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CA PROSTATE
1.
2. GUIDELINES FOR
MANAGEMENT
Dr ANKITA SINGH PATEL
MBBS,MD(KGMU)
CONSULTANT
Apex Hospital Cancer Institute
TRAINING AND FELLOWSHIP
Fortis Research Institute ,New Delhi
Tata Memorial Hospital,MUMBAI
Mob. 8765845035,9305421547
Email: dr.ankitapatel.onco@gmail.com
3. INCIDENCE
Prostate cancer (PCa) is the second most common
cause of cancer and the sixth leading cause of cancer
death among men worldwide.
RISK FACTORS: Age ,Race , Family history/age of onset
, Diet / fat , Cadmium, cigarette
4. PROSTATE CANCER
Tumor distribution
% of
glandular
tissue in
prostate
% of cancers
in zone
10% 25% 65%
5-10% 70%20%
Oesterling J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;1322-1386.
Transition zone Central zone Peripheral zone
14. GLEASON SCORE
PRIMARY GRADE – Most predominant pattern.
SECONDARY GRADE – Highest grade in all the samples.
When these two grades are added together, the total is called the Gleason score.
EXAMPLE if the biopsy samples show that:
most of the cancer seen is grade 3
the highest grade of any other cancer seen is grade 4, then
the Gleason score will be 7 (3+4).
A Gleason score of 4+3 shows that the cancer is slightly more aggressive than a
score of 3+4, as there is more grade 4 cancer.
19. American Society Prostate
Cancer Screening
Guidelines
Average risk: annually beginning age 50 years with 10+
year life expectancy
Age 45 if high risk: High risk includes African-American
men or those with first-degree relative with prostate cancer
<65 years of age
Age 40 if very high risk: Very high risk includes multiple
family members with prostate cancer at early age
If testing performed, PSA with or without DRE
2009 guidelines reaffirmed in 2013
20. PSA
Cutpoints for
Biopsy
Recommendations
PSA RANGE RECOMMENDATION
0-3.9ng/mL
“normal “ range;
biopsy not generally recommended
4-9 ng/mL
Biopsy recommended ;
probability of detecting cancer ranges from 25% to
30%.
>10 ng/mL
Biopsy recommended ;
high probability of detecting cancer (>=50%)
22. PROSTATE CANCER SUSPECTED(PSA/Screening)
COMPLETE HISTORY AND PHYSICAL EXAMINATION INCLUDING DRE
TRUS GUIDED BIOPSY
Life expectancy <=5 yrs and
Asymptomatic
No further workup or treatment
until symptomatic except in
high or very high risk group.
Life expectancy >5 yrs OR
symptomatic
Risk classification
WORK UP depends on Risk Classification
BONE SCAN IF
1. T1 and PSA>20
2. T2 and PSA>10
3. Gleason score >=8
4. T3,T4
5. Symptomatic
1. T3,T4
2. T1-T2 and normogram indicated
probability of lymph node
involvment>10%
Pelvic CT or MRI or PETCT
23. VERY LOW RISK GROUP
EXPECTED SURVIVAL INITIAL THERAPY ADJUVANT
THERAPY
ACTIVE SURVEILLANCE
•PSA 6 monthly and SOS
•DRE 12 monthly and SOS
•repeat prostate biopgy 12 monthly and SOS
>=20yrs EBRT OR Brachytherapy
Radical Prostatectomy(RP)+PLND if
predicted probability of LN mets is >=2%
Roach formula
LN metastasis (%) = 2/3 PSA + 10×
(Gleason-6)
ADVERSE FEATURES
(Detectable PSA,positive
margin,seminal vesicle
invasion,ECE)
EBRT
LYMPH NODE
METASTASIS
ADT+EBRT
10-20YRS ACTIVE SURVEILLANCE
<10 YRS OBSERVATION
•T1c
•Gleason score<=6
•PSA<10 ng/ML
•Fewer than 3 prostate biopsy cores
positive,<=50% cancer in each core
24. LOW RISK
EXPECTED SURVIVAL INITIAL THERAPY ADJUVANT THERAPY
>=10YRS ACTIVE SURVEILLANCE
EBRT OR Brachytherapy
RADICAL
PROSTATECTOMY(RP)+PLN
D if predicted probability of LN
mets is >=2%
ADVERSE FEATURES (Detectable
PSA, positive margin, seminal
vesicle invasion, ECE)
EBRT
LYMPH NODE METASTASIS
ADT+EBRT
<10YRS OBSERVATION
•T1-T2a
•Gleason score<=6
•PSA<10 ng/ML
25. INTERMEDIATE RISK
EXPECTED SURVIVAL INITIAL THERAPY ADJUVANT THERAPY
>=10 Year
RADICAL
