Clark Atlanta University
Center for Cancer Research and Therapeutic Development
Prostate Cancer Symposium
July 17th, 2010
Prostate Cancer Treatment:
What’s Best For You?
Rajesh G. Laungani, MD
Director, Robotic Urology
Chairman, Prostate Cancer Center
Saint Joseph’s Hospital, Atlanta
2008 Estimated US Cancer Cases*
Prostate
25%
Lung and bronchus
15%
Colon and rectum
Men
745,180
Women
26%
692,000
Breast
14%
Lung and bronchus
10%
10%
Colon and rectum
Urinary bladder
7%
6%
Melanoma of skin
5%
Non-Hodgkin
5%
4%
4%
lymphoma
Kidney
4%
Leukemia
3%
Oral Cavity
3%
Pancreas
3%
Uterine corpus
Non-Hodgkin
lymphoma
Melanoma
of skin
4%
Thyroid
3%
Ovary
3%
Kidney
3%
Leukemia
*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.
Source: American Cancer Society, 2008.
JEMAL ET AL. CA CANCER J CLIN 2008
2008 Estimated US Cancer Deaths*
Lung and bronchus
31%
Prostate
10%
Men
294,120
Women 26%
271,530
15%
Lung and bronchus
Breast
Colon & rectum
8%
9%
Colon and rectum
Pancreas
6%
6%
Ovary
Leukemia
4%
Esophagus
4%
Liver and intrahepatic
bile duct (IBD)
4%
Non-Hodgkin
3%
Lymphoma
Urinary bladder
3%
Kidney
3%
6%
3%
3%
3%
Pancreas
Leukemia
Non-Hodgkin
lymphoma
Uterine corpus
2%
Liver & IBD
2%
Brain/ONS
ONS=Other nervous system.
Source: American Cancer Society, 2005.
JEMAL ET AL. CA CANCER J CLIN 2008.
Approach To Treatment of
Prostate Cancer:
A Multidisciplinary &
Individualized Approach
External Beam
Radiation
Open Surgery
Brachytherapy
Robotic Surgery
Watchful Waiting
Treatment Options for Prostate Cancer
• Active Surveillance
• Radiation Therapy
– External Beam
– Brachytherapy aka
“seeds”
– HDR Therapy
– Proton Therapy
• Hormonal Therapy
• Chemotherapy
• Surgery
– Robotics
– Laparoscopic
– Traditional Open
• Retropubic
• Perineal
– Cryosurgery
– HIFU
“One Size Does NOT Fit All”
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•
•
•
•
Age
Gleason Grade
Stage
Co-Morbidities
Individual Characteristics
What does a positive biopsy mean?
Gleason Grade
Gleason 6
Gleason 10
7 8 9
LOW GRADE
HIGH GRADE
Staging
• Clinical:
–
–
–
–
DRE
CT Scan
Bone Scan
MRI
• Pathological:
–
–
–
–
Margins
Lymph nodes
Extracapsular Extension
Seminal Vesical Invasion
STAGE
SUB-STAGE
T1
T4a
T4b
Clinically unapparent tumor, not detected by DRE nor visible by imaging
Incidental histologic finding; <5% of tissue resected during TURP
Incidental histologic finding; >5% of tissue resected during TURP
Tumor identified by needle biopsy due to elevated PSA
Confined within the prostate (detectable by DRE, not visible on TRUS)
Tumor involves half of the lobe or less
Tumor involves more than one half of one lobe but not both lobes
Tumor involves both lobes
Tumor extends through the prostate capsule but has not spread to other organs
Unilateral extracapsular extension
Bilateral extracapsular extension
Tumor invades seminal vesicle(s)
Tumor is fixed or invades adjacent structures other than seminal vesicles
Tumor invades bladder neck and/or external sphincter and/or rectum
Tumor invades levator muscles and/or is fixed to pelvic wall
SUB-STAGE
DEFINITION
N0
N1
N2
N3
Regional lymph nodes
No lymph nodes metastasis
Metastasis in single lymph node <2 cm in greatest dimension
Metastasis in single lymph node >2cm but <5 cm in greatest dimension, or multiple lymph nodes, none >5 cm
Metastasis in lymph node >5 cm in greatest dimension
SUB-STAGE
DEFINITION
T1a
T1b
T1c
T2
T2a
T2b
T2c
T3
T3a
T3b
T3c
T4
STAGE
Node (N)
STAGE
DEFINITION
Metastasis
M0
M1a
M1b
M1c
Systemic spread
No distant metastasis
Non-regional lymph node metastasis
Bone metastasis
a) Axial skeleton only
b) Extending to peripheral skeleton also
Metastasis at other sites
Robotic Surgery
• Decreased Pain
• Shorter Hospital Stay
• Decreased Blood Loss
• Quicker Recovery
• Improved Quality of Life after Surgery
Current Trends
U.S. Robotic Prostatectomy Trends
80000
70000
60000
48,000
50000
32,631
40000
30000
17,582
20000
10000
36
247
766
2648
8,642
0
2000 2001 2002 2003 2004 2005 2006 2007 2008
36%
63%
Robotic Prostatectomy
Do Advanced Tools result in Better
Outcomes ?
Vision and Control
How do attributes of robotic surgical
systems translate into outcomes?
• Operative parameters
• Oncologic parameters
• Quality of life parameters
• Potency & continence
Urinary Continence
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•
•
•
•
•
•
Joseph et al. 2006
N=325
Mean age: 60
Method of Assessment: Questionairre
Definition used: No pad
Time of assessment: 6 mos
Continence Rate: 96%
Joseph et al. J Urol 2006
Bilateral Nerve Preservation Technique
“The Veil of Aphrodite”
•
•
•
•
•
•
•
Menon et al.
N=250
Mean age: 59.9
Method of Assessment: Questionairre
Definition used: Intercourse
Time of Assessment: 6 mos
Potency Rate: 64%
Menon et al. Urol Clin of Amer 2004
Oncologic Efficacy
•
•
•
•
Badani et al.
N=2766
Gleason 7 or >: 64%
Median follow up: 22 mos
– PSA recurrence rate: 7.3%
• 5 year biochemical free survival: 84%
Badani et al. Cancer 2007
Robotics vs. Open vs. Laparoscopic
Parameter
RRP
LRP
daVP
Op time (min)
164
248
140
Blood Loss(ml)
900
380
<100
Positive Margins
12%
24%
8%
Complications
15%
10%
5%
Catheter(d)
15
8
5-7
Hospitalization
3.5
1.3
1.2
How do I choose the best surgeon?
What questions should I ask?
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•
•
•
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Training?
Fellowship?
Experience?
How many cases have you done?
Reputation?
• Having a robot and knowing how to do
robotic surgery are very different things?
Steady and Experienced
Behind the Wheel
Thank You