Presentation on "table prostate cancer" at Easthampstead Park Conference Centre as part of BASE meeting

1. Primary Care Management of
Stable Prostate Cancer
By
Marc Laniado MD FEBU FRCS(Urol)
marc.laniado@nhs.net
BASE 1 Dec, 2015
Easthampstead Park Conference Centre

2. 181,000 men living with prostate cancer

3. Many men with prostate cancer who won’t die

4. NICE CG175 OFFER FOLLOW UP OUTSIDE HOSPITAL

5. Learning more about prostate cancer for 1° care

6. If we don't make changes….

7. Benefits for all
• Patients
• care closer to home
• ↓appointment burden
• NHS
• ↑efficiency
• ↓ 2° care tariffs
• Optimisation of LHRH
injections, PSA testing
& follow ups

8. Primary care management of prostate cancer

9. Prostate examination
▪ Prostate
▪ Size
▪ Normal – golf ball
▪ > 50 cm3 – tennis ball
– Consistency
▪ Nodule/asymmetric? Cancer
– Anatomical limits
▪ Should be able to feel median sulcus,
lateral and cranial borders
▪ Seminal vesicles impalpable
– Normal anal tone and sensation
T1: feels benign
T2: hard but mobile
T3: hard, not mobile
T4: fixed

10. DRE unnecessary if PSA normal
for age in watchful waiting
Age Range PSA Threshold
40 to 49 years 2
50 to 59 years 3
60 to 69 years 4
Over 70 years 5

11. PSA varies by 15% & affected by
many factors - best to avoid them

12. Natural history of prostate cancer

13. Years aZer diagnosis
Dead from
prostate
cancer
Dead
from
other
causes
4% chance of dying aZer 10 y for low risk
disease in PSA era in 65 year old
Contains Gleason pa^ern 3 only
1 2 3 4 5

14. 40% chance of dying at 10 years for high risk
disease in PSA era in a 65 year old
Years aZer diagnosis
Dead from
prostate
cancer
Dead from
other
reasons
Gleason pa^ern 4 or 5
1 2 3 4 5

15. CG175 NICE risk stratification

16. Low risk cancers are about
50% of new cancer diagnoses
High
Intermediate/high
Intermediate
Low

17. Many features discriminate low and high risk
prostate cancer
• Cancer characteristics
• Gleason score
• PSA absolute level
• Clinical stage
• Tumour volume
• Patient characteristics
• Biological more than chronological age
• Multiparametric mpMRI
• restricted diffusion

18. Clinical clues indicate progression possible
• Deteriorating urinary symptoms
• IPSS/incontinence/haematuria/UTI
• Progressive changes on digital rectal examination
• Loin pain
• Bone pain
• Increased use of NSAIDs/analgesics
• Weight loss
• New onset neurology/spinal cord compression
• PSA rising
• Falling eGFR

19. Stable prostate cancer is what we want!

20. “Stable” Prostate Cancer can be handed over to
primary care (NICE CG175)
Active
Surveillance/
monitoring?
- SHARED CARE
-
Watchful
Waiting
radical prostatectomy/brachytherapy/external beam/ Androgen
deprivation agonists

21. Unsuitable Patients - relapsing after local
treatment & castrate resistant

22. Watchful Waiting = delayed palliative intervention with no intention
to cure
• Ideal candidate: early intervention won’t reduce
morbidity
• Assess
• 4 months x 1 yr, then 6 mo x 1 yr, then annually
• PSA at least annually for life (NICE)
• If UTI, cipro/nitrof. for 4 weeks, then repeat
• NO DRE unless PSA > age-specific
• Indications for referral to
secondary care
• PSA > 15-20 or doubling every 6 months
• Deteriorating LUTS or IPSS > 20/35
• Bone pain/weight loss/neurology