PROSTATECTOMY(RP)+P
LND if predicted probability
of LN mets is >=2%
ADVERSE FEATURES
(Detectable PSA, positive margin,
seminal vesicle invasion, ECE)
EBRT
LYMPH NODE METASTASIS
ADT+EBRT
EBRT +- ADT(4-6 month) OR
Brachytherapy alone
<10 yr EBRT +- ADT(4-6 month) OR
Brachytherapy alone
Observation
•T2b-T2c or
•Gleason score 7 or
•PSA 10-20ng/mL
26. HIGH RISK
INITIAL THERAPY ADJUVANT THERAPY
EBRT + ADT (2-3 YRS)
or
EBRT + + brachytherapy +ADT (2-3 YRS)
or
RP +PLND ADVERSE FEATURES (Detectable PSA, positive
margin, seminal vesicle invasion, ECE)
EBRT
LYMPH NODE METASTASIS
ADT+EBRT
•T3a or
•Gleason score 8-10 or
•PSA>20 ng/mL
27. VERY HIGH GRADE
INITIAL THERAPY ADJUVANT THERAPY
EBRT + ADT (2-3 YRS)
or
EBRT + + brachytherapy +ADT (2-3 YRS)
or
RP +PLND ADVERSE FEATURES (Detectable PSA, positive
margin, seminal vesicle invasion, ECE)
EBRT
LYMPH NODE METASTASIS
ADT+EBRT
ADT in select patient
•T3b-T4 or
•Primary Gleason pattern 5 or
•>4 cores with Gleason score 8-10
28. METASTATIC
Any T , N1 ADT or
EBRT +ADT(2-3 YRS)
Any T , Any N , M1 ADT + EBRT to site of metastasis ,if in
weight bearing bones , or symptomatic
•Any T,N1 or
•Any T,Any N , M1
29. MONITERING AFTER INITIAL
MANAGEMENT
PSA every 6-12 months for 5 yr , then every year.
DRE every year, but may be omitted if PSA undetectable
N1 ,M1 - Physical examination +PSA every 3-6 month
POST RP Failure of PSA to fall to undetectable levels (PSA
PERSISTENCE)
RADICAL
PROSTATECTOMY
BIOCHEMICAL FAILUREUndetectable PSA after RP with a subsequent
detectable PSA that increases on 2 or more
determination (PSA RECURRENCE)
POST EBRT Biochemical failure (PSA increase by 2ng/mL or more
above nadir)
Or
Positive DRE
RADIATION THERAPY
RECURRENCE
30. RADICAL PROSTATECTOMY
BIOCHEMICAL FAILURE
PSADT
+- CT/MRI TRUS
+- Bone Scan
+-PET CT
+-Prostate bed
biopsy (especially if
imaging suggests
local recurrence)
Studies negative
for distant
metastasis
EBRT +- ADT
OR
Observation
Studies positive
for distant
metastasis
ADT + EBRT to site of metastasis ,if in
weight bearing bones , or symptomatic
31. RADIATION THERAPY
RECURRENCE
Candidate for
LOCAL
THERAPY
•PSADT
•TRUS
Biopsy
• Bone Scan
•PET
CT/CT/MRI
•+Prostate
MRI
TRUS Biopsy
+ metastatic
-
•Observation or
•RP or
•Cryosurgery or
•Brachytherapy
•ADVANCED
DISEASE
TRUS Biopsy -
metastatic
-
•Observation or
•ADT or
•Clinical trial or
•More aggressive
workup for local
recurrence
ADVANCED
DISEASE
metastatic
+
•ADVANCED
DISEASE
Not a candidate
for LOCAL
THERAPY
ADT
Or
observation
ADVANCED
DISEASE
32. ADVANCED DISEASE
:SYSTEMIC THERAPY
•Orchidectomy or PROGRESSION
•LHRH agonist +- antiandrogen >= 7 days to prevent
testosterone flare or
•Castration
•LHRH agonist + antiandrogen or •Resistant
•LHRH antagonist or •Prostate
•Observation(for M0 disease) or •Cancer
•Continous ADT and Docetaxel 75mg/m2 w/o prednisolone for
6 cycles( for castration sensitive high volume M1 only)
33. Definition of Castration Resistant
Prostate Cancer
Serum testosterone <50 ng/Ml
And one or more of the following:
• Rising PSA from nadir on androgen deprivation therapy(ADT)
• Radiographic progression on ADT.
• Clinical progression
34. APPROVED THERAPY FOR CRPC
NAME DRUG TYPE APPROVAL INDICATION
Docetaxel
(Taxotere)+Prednisolone
Chemotherapy FDA,EMA First line
Denosumab(Xygeva) Targeted therapy(
RANKL)
FDA Prevention of SREs in patients
with bone metastasis
Cabazitaxel
(Jevtana+
Prednisolone
Chemotherapy FDA,EMA Second line
Sipuleucel-T
(Provenge)
Immunotherapy FDA First line asymptomatic or
minimally symptomatic mCRPC
Abiraterone
acetate(Zytiga)
Targetederapy(an
ti-androgen)
FDA,EMA First and second line
Enzalatumide
(Xtandi)
Targeted
THerapy(anti-
androgen)
FDA Second line advanced mCRPC
