INTRODUCTION TO RADICAL PROSTATECTOMY: Surgical Treatment for Prostate Cancer Dr. Alan So Associate Professor Dept of Urologic Sciences Vancouver Prostate Centre University of British Columbia Chair, GU Tumour Group at BC Cancer Biography: A graduate of the University of Alberta, Dr. So came to the Prostate Centre as a Clinical Fellow in 2002, following completion of his residency at Dalhousie University. His current research focuses on discovery and development of novel agents to treat bladder cancer as well as development of the mechanisms of treatment resistance in renal cell carcinoma. Currently, he is associate professor at the University of British Columbia and Vancouver Prostate Centre. As well, leads the Clinical Trials Unit at the Vancouver Prostate Cancer, is the Fellowship Director of the Uro-oncology Program at UBC, and is the Chair of the GU Tumour Group at the BC Cancer.
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INTRODUCTION TO RADICAL PROSTATECTOMY: Surgical …€¦ · INTRODUCTION TO RADICAL PROSTATECTOMY: Surgical Treatment for Prostate Cancer Dr. Alan So Associate Professor Dept of Urologic
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INTRODUCTION TO RADICAL PROSTATECTOMY:
Surgical Treatment for Prostate Cancer
Dr. Alan So
Associate Professor
Dept of Urologic Sciences
Vancouver Prostate Centre
University of British Columbia
Chair, GU Tumour Group at BC Cancer
Biography:
A graduate of the University of Alberta, Dr. So came to the Prostate Centre as a
Clinical Fellow in 2002, following completion of his residency at Dalhousie University.
His current research focuses on discovery and development of novel agents to treat
bladder cancer as well as development of the mechanisms of treatment resistance in
renal cell carcinoma. Currently, he is associate professor at the University of British
Columbia and Vancouver Prostate Centre. As well, leads the Clinical Trials Unit at
the Vancouver Prostate Cancer, is the Fellowship Director of the Uro-oncology
Program at UBC, and is the Chair of the GU Tumour Group at the BC Cancer.
• median f/u 5 years, freedom from biochemical failure 84% both arms
Knight Cancer Instituteat Oregon Health & Science University
SBRT as primary radiation treatment for prostate cancer
Scandinavian HYPO-RT-PC Figure 3: Urinary toxicity and patient-reported problems
Knight Cancer Instituteat Oregon Health & Science University
SBRT as primary radiation treatment for prostate cancer
Scandinavian HYPO-RT-PC Figure 4: Bowel toxicity and patient-reported problems
Knight Cancer Instituteat Oregon Health & Science University
SBRT as primary radiation treatment for prostate cancer
bowel protection – SpaceOAR hydrogel
Knight Cancer Instituteat Oregon Health & Science University
SBRT as primary radiation treatment for prostate cancer
bowel protection – SpaceOAR hydrogel
Knight Cancer Instituteat Oregon Health & Science University
SBRT for Oligometastases
Oligo- From the Greek ‘oligos’, few, scanty
• Traditional treatment of patients with metastatic disease has been
based on systemic therapies that aim to delay progression and extend
life, but not to eradicate the disease completely.
• The oligometastatic paradigm suggests that in some patients,
metastatic disease is not widespread and may be constrained to
develop in only a small number of sites.
• This paradigm suggests that patients with oligometastases might be
amenable to a curative treatment approach.