23. PSA 15% normal variation
0
2
4
6
8
10
12
14
16
18
PSA
PSA 1

24. Active Surveillance = delayed selective intervention with
intention to cure
• Ideal candidate: early intervention
may be unnecessary but can
reduce morbidity/mortality so
needs careful watching
• Complex area - but improving
rapidly
• Assessment of PSA, multiparametric
MRI, MRI-targeted prostate biopsy in
hospital allow better selection of
patients

26. At 5 and 10 years, 24% and 36% have
come off active surveillance
26 Klotz 2015 JCO

27. Enhanced mpMRI
can “see” prostate
cancer that cannot
be felt or hit by
transrectal biopsy
The same part of the prostate examined by MRI in different
ways (“multiparametric MRI”) exposes cancer
Cancer in
prostate
Bladder
Rectum
Anus

28. Active Surveillance better now
with mpMRI & template biopsies
Back
Front
Prostate
Cancer Transrectal biopsies
many problems
Back
Front
Prostate
Cancer
``
``
Transperineal
biopsies hits the
significant cancer
Unlikely to miss
important cancer

29. Mulitparametric MRI: restricted diffusion
predicts failure of active surveillance
Henderson
2015 Eur Urol
Follow up 12 years
n=86
MRI results not available
to investigators

30. Post radical prostatectomy: PSA very sensitive
indicator of recurrence
• NICE: “…after 2 years, men with stable
PSA and no significant treatment
complications…”
• Assess PSA annually at least, IPSS,
eGFR
• DRE unnecessary
• Indications for referral to
secondary care
• PSA rising
• ≥ 0.06 ng/ml or consultant threshold
• Deteriorating LUTS/incontinence/UTI
• Bone pain/weight loss/neurology/loin pain

31. Post brachytherapy/radiotherapy: can be more
tricky to determine if necessary to refer back
• NICE: “…after 2 years, men with stable PSA
and no significant treatment
complications…”
• Assess PSA annually at least, IPSS, eGFR
• No DRE unless PSA > age-specific PSA
• Indications for referral to
secondary care
• PSA rising
• 2 ng/ml above nadir or specified consultant
threshold
• Deteriorating LUTS or bowel symptoms
• Bone pain/weight loss/neurology/loin pain

32. Post hormonal therapy:
• NICE: “…after 2 years, men with stable PSA
and no significant treatment
complications…”
• Assess PSA annually at least, IPSS, eGFR
• Indications for referral to
secondary care
• PSA rising
• specified consultant threshold or doubling
every 6 months
• Deteriorating LUTS or bowel symptoms
• Bone pain/weight loss/neurology/loin pain/
spinal cord compression

33. Hot flushes on androgen
deprivation therapy
• Medroxyprogesterone
• 20 mg per day
• for 10 weeks, [new 2014]
• Cyproterone acetate
• 50 mg bd for 4 weeks [new 2014]
• no good-quality evidence for the use
of complementary therapies to treat
troublesome hot flushes. [new 2014]

34. Exercise to fight fatigue from
androgen deprivation
• supervised resistance
and aerobic exercise
• at least twice a week
• 12 weeks [new 2014]

35. Transferring from secondary to primary care

36. Identifying patients to transfer
Hospital Clinic Medical Records
EMIS codes B46

37. Welcome Letter: introduces
man to 1° care management
• Indicates date of check up
• Support information
• symptoms to look out for
• list of local support services
• definition of commonly used
terms
• holistic care plan

38. Holistic Care Plan to be completed
before GP/nurse appointment

39. Stable prostate cancer
PSA appointment

40. Reporting Tool

41. iQudos system facilitates stable prostate
cancer management in primary care

42. Protocol requires hand-over letter with clinical
information and GP to confirm acceptance in writing
Patient Assessed Stable
Consultant
Consultant sends discharge letter to GP
practice including contact details and shared
care protocol for discharged patients
Practice does not
agree to take on
patient
GP has 4 weeks to agree to take on patient
GP accepts and signs agreement to take on
patient GP sends this along with contact details
to Consultant and informs Urology CNS or PSN
GP has Choice discussion with patient
GP
Shard Care Protocol for follow up checks
Recording and sharing of patient follow ups
between PSN and GP
Mechanism for alerting GP’s PSN, Consultant
over concerns
New referral faxed to
Consultant’s office
Patient needs to return to secondary carePatient remains stable
PSN
Patient discharged to Primary Care

