Dan Burke
Consultant Urological Surgeon
Uro-Oncology & Complex Laparoscopic Surgery


2008

37 051 new cases in UK

10 168 deaths from Ca Prostate

101 men diagnosed every day

One new diagnosis every 15 minutes

Accounts for 3% of male mortality daniel.burke@cmft.nhs.uk

Figure 1.1: The 20 most common causes of death from cancer, UK, 2008
Lung
Colorectal
Breast
Prostate
Pancreas
Oesophagus
Stomach
Bladder
Non-Hodgkin lymphoma
Ovary
All leukaemias
Kidney
Brain with central nervous system
Liver
Multiple myeloma
Mesothelioma
Malignant melanoma
Oral
Uterus
Bone and connective tissue
Other cancers
Males
Females
0 10,000 20,000 30,000 40,000
Number of deaths daniel.burke@cmft.nhs.uk

8,000
6,000
4,000
2,000
0
Male Cases Male Rates
Age at diagnosis daniel.burke@cmft.nhs.uk
800.0
600.0
400.0
200.0
Rat e per
10
0,0
00 mal es
0.0


PSA – relative risk

Age related





<50 ??
50-60 <2.5
60-70 <3.5
70-80 <6.0
0ver 80 – abnormal DRE

2 raised readings - beware UTI’s, LUTS(acute), big prostates

PSA Velocity >0.75 / year

Low readings <0.7 Reassurance daniel.burke@cmft.nhs.uk





>0.75 per year
Doubling time
Patterns over time (fluctuating PSA’s with large prostates)
Accept higher PSA levels with larger prostates
– but obtain a predicted PSA with TRUSS

Changes of PSA with dutasteride / finasteride daniel.burke@cmft.nhs.uk

daniel.burke@cmft.nhs.uk

daniel.burke@cmft.nhs.uk

daniel.burke@cmft.nhs.uk

PSA Chances of detecting a cancer
Chances of detecting a high grade cancer
0.9
13.2% 1%
12 57.8% 22.1% daniel.burke@cmft.nhs.uk

Abnormal
DRE & FH
PSA 3.2
Abnormal
DRE & FH
PSA 12
Chances of detecting a cancer
Chances of detecting a high grade cancer
59% 12.3
>75% 43% daniel.burke@cmft.nhs.uk

daniel.burke@cmft.nhs.uk

March 2009
All men over the age of 50 could be tested for prostate cancer after the largest international study ever conducted suggested that screening could save thousands of lives a year in Britain. daniel.burke@cmft.nhs.uk

Screening and Prostate-Cancer Mortality in a Randomized European Study
Published at www.nejm.org March 18, 2009 (10.1056/NEJMoa0810084)
182,000 men
Mortality Results from a Randomized Prostate-Cancer Screening Trial
Published at www.nejm.org March 18, 2009 (10.1056/NEJMoa0810696)
76,693 men daniel.burke@cmft.nhs.uk

820 / 10,000
Carcinoma of the Prostate diagnosed in screened arm vs
480 / 10,000
Carcinoma of the Prostate diagnosed in control arm daniel.burke@cmft.nhs.uk

73,000 men screened
17,000 biopsies daniel.burke@cmft.nhs.uk

227/10,000 radical prostatectomies performed in screened arm
Vs
100/10,000 in control arm daniel.burke@cmft.nhs.uk

214 / 10,000
Deaths due to prostate cancer
(Screened arm)
Vs
326 / 10,000
Deaths due to prostate cancer
(unscreened arm) daniel.burke@cmft.nhs.uk

1410 people screened
48 treated
1life saved
Over a 10 year period daniel.burke@cmft.nhs.uk

European Study – Screening has its place
Based on improved rate of cancer deaths
American Study – No role for screening
Risk of over treating too many for a small gain
BUT NEITHER STUDY WAS CONCLUSIVE daniel.burke@cmft.nhs.uk

Afro-Caribbean men – 3x and diagnosed younger
1 st degree relative diagnosed at a young age – 3x increase risk
Strong family history – 5x increase risk
The concerned informed patient daniel.burke@cmft.nhs.uk

YES
Young men
Family history
Afro-caribean rising PSA
Age related PSA
Symptomatic / advanced CaP
NO
<10year life expectancy
Over 80 with normal DRE
Raised PSA with UTI daniel.burke@cmft.nhs.uk

30
25
20
15
10
5
0
50 55 60 65 70 75
Current age daniel.burke@cmft.nhs.uk
80 85 90 95 100

daniel.burke@cmft.nhs.uk

10:00PM BST 16 APR 2012
A study has found that focal HIFU, high-intensity focused ultrasound, provides the 'perfect' outcome of no major side effects and free of cancer 12 months after treatment, in nine out of ten cases. Study of 41 patients.
daniel.burke@cmft.nhs.uk

daniel.burke@cmft.nhs.uk

STANDARD TEMPLATE daniel.burke@cmft.nhs.uk

SATURDAY 28 APRIL 2012
Experts shaken by verdict suggesting thousands of men go through painful treatment for nothing
USA study of an older age group average age 67, many low grade disease that would not have been offered surgery in the UK daniel.burke@cmft.nhs.uk

