s in Prostate Diseases Europa Uomo Masterclass L. Denis Krakow, February 6, 2009
Jan 28, 2016
Controversies in
Prostate DiseasesEuropa Uomo Masterclass
L. DenisKrakow, February 6, 2009
Understanding Prostate Diseases
Prostate Cancer is a chronic Disease
Purpose of this Chat Session
1. Highlight the uncertainty in prostate diseases.
2. Address overdetection / overtreatment.
3. Address undertreatment
OCA 2009
Europa Uomo Strategy and Aims
1. Protect the patient with focus on quality of life & solidarity.
2. Inform and educate evidence based care and values our business.
3. Collaborate and understand optimal medical care.
OCA 2009
The Way Forward
1. Individual prevention and treatment according to optimal treatment and care.
2. Reduce over- and undertreatment.
OCA 2009
The lost patient
Tsunami information (Professionals, media, friends)
The medical labyrinth
EBM GuidelinesNomograms
Loss of personality
Outcome resultsStatistics
PANIC
OCA 2009
Request of a Patient
• Professional expertise specialist
• Expertise and guidance general practitioner
• Support from his environment
Cure or ControlQuality of Life
We want our place in Society
OCA 2009
Uncertainties Prostate Cancer
• Early prostate cancer has no symptoms
• DRE not much help
• PSA non specific, variable
• Imaging TRUS, MRI not perfect
• Biopsy techniques / pathology reports
• Treatment choice
We need: - Marker for Progression
- % of trifectaOCA 2009
Uncertainty with the Doctor
1. Limits of knowledge & training
2. Feels secure in his own specialty
3. Never enough time to communicate with the patient
OCA 2009
Localized Prostate Cancer
Preferred RXAll
Replies (%)
U.S. Physicians
R.O. (%)
Urol. (%)
M.O. (%)
Radiotherapy 40 92 8 46
Prostatectomy 40 8 80 42
Other RX 20 0 12 12
Do we have time for a secure diagnosis / find rest with the idea.
1. PCa begins at age 30, present in half of men age 50 and increasing with age.
2. These cancers need 20 year (38 doublings) to be detected.
3. From diagnosis to death 15 years. With PSA 5 year survival obsolete.
OCA 2009
Relativity of Prostate Cancer in Belgium KCE (knowledge)
Of 100 Belgian men before 75 years of age
- 64 have latent cancer
- 2 to 6 are diagnosed
- 1 died of PCA
OCA 2009
Overdetection is a fact
Men PCa Women Bra
Inc. Mortality Inc. Mortality
2004 202,1 68,2 275,1 88,4
2006 301,5 67,8 319,985,3
Europa 25 * thousands, IARC
Incidence en Mortality 2004 - 2006
PSA ng/ml Number of men
Number (%) with prostate cancer
Number (% of cancer) withhigh-grade prostate cancer
< 0.5 486 32 (6.6) 4 (12.5)0.6 – 1.0 791 80 (10.1) 8 (10.0)1.1 – 2.0 998 170 (17.0) 20 (11.8)2.1 – 3.0 482 115 (23.9) 22 (19.1)3.1 – 4.0 193 52 (26.9) 13 (25.0)Total 2950 449 (15.2) 67 (14.9)
Indolent Cancer is a FactPCa and HGca (>7 Gleason) by PSA level (>4 ng/ml) in the Prostate Cancer Prevention Trial study.
Bowery Series: Arbitrary Open BiopsyAge, frequency, and diagnosis of prostatic disease in
300 patients
Age BPH Ca % Ca
30 – 39 2 --- ---
40 – 49 46 2 4.2
50 – 59 116 17 12.9
60 – 69 82 17 16.1
70 – 79 14 3 16.9
80 – 89 1 --- ---
Total: 261 39
P. Hudson, Cancer 1954
Primary Treatment according to Specialist Consult (N-85.088)
Specialty RP % XRT % Hormones % A.S.
Urology (N = 42,309)65-69 (N = 12,248) 70 5 7 18
70-74 (N = 10,751) 40 8 17 31
75+ (N = 19,310) 5 4 45 46
Urology / Medical Oncology (N = 2,329)65-69 (N = 601) 53 17 14 16
70-74 (N = 657) 38 22 17 23
75+ (N = 1,071) 5 15 46 34
T. Jang, NCI, 2007
Primary Treatment according to Specialist Consult (N-85.088)
Specialty RP % XRT % Hormones % A.S.
Urology / Radiation Oncology (N = 37,540)65-69 (N = 10,604) 15 78 3 470-74 (N = 14,058) 7 85 4 475+ (N = 12,878) 2 85 7 6
Urology, Radiation & Medical Oncology (N = 2,910)65-69 (N = 890) 19 70 6 570-74 (N = 1,037) 8 80 7 5
75+ (N = 983) 2 79 12 7
T. Jang, NCI, 2007
Active Surveillance vs. Watchful Waiting
Fit Patient Co-Morbidity
Low risk Cancer High risk Cancer
PSA dynamics define treatment
(+ biopsies)
Symptoms define treatment
Option: Cure Option: PalliationOCA, 2008
Mismatch
• Organ dysfunction increases toxicity / side-effects
• Out of 438 patients, 389 (89%) with known dysfunction.
• More than 1/3 received inappropriate treatment
• Communication problems ?
Chen 2008
New Technology
1. Not the necessity but availability defines frequent use.
2. Good treatment not supported by industry fails.
3. Replacement ‘old’ treatments by new ones.
4. The learning curve of technology.
W. Oosterlinck 2008
Choice of Curative Treatment
1. Surgery: Anatomic Prostatectomy in T1, T2 and T3 cases
2. Radiatation: EBRT / Brachytherapy
in T1, T2 well and intermediate risk
in T3 combination hormones
3. Active Surveillance
OCA 2009
Avoid Undertreatment
1. Treatment decision based on SIOG evaluation
2. Salvage treatment after RP (ECE, rising PSA) EBRT or reverse
3. A double negation in watchful waiting (no symptoms, less than calculated life expectancy)
OCA 2009
Castration Resistant Prostate Cancer
1. About 20% of diagnosed, advanced PCa has diminished lowering PSA below 4 ng/ml
2. After secondary hormonal treatment:
AA withdrawal – DES – MAB – Abiraterone seen as resistant
3. Docetaxel & combinations first choice
4. Experimental: Immunotherapy, growth factors, gen therapy
5. Lifestyle in all casesOCA 2009
Close Communication Problems
Knowledge Reality
Prevention Treatment
Rich Poor
Collaboration Olympic stand
Transparant ObscureOCA, 2009
Life Expectancy
• Age
• Health
• Activity
• Address
• Social Status
OCA 2009
Partnerships Europa Uomo
EPPOSI OECI ESU ESOP – ESMO
EAU – EONS – ECCO
ECPC Eurocan+Plus Europa Donna PROCABIO
WWPCC TRANSMARK
Europa Uomo - ESO
Europa Uomo 2009
Thank you for not sleeping.
Don’t shoot the pianist.
OCA, 2009