A "Movemeber" slide show outlining recent advancements in the diagnosis and management of prostate cancer.

1. New Advancements in the Treatment of
Prostate Cancer
Simon Treissman MD FRCSC
Royal Inland Hospital
Department of Surgery
Kamloops Rotary
Hilton Doubletree Kamloops
November 27, 2013

2. New Advancements in the Treatment of prostate Cancer
“Movember” Madness
Started in 2003 in Melbourne Australia by 30 “MO Bros”
Has Now spread to 45 countries and raised $447 million

3. New Advancements in the Treatment of prostate Cancer
Discussion:
– Structure and Function of the normal prostate gland
– What can go wrong with the prostate?
– The problem of prostate cancer
– Historical Perspectives
– Traditional therapies
– New advancements
– The future

4. What is the prostate gland?
• What does a normal prostate gland look like?
Bladder
Prostate
Urethra
The prostate is located at the
base of the bladder.
Urine must pass through
it on its way to the toilet.
Schematic

5. What is the prostate gland?
• Where in the body is the prostate gland located?
Anatomical image

6. What is the prostate gland?
• What does the normal prostate gland do?
– Largest, most active male sex gland
– Located at the base of the male pelvis
– Lies “astride” the male urethra
– Produces most of the ejaculate by volume
– Ranges in size from 10 – 25 grams
– Healthy function is necessary for successful fertilization.

7. The Abnormal Prostate Gland (pathology)
• What can go wrong with the prostate gland?
– Postatitis
– Benign Prostate Hyperplasia (BPH)
– Prostate Cancer (ACP)
Anatomical Schematic

8. The Abnormal Prostate Gland: Prostate Cancer
• What can go wrong with the prostate gland?
– Age dependant
– Immortal “Clone” of malignant cells
– Originates within the “peripheral zone”
– Can “invade” and “metastasize”
Prostate cancer
Schematic

9. The Abnormal Prostate Gland: Prostate Cancer
• What can go wrong with the prostate gland?
– ACP anatomical images

10. The Abnormal Prostate Gland: Prostate Cancer
• Local “invasion”
• Prostatism (LUTS)
• Bladder outlet obstruction
• Hydronephrosis
• Renal Insufficiency
• Obstructive Renal Failure

11. The Abnormal Prostate Gland: Prostate Cancer
• Metastatic Disease
• Lymph nodes
• Skeletal “mets”
– Skull
– Spine
– Ribs

12. The Abnormal Prostate Gland: Prostate Cancer
• What can go wrong with the prostate?
– ACP metastatic disease

13. The abnormal Prostate Gland: Prostate Cancer
• Incidence of prostate
cancer by age:
0
10
20
30
40
50
60
70
80
90
10 20 30 40 50 60 70 80 90
Average
number of
cases per year
(100's)
Average Number of new cases per yr UK – 2008 – 20102
.
ACP is age dependent

14. Consider the Human Male: Historical Perspective
Evolutionary considerations
• Primitive / Modern
Survive
Procreate
Evade predators / seat belt
Hunt wooly mammoth / job
Find suitable shelter / mortgage
Harem / Marriage

15. Consider the primitive Human Male:
• Primitive Man (3 million years)
– Life is tough
• No running water / sanitation, unsatisfactory housing, inadequate
food, no textiles
• Predators, microbial illnesses, viral illnesses, no vaccination
– Life is short
• Life Expectancy at Birth (LEB) = early forties

16. Consider the modern Human Male:
• Modern Man ( 200,000 - 50,000 years)
– Life is good!
• Lots of carbohydrates, protein, foods out of season
• Better living conditions
• Relative freedom from predators / pathogens
This happy Canadian fellow can expect to live to 80!

17. New Advancements in the Treatment of prostate Cancer
• “Rectangularization” of the survival curve
Survivors out of 100,000 born alive by age, Canada1
100
50
25
10 20 30 40 50 60 70 80 90
1981 -
1951 -
1921 -

18. New Advancements in the Treatment of prostate Cancer
• Primitive man VS Modern man
LEB = 40 years LEB = 80 years
Life has changed but procreation hasn’t

19. New Advancements in the Treatment of prostate Cancer
• Combination of age related incidence and growing
life expectancy -

20. New Advancements in the Treatment of prostate Cancer
• “Traditional” Treatments for prostate cancer
– Surgery
– Irradiation (XRT / EBRT)
– Hormonal manipulation (ADT)

21. New Advancements in the Treatment of prostate Cancer
Traditional Therapy
• Surgery
– Radical Retropubic Prostatectomy (RRP)
Terence Millin (1940’s)
– “Anatomical” RRP Patrick Walsh (1980’s)
“Bzzzzzzzz
zzzzzzzz”

22. New Advancements in the Treatment of prostate Cancer
Traditional Therapy
Irradiation (XRT)
Radium (1920’s)
X-ray therapy (1930’s)
Cobalt 60 (1940’s - p)
Linear accelerator (1950’s – p)
“Brachy” therapy (1960’s - p)

23. New Advancements in the Treatment of prostate Cancer
Traditional Therapy
• Hormonal manipulation
– Charles Huggins
– Born Halifax, Nova Scotia, 1901
– BA Acadia 1920
– MD Harvard 1924
– Surgery (Urology) Chicago 1930
– University of Chicago 1930 – 1969
– Nobel prize medicine
– Chancellor Acadia 1972 - 1979

24. New Advancements in the Treatment of prostate Cancer
Traditional Therapy

25. New Advancements in the Treatment of prostate Cancer
• Advanced prostate cancer
– “Huggins operation” Bilateral orchiectomy (castration)
– Delivers remission of 18 months – 5 yrs!
– Estrogens (stilbestrol)
– Progestins (AndrocurR
)
– LHRH agonist antagonists
– “non” steroidal androgen antagonists

26. New Advancements in the Treatment of prostate Cancer
• Surgery
– Suitable for younger healthier ACP patient
– Minimally invasive (laparoscopic) procedures
– Robotic Surgery ( da Vinici surgical robot)

27. New Advancements in the Treatment of prostate Cancer
• Irradiation
– Brachytherapy
• 1960’s Au 98 (98
Au)
• 1990’s Iridium 192 (192
Ir)
• 2000’s Iodine 125 (125
I)
• High Intensity Focused Ultrasound (HIFU)
– Proton Therapy
• Particle accelerator
• Increased Dose intensity
• Improved precision

28. New Advancements in the Treatment of prostate Cancer
• Hormonal Manipulation
– Huggins operation
– Estrogens
– Progestins
– LHrH’s
– Non-steroidal agents
– Intracellular ADT therapy
• Abiraterone (ZytingaR
)
• Enzalutamide (XtandiR
)
abiraterone
“Abiraterone targets testosterone
receptor inside the cell”

29. New Advancements in the Treatment of prostate Cancer
• Intra-cellular anti-androgens
– Enzalutamide
• Reduces PSA by on average 89%
• Extended survival by on average 5 months
• Relatively non-toxic
• FDA stopped trials in November 2011 – rushed to market

30. New Advancements in the Treatment of prostate Cancer
• RIH department of surgery
– Established 1905
– All major specialties represented
– Major cases undertaken everyday
– 24 / 7 / 365 coverage
– Current OR completed 1962