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This document summarizes risk stratification and treatment options for prostate cancer. It discusses using risk prediction models to stratify patients into low, intermediate, and high risk groups to help determine appropriate initial treatment. Options include active surveillance, radical prostatectomy, radiotherapy, and hormone therapy depending on risk level. Treatment selection involves weighing factors like life expectancy, disease control, and side effects.
![Prostate Imaging-Data and Reporting System
[PI-RADS]](https://image.slidesharecdn.com/linesoftttofpca-180720200204/85/Lines-of-ttt-of-p-ca-14-320.jpg)
![Comorbidity
• Comorbidity is a major predictor of non-
cancer-specific death in localised Pca
• Cumulative Illness Score Rating-Geriatrics
(CISR-G] is the best tool for assessing mortality
risk unrelated to Pca](https://image.slidesharecdn.com/linesoftttofpca-180720200204/85/Lines-of-ttt-of-p-ca-28-320.jpg)
![Cognitive impairment
• Cognitive impairment is associated with
increased mortality risk in senior adults
• In patients undergoing major elective surgery,
there is an association between baseline
cognitive impairment and long-term
postoperative complications and mortality
[598].
• Intervention is unlikely to reverse cognitive
impairment, except in depression](https://image.slidesharecdn.com/linesoftttofpca-180720200204/85/Lines-of-ttt-of-p-ca-37-320.jpg)
Lines of ttt of p ca
- 2. Prostate cancer: Risk stratification and choice of initial treatment
- 4. • RISK STRATIFICATION • Or • cancer risk prediction models
- 5. • Weigh therapeutic options on comparative benefits and risks in domains, such as life expectancy, disease control, health-related quality-of life and treatment complications. • Reduction of inconsistent management due to physician bias, or differences in experience and knowledge
- 6. Cancer risk prediction models • Planning intervention trials • Assisting in creating benefit–risk indices • Estimating the cost of the population burden of disease • Identifying individuals at high risk • Designing population prevention strategies • Improving clinical decision-making (genetic counseling)
- 7. Pre-treatment PSA clinical T category Gleason score overall survival disease-free survival metastasis-free survival extracapsular disease seminal vesicle involvement positive margins lymph node positivity PSA biochemical-free failure
- 10. Prediction tables and algorithms Prediction tables and algorithms • Partin et al, 1997, 2001; • Makarov et al, 2007; • Eifler et al, 2013
- 11. • However, such statistical aids are more useful in groups of patients than in individual patients • wide confidence intervals surrounding estimates of outcomes may limit the usefulness of risk assessment for an individual patient. • Accordingly, it has been claimed that the simultaneous assessment of multiple variables in nomograms provides more accurate predictions than do tables for individual patients (Kattan, 2003).
- 14. Prostate Imaging-Data and Reporting System [PI-RADS]
- 15. • Characterization of the Primary Tumor • Evaluation of the Patient
- 16. Characterization of the Primary Tumor • DRE • prostate ultrasound • serum PSA data including the total PSA level, the rate of change of PSA (PSA velocity and doubling time), the PSA density (serum PSA divided by prostate volume), the percentage of PSA in the free or complexed isoforms • Prostate Health Index are significantly associated with prostate cancer aggressiveness • (Benson et al, 1992; Carter, 1997; Catalona et al, 1998; D’Amico et al, 2004; Thompson et al, 2004; Kundu et al, 2007; Catalona et al, 2011).
- 17. Characterization of the Primary Tumor The biopsy findings • Gleason score • number of cores containing cancer • distribution and volume of cancer in the biopsy cores • presence of perineural space invasion, lymphovascular invasion, • ductal, signet ring, or neuroendocrine differentiation) also correlate • with cancer aggressiveness and the likelihood of the cancer’s being organ confined (Loeb et al, 2010a).
- 21. • Evaluation of the Patient
- 23. Evaluating the patients Evaluation of life expectancy Health status • Comorbidity • dependence in daily activities • malnutrition • Cognitive impairment
- 25. PRINCIPLES OF LIFE EXPECTANCY ESTIMATION • critical to informed decision-making in prostate cancer early detection and treatment. • Life expectancy can be estimated using the • Social Security Administration tables (www.ssa.gov/OACT/STATS/table4c6.html) • the WHO’s Life Tables by country (http://apps.who.int/gho/data/view.main.60 000?lang=en).
- 26. • Life expectancy can then be adjusted using the clinician’s assessment of overall health as follows: • Best quartile of health - add 50% • Worst quartile of health - subtract 50% • Middle two quartiles of health - no adjustment
- 28. Comorbidity • Comorbidity is a major predictor of non- cancer-specific death in localised Pca • Cumulative Illness Score Rating-Geriatrics (CISR-G] is the best tool for assessing mortality risk unrelated to Pca
- 34. Dependence in daily activities • The level of dependence in daily activities influences survival in senior adults. • The Activities of Daily Living (ADL) scale rates accomplishment of basic activities of daily living, while the Instrumental Activities of Daily Living (IADL) scale rates activities requiring higher cognition and judgment.