Knight Cancer Instituteat Oregon Health & Science University
SBRT for OligometastasesSABR-COMETStereotactic ablative radiotherapy versus standard of care palliative treatment in patients with oligometastatic cancers: a
randomised phase 2, open-label trial
• 99 patients randomized to control (standard treatment) vs. radiation
– 1 – 5 metastatic lesions
– original tumor: breast, colorectal, lung, prostate, other
Knight Cancer Instituteat Oregon Health & Science University
SBRT for OligometastasesSABR-COMETStereotactic ablative radiotherapy versus standard of care palliative treatment in patients with oligometastatic cancers: a
randomised phase 2, open-label trial
Knight Cancer Instituteat Oregon Health & Science University
SBRT for OligometastasesSABR-COMETStereotactic ablative radiotherapy versus standard of care palliative treatment in patients with oligometastatic cancers: a
randomised phase 2, open-label trial
Knight Cancer Instituteat Oregon Health & Science University
SBRT for OligometastasesSABR-COMETStereotactic ablative radiotherapy versus standard of care palliative treatment in patients with oligometastatic cancers: a
Knight Cancer Instituteat Oregon Health & Science University
SBRT for OligometastasesSTOMP Surveillance or Metastasis-Directed Therapy for Oligometastatic Prostate Cancer Recurrence
• 62 patients randomly assigned to standard treatment or
metastasis-directed therapy
– 3 or fewer lesions on PET
– metastasis-directed therapy
• surgery to remove disease
• or SBRT (30 Gy over 3 fractions)
– primary endpoint: Can metastasis-directed therapy delay the
need to start ADT
– ADT start: symptomatic progression, > 3 metastases, or local
progression of baseline-detected metastases
Knight Cancer Instituteat Oregon Health & Science University
SBRT for OligometastasesSTOMP Surveillance or Metastasis-Directed Therapy for Oligometastatic Prostate Cancer Recurrence
• @ 3 years of f/u
– 30% Metastasis-Directed Therapy
had not started ADT
– no grade 2 to 5 toxicity
– QOL similar at baseline and 3-
month and 1-year
Knight Cancer Instituteat Oregon Health & Science University
SBRT for OligometastasesSTOMP Surveillance or Metastasis-Directed Therapy for Oligometastatic Prostate Cancer Recurrence
• @ 3 years of f/u
– 25% with biochemical recurrence-
free survival in the metastasis-
directed group
• median ADT-free survival
– 13 months in surveillance group
vs.
– 21 months for the metastasis-
directed therapy group
Knight Cancer Instituteat Oregon Health & Science University
SBRT for OligometastasesORIOLE Outcomes of Observation vs. Stereotactic Ablative Radiation for Oligometastatic Prostate Cancer
• Phase 2 study (1 - 3 metastases)
• 64 men randomized 2:1 to
receive SABR or observation
• primary outcome was
progression @ 6 months
• Progression-Free Survival
– observation 5.8 months
– SABR not yet reached (p=0.005)
Knight Cancer Instituteat Oregon Health & Science University
Advances in Radiation Technology
• Radiation technology has enabled better targeting
–IMRT
–SBRT
• Targeted Therapy with Radiation = – Reduced Toxicity
– Better Tumor Control
Preserving Quality of Life while eradicating cancer.
Knight Cancer Instituteat Oregon Health & Science University
Advances In Radiation Therapy
for Prostate Cancer
Arthur Hung, M.D.
Julie N. Graff, MD
Section Chief of Hematology/Oncology
VA Portland Health Care System
Associate Professor of Medicine
Knight Cancer Institute
Oregon Health & Science University
Biography:
Dr. Graff went to medical school at George Washington University where she received her MD with distinction in 2003. She moved to Portland, OR,
and completed residency and fellowship at the Oregon Health & Science University in 2009. Since that time, she has been on the faculty at the Knight
Cancer Institute OHSU and on the staff at VA Portland Health Care System, where she has been the chief of hematology/oncology since 2018.
Dr. Graff focuses on helping patients with cancer live well. She sees patients with genitourinary cancers, such as prostate, kidney, bladder and
testicular cancers, but her research is on prostate cancer. She has designed and implemented many clinical trials that have resulted in some dramatic
results. She became internationally recognized for her work in immunotherapy in prostate cancer. This work has spun off into multiple trials. In 2018,
she earned a prestigious $1M Movember Challenge Award from the Prostate Cancer Foundation to study the effect of manipulation of the gut
microbiota on responses to immunotherapy in Veterans with advanced prostate cancer. The correlative work for this first-in-field research is led by co-
principal investigators Dr. Amy Moran (immunologist) and Dr. Karen Sfanos (molecular pathologist). The critical work of understanding the genetic
underpinnings of the biopsied tumors is led by Reid Thompson, MD, PhD. Together they hope to enhance prostate cancer responses to
immunotherapy.
