HP 330: Dr. Joudi - Prostate Cancer Perspectives & Controversies
HP 330: Dr. Joudi - Prostate Cancer Perspectives & Controversies HP 330
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This 4 page Study Guide was uploaded by Sydney Brummett on Thursday October 6, 2016. The Study Guide belongs to HP 330 at Wichita State University taught by Dr. Paul Danner in Fall 2