Approach to Primary Care follow-up of patients with prostate cancer

Approach to Primary Care follow-up of patients with prostate cancer Eric Fox PGY-2 (Primrose) Case #1 • Mr A. is a healthy 71-year-old man treated for prostate cancer (Gleason score 6, pretreatment prostatespecific antigen [PSA] level 9 ng/mL) with radical prostatectomy 5.5 years ago. • His care has now been transferred back to you. His PSA level has increased from undetectable 6 months ago to 0.7 ng/mL currently. He has no new clinical symptoms. • Do you need to be concerned by this increase? Case #2 • Mr P. is a 63-year-old man who underwent brachytherapy 4 years ago for prostate cancer (Gleason score 5, PSA 7 ng/mL) and is now under your care for his ongoing follow-up. • His PSA nadir was 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? A few Statistics • Doesn’t affect women! • 2nd most common cause of cancer-related death in men • Lifetime risk of diagnosis is 12-16.7% – Lifetime risk of Breast Ca diagnosis 11.1-12.5% • ¼ people with prostate Ca die of their disease – Mortality rate for African Americans 2 x white men • Incidence of prostate Ca increasing over past 30 years due to screening and incidental detection following TURP Prostate Ca Screening • U.S. Preventive Services Task Force (2008) assigned I rating (insufficient evidence) of men <75 years and a D rating (recommend against) in men >75 years DRE – Advantages: easy, fast, cheap – Shortcomings: Cannot reach anterior of the prostate and misses >40% of cancers PSA – Advantages: Simple, assesses entire prostate, can follow a number value – Disadvantages: • False +ve: 10/100 PSA > 4 • • – 7/10 of those will not have prostate Ca – Causes: BPH, prostatitis, cystoscopy, urinary retention, elevated for 2 days after ejaculation • False –ve: 90/100 PSA < 4 – 1/90 will have prostate Ca Diagnosis • Trans-rectal ultrasound with biopsy (TRUS) • Risks of TRUS and biopsy – Pain – Hematuria – Hemospermia – Infection – Emotional Stress Staging of Prostate Ca • TNM Classification – T1: Clinically inapparent, not palpable or visible on imaging – T2: Palpable, confined to the prostate – T3: Extends through prostate capsule – T4: Fixed or invades structures other than seminal vesicles • Histological Grading – Gleason Score 2-4: Well differentiated – Gleason Score 5-7: Moderately differentiated – Gleason Score 8-10: Poorly differentiated Treatment Options • Depends on the age and health of the patient as well as the Stage and Grade of the Tumour • Active Surveillance • Androgen ablation (LHRH agonists or anti-andorogens) • External Beam radiation • Brachytherapy • Radical Prostatectomy F/U of patients with Prostate Ca • No clear concensus • Visit schedule for low-risk disease (no nodal or mets) – Q3-4 months x 1 yr, then q6 mo x 4 yr, then annually • Visit schedule for high-risk patients (nodes or mets) – Q3-6 mo as needed • Monitor systemic Sx (fatigue, wt loss), bone pain, urinary Sx, PSA measurements – DRE, TRUS optional Utility of DRE • Low Risk Disease – Active Surveillance – Some experts recommend DRE q3 mo for 1-2 yrs • National Comprehensive Cancer Network suggest DRE every six months • Post Radiation – – – – Utility questionable Scar tissue difficult to differentiate from nodules Residual tumour may not be palpable Recurrent nodules are noted within a background of an increasing PSA Transrectal U/S and Biopsy • Low Risk Disease – Active Surveillance – National Comprehensive Cancer Network suggest Biopsy during the first year • Post Radiation – 80% of patients can have positive biopsies after radiotherapy but no other suggestion of active disease – Not advisable as standard protocol PSA Monitoring • Active Surveillance – Pt’s still curative candidates – PSA testing q6 months – Curative therapy should be considered if escalating PSADT (doubling time) < 3 yrs, upstaging on Bx, or change in DRE • Radical Prostatectomy – PSA should be undectectable within 3-6 wks – Persistent elevation is suggestive of residual local or distant disease, but can reflect residual normal tissue – PSA of 0.2-0.4 ng/ml is considered a BCR (Biochemical Recurrence) 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 – BCR: Lowest PSA + 2.0 ng/ml • Brachytherapy: PSA Monitoring unclear – Assumed similar to EBRT 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 BCR – 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 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 Case #1 • Mr A. is a healthy 71-year-old man treated for prostate cancer (Gleason score 6, pretreatment prostatespecific antigen [PSA] level 9 ng/mL) with radical prostatectomy 5.5 years ago. • His care has now been transferred back to you. His PSA level has increased from undetectable 6 months ago to 0.7 ng/mL currently. He has no new clinical symptoms. • Do you need to be concerned by this increase? • Mr. A has evidence of BCR and needs rapid referral for potential salvage therapy. Case #2 • Mr P. is a 63-year-old man who underwent brachytherapy 4 years ago for prostate cancer (Gleason score 5, PSA 7 ng/mL) and is now under your care for his ongoing follow-up. • His PSA nadir was 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? • Mr. P is likely having a PSA bounce and hasn’t met the criteria for a BCR. Continue to monitor his PSA levels and symptoms. References • Can Fam Physician 2008;54:204-10 • American College of Physicians: Clinical Guideline. 3. Screening for prostate cancer, Ann Intern Med 126:480-484, 1997. • Labrie F, Candas B, Dupont A, et al: Screening decreases prostate cancer death: first analysis of the 1988 Quebec Prospective Randomized Trial, Prostate 38:83-91, 1999. • Up To Date • U.S. Preventive Services Task Force. http://www.ahrq.gov/clinic/uspstf/uspsprca.htm