'Currently, radical prostatectomy is the only treatment for localised prostate cancer that has shown a cancer-specific survival benefit...in a prospective, randomized trial.'
European Association of Urologists
Guidelines on Prostate Cancer,
2008.
daniel.burke@cmft.nhs.uk

2 APRIL 2012
Surgeons at Manchester Royal Infirmary claim to be the first in the UK to use a full 3D projection during an operation.
During the operation, a high definition screen carried a 3D image of a hand-held robotic arm developed to carry out intricate surgical techniques daniel.burke@cmft.nhs.uk

daniel.burke@cmft.nhs.uk





Mean survival 3 months
Cost approx £3000 for 30 days
NICE approved
1g a day single dose 4x250mg tablets daniel.burke@cmft.nhs.uk

daniel.burke@cmft.nhs.uk

Prostate Cancer patients have a worse experience of care including after care than other cancer patients
 Department of Health - 2005 daniel.burke@cmft.nhs.uk


Who should do it?

Who should have it?

What’s the evidence / guidelines daniel.burke@cmft.nhs.uk

Post Radical Treatment
 PSA at the earliest 6 weeks post treatment
 PSA at least every 6 months for the next 2 years
 PSA then at least once a year thereafter daniel.burke@cmft.nhs.uk

After 2 years
Stable PSA and no complications then follow up should be offered outside the hospital
Telephone follow up
Primary care
Electronic communications daniel.burke@cmft.nhs.uk

DRE
(changed from 2002)
Now NOT recommended in men with localised prostate cancer while PSA remains stable
Warren KS, McFarlane JP
J Urol 2007 Jul:178(1):11-9 daniel.burke@cmft.nhs.uk

Follow-up
Watchful waiting
Should normally be followed up in primary care in accordance with protocols agreed by the local MDT
PSA should be measured at least once a year daniel.burke@cmft.nhs.uk

NICE
Primary care manage day to day complications
Sweden
More regular PSA testing
Canada
Less regular PSA testing daniel.burke@cmft.nhs.uk

Post Laparoscopic Radical Prostatectomy
8/52 post op PSA & Clinical assessment
3/12 for 1 year
6/12 for 1-2 years
Discharged to Primary Care
Exceptions: Gleason 8/9/10 and/or positive margins and/or BCR daniel.burke@cmft.nhs.uk

Active Surveillance
3/12 PSA
1 year repeat TRUSS + biopsy
6/12 PSA for 2 years
Primary care follow up
Exceptions: unstable/fluctuating PSA, Age <65, patient request daniel.burke@cmft.nhs.uk

Watchful waiting
3/12 PSA for 1 year
6/12 PSA for 1 year
Primary Care follow up
Exceptions: GP or patient request daniel.burke@cmft.nhs.uk

Metastatic disease
3/12 PSA initially
Symptomatic management
Patient specific follow-up daniel.burke@cmft.nhs.uk

Agreed pathways
Avoids ‘double’ tests
Avoids unnecessary re-referrals
Patient copied into communications
Agreements on costings of follow-up / new appointments daniel.burke@cmft.nhs.uk

daniel.burke@cmft.nhs.uk

PROPOSED PSA PATHWAY CMFT
Post Radical Surgery
2 years post surgery
No functional problems
PSA Unrecordable
Discharge for primary care follow-up
6 monthly PSA
PSA unrecordable detectable PSA
Continue PSA referral back tertiary care daniel.burke@cmft.nhs.uk

Post Radical Radiotherapy
2 years post radiotherapy
(+/- hormonal treatment )
No functional Problems + PSA Stable
Discharge for primary care follow up
With instructions on length of hormonal treatment
PSA <2.0 + asympotomatic
6 monthly PSA
PSA >2.0 or symptomatic
6 monthly PSA Referral to Urologist or Oncologist daniel.burke@cmft.nhs.uk

Hormonal Treatment
PSA Stable for 2 years or satisfactory PSA response
Asymptomatic
Discharge to primary care
Individual follow-up plan
PSA every 3 / 6 or 12 months as directed
PSA above designated level or patient symptomatic
Referral back to Urologist
PSA stable patient asymptomatic
Continue PSA follow-up as directed daniel.burke@cmft.nhs.uk

Active Survaillence
To remain under consultant care
Watchful waiting
PSA stable for 1 year
Patient asymptomatic
Discharge to primary care for follow-up
3/6 or 12 monthly PSA as directed at discharge
PSA below recommended level
Patient asymptomatic
Remain under primary care
PSA above commended level or patient symptomatic referred back to urologist daniel.burke@cmft.nhs.uk

PSA PATHWAY
NO DIAGNOSIS OF CA PROSTATE
Individual follow up
Patient specific
Clear discharge letter daniel.burke@cmft.nhs.uk

‘THE DEFINITION OF
INSANITY IS DOING THE
SAME THING OVER AND
OVER AND EXPECTING
DIFFERENT RESULTS’ daniel.burke@cmft.nhs.uk