43. Secondary to Primary Care Referral Form
clinical details in top half

44. Secondary to Primary Care Referral Form:
Reply back so we know you accept

45. Primary back to secondary care: use 2 week wait
or give us a call!
Please refer back using the
2 week wait proforma

46. Case #1
• Case 1
– healthy 71-year-old man treated for prostate cancer
(Gleason score 6, PSA level 9 ng/mL, T2) with radical
prostatectomy 5.5 years ago.
– PSA 0.001 to 0.7 ng/mL, asymptomatic
• Do you need to be concerned by this increase?

47. Case #2
• 63-year-old man
– brachytherapy 4 years ago for prostate cancer
(Gleason score 6, PSA 7 ng/mL ,T2)
– PSA nadir 0.2 ng/mL, and PSA values taken every 3
months have been 0.7 ng/mL, 1.0 ng/mL, 0.8 ng/mL,
and, most recently, 0.5 ng/mL.
• What should you do?

48. PSA Monitoring
• Radical Prostatectomy
– PSA should be undetectable (<0.2 ng/ml within 3-6 wks)
– Persistent elevation
• suggestive of residual local or distant disease,
• reflect residual normal tissue
– PSA of 0.2-0.4 ng/ml is considered a BCR (Biochemical
Recurrence)
– What should you do?

49. PSA Monitoring
• External Beam Radiotherapy
– PSA should be 50% its pre-treatment level 3 months post-treatment
– PSA should decrease to 0.2-0.5 ng/ml within 36 months
– PSA bounce
• Transitory rise of 0.4 ng/ml or 15% of previous PSA
• Spontaneously resolves
• Seen in 10-30% of people treated with EBRT
• Usually occurs within 9 months of treatment
• Can occur after 60 months
– PSA failure: Lowest PSA + 2.0 ng/ml
• Brachytherapy: PSA Monitoring unclear
– Assumed similar to EBRT

50. Local vs. Distant Recurrence
• Factors suggestive of local recurrence
– Initial pathology: Gleason <7, +ve surgical margins, no nodal involvement
– >1-2 yrs after treatment to PSA failure
– Pre-treatment PSA <10
– PSADT >12 months
• Factors suggestive of distant recurrence
– Initial pathology: Gleason >7, extra-prostatic involvement, nodal
involvement
– <1 yr after treatment to BCR
– Pre-treatment PSA >10
– PSADT <12 months

51. Patients With Incurable Disease
• Visits q6 months
– PSA testing, optional DRE
– BMD q2 yrs if on Androgen Deprivation Therapy (ADT)
– Bone scan if PSA >20 or clinically indicated
– Evidence of increased disease activity
• PSA > 10
• PSADT < 6 mo
• Symptomatic
• Consider ADT if not already receiving it
• Consider secondary hormonal therapy or chemo if already
receiving ADT

52. Case #1
• Case 1
– healthy 71-year-old man treated for prostate cancer
(Gleason score 6, PSA level 9 ng/mL, T2) with radical
prostatectomy 5.5 years ago.
– PSA 0.001 to 0.7 ng/mL, asymptomatic
• Do you need to be concerned by this increase?
• Mr. A has evidence of BCR and needs rapid referral for
potential salvage therapy.

53. Case #2
• 63-year-old man
– brachytherapy 4 years ago for prostate cancer
(Gleason score 5, PSA 7 ng/mL ,T2)
– PSA nadir 0.2 ng/mL, and PSA values taken every 3
months have been 0.7 ng/mL, 1.0 ng/mL, 0.8 ng/mL,
and, most recently, 0.5 ng/mL.
• What should you do?
– PSA bounce likely
– ≠BCR.
– Monitor PSA levels & symptoms.