- 36. Malnutrition • Malnutrition is associated with increased mortality in senior patients • Nutritional status can be estimated from body weight during the previous three months: • • Good nutritional status < 5% weight loss; • • Risk of malnutrition: 5-10% weight loss; • • Severe malnutrition: > 10% weight loss.
- 37. Cognitive impairment • Cognitive impairment is associated with increased mortality risk in senior adults • In patients undergoing major elective surgery, there is an association between baseline cognitive impairment and long-term postoperative complications and mortality [598]. • Intervention is unlikely to reverse cognitive impairment, except in depression
- 38. • The mini-COG is the best available tool to evaluate cognitive function in order to assess the patient’s ability to make an informed decision
- 41. • Baseline screening using the G8 screening tool The International Society of Geriatric Oncology (SIOG) PCa Working Group (PCWG) recommends that btreatment for senior adults should be based on a systematic evaluation of health status
- 42. • The G8 (Geriatric 8) health status screening tool is described, the Karnofsky and ECOG Scores .
- 48. Definitive DISEASE MANAGEMENT • Deferred treatment (active surveillance/watchful waiting • Radical prostatectomy • Definitive radiotherapy • Options other than surgery and radiotherapy for the primary treatment of localised prostate cancer • Hormonal therapy
- 49. Active surveillance • achieve correct timing for curative treatment in patients with clinically localised PCa, rather than delay palliative treatment . • Patients remain under close surveillance, and treatment is prompted by predefined thresholds indicative of potentially life- threatening disease, still potentially curable, while considering individual life expectancy.
- 50. Watchful waiting • known as deferred or symptom-guided treatment. • conservative management, until the development of local or systemic progression with (imminent) disease-related complaints. • Patients are then treated according to their symptoms, in order to maintain QoL.
- 55. Low-risk PCa • Radical prostatectomy
- 57. Low-risk PCa
- 59. Intermediate-risk PCa • Radical prostatectomy
- 62. High-risk PCa • Watchful waiting
- 63. High-risk PCa • Active surveillance
- 64. High-risk PCa • Radical prostatectomy
- 66. • Radiotherapy
- 67. • Androgen suppression monotherapy
- 69. • pN1 after extended lymph node dissection (eLND)
- 70. Metastatic PCa
- 71. Metastatic PCa • Androgen suppression
- 72. Metastatic PCa
- 73. Metastatic PCa
- 74. Metastatic PCa
- 83. Communicate with your patients
- 84. External beam radiation therapy Radical prostatectomy •Effective long-term cancer control with high- dose treatments •Very low risk of urinary incontinence •Wide range of ages and in those with significant comorbidity •Combined with hormone therapy treatment, •eradicate extensions of tumor beyond the margins of the prostate •Effective long-term cancer control •pathologic features in specimen •Pelvic lymph node dissection is possible through the same incision •PSA failure is easy to detect Brachytherapy Active Observation •Cancer control rates appear equal to surgery and EBRT for organ-confined tumors •Quicker than EBRT (single treatment) •Risk of incontinence is low in patients without a previous TURP •Available for cure of patients over a wide range of ages and in those with some comorbidity •Reduces overtreatment •Avoids or postpones treatment- associated complications •Has no effect on work or social activities
- 85. External beam radiation therapy Radical prostatectomy •Significant risk of impotence •Best outcomes require 3-D conformal treatments with doses above 72 Gy •Low risk of later rectal symptoms •Knowledge of possible metastasis to lymph nodes is not available •Up to half of patients have some temporary bladder or bowel symptoms during treatment •Significant risk of impotence •Risk of operative morbidity •The risk of complications is operator dependent, to some extent •Low risk of long-term incontinence Brachytherapy Active Observation •Significant risk of impotence •Successful cancer control is operator dependent, to some extent •Low risk of later rectal symptoms •Knowledge of possible metastasis to lymph nodes is not available •Treatment not appropriate for tumor outside the prostate capsule •Up to half of patients have some temporary bladder or bowel symptoms with treatment •Tumor may progress beyond the possibility for cure •Later treatment may result in more side effects •Living with untreated cancer may cause anxiety
- 86. External beam radiation therapy Radical prostatectomy •Previous pelvic irradiation •Active inflammatory disease of the rectum •Very low bladder capacity •Chronic moderate or severe diarrhea from any cause •Higher medical operative risk, •Neurogenic bladder Brachytherapy Active Observation •Previous pelvic irradiation •Prior TURP •Large-volume gland •Marked voiding symptoms •Large or high-grade tumor burdens •Chronic moderate or severe diarrhea •Active inflammatory disease of the rectum •High-grade tumors •Expected survival of more than 10 years
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