbidity
•Reduces overtreatment
•Avoids or postpones treatment-
associated complications
•Has no effect on work or social activities

85. External beam radiation therapy Radical prostatectomy
•Significant risk of impotence
•Best outcomes require 3-D conformal
treatments with doses above 72 Gy
•Low risk of later rectal symptoms
•Knowledge of possible metastasis to lymph
nodes is not available
•Up to half of patients have some temporary
bladder or bowel symptoms during treatment
•Significant risk of impotence
•Risk of operative morbidity
•The risk of complications is operator
dependent, to some extent
•Low risk of long-term incontinence
Brachytherapy Active Observation
•Significant risk of impotence
•Successful cancer control is operator dependent,
to some extent
•Low risk of later rectal symptoms
•Knowledge of possible metastasis to lymph
nodes is not available
•Treatment not appropriate for tumor outside
the prostate capsule
•Up to half of patients have some temporary
bladder or bowel symptoms with treatment
•Tumor may progress beyond the
possibility for cure
•Later treatment may result in more
side effects
•Living with untreated cancer may
cause anxiety

86. External beam radiation therapy Radical prostatectomy
•Previous pelvic irradiation
•Active inflammatory disease of the rectum
•Very low bladder capacity
•Chronic moderate or severe diarrhea from
any cause
•Higher medical operative risk,
•Neurogenic bladder
Brachytherapy Active Observation
•Previous pelvic irradiation
•Prior TURP
•Large-volume gland
•Marked voiding symptoms
•Large or high-grade tumor burdens
•Chronic moderate or severe diarrhea
•Active inflammatory disease of the rectum
•High-grade tumors
•Expected survival of more than 10
years

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