Dr. Graff is passionate about education and mentors multiple learners, ranging from pre-medical students to assistant professors. She is the recipient
of resident and fellowship teaching awards. She is also very interested in diversity of leadership and is heading an effort to help female junior faculty in
hematology/oncology. Also, she is incredibly passionate about giving Veterans the best cancer care in Oregon and beyond.
No evidence of disease:Nothing on imagingPSA undetectable
PSA Recurrence:Nothing on imagingPSA detectable
Metastatic Cancer:Spread on imagingPSA detectable
Adapted from Saylor. Journal of Clinical Oncology 2011; 29(27): 3705.
*Some disagreement
This study included 1997 men who had a radical prostatectomy at Johns Hopkins between 1982 and 1997. They were followed for a mean of 5.3 years (range of 0.5-15 years).
Of the 1997 men, 315 (15%) had a biochemical recurrence, defined as a PSA ≥ 0.2 mg/ml. Eleven of them received early hormonal therapy and were not included in this analysis.
Pound. JAMA 1999; 28 (17): 1591.
Pound. JAMA 1999; 281 (17): 1591.
Pound. JAMA 1999; 281 (17): 1591.
Those you can
see
Those you can
feel
Other
Weight gain Hot flashes Bone density
loss
Muscle loss Fatigue Lipid changes
Hair pattern
changes
Depression Decreased
insulin
sensitivity
Fat
redistribution
Mental slowing Heart
disease(?)
Testicle/penis
size decrease
Anemia
• Statistics
• Some may not do well
• Gleason 8, 9, 10
• Pre-treatment PSA >
2.0 ng/ml
• Negative margins
• PSA doubling time ≤ 10
months
• Seminal vesicle
invasion
Bicalutamide plus radiation versus radiation alone
Active Surveillance
Albertsen, P. C. et al. JAMA 2005;293:2095-2101.
*Until 1999, PSA ≤15 and Gleason ≤3+4 were used.
Romero-Otero J, et al. Int J Urol 2015; Epub Nov 2015
Romero-Otero J, et al. Int J Urol 2015; Epub Nov 2015
Laurence Klotz et al. JCO 2015;33:272-277
Mark Garzotto, MDProfessor of Urology and Radiation Medicine, OHSU Knight Cancer InstituteUrology Section Chief, VA Portland HCS
Multidisciplinary Care of High-Risk Localized Prostate Cancer
Biography:Dr. Garzotto has a long standing interest in trying to refine the diagnostic approaches to the detection of prostate cancerincluding incorporation of MRI and novel statistical methods such as machine learning. His research group identified theViet Nam war-era defoliant, Agent Orange as a risk factor for aggressive prostate cancer. He is considered an expert inthe design of novel treatment regimens for locally advanced prostate cancer including combination therapy such aschemoradiation and immuno-hormonal regimens. He is the Chief of the Urology at the Portland VA Medical Centerwhere he also serves as the Lead Investigator for the VA NAVIGATE Program that conducts NCI-sponsored trials formultiple cancer types. Understanding the molecular drivers of cancer is a prime interest of his, as he feels thisknowledge is essential to the pursuit of improved outcomes for patients. He has a strong interest in teaching as he feelsthe future of medicine is dependent on the continued growth in knowledge. He has been awarded the DepartmentFaculty Teacher of the Year Award several times.
Cancer Statistics, 2020:
Trends in Male Cancer Mortality, US 1930-2017
CA: A Cancer Journal for Clinicians, Volume: 70, Issue: 1, Pages: 7-30, First published: 08 January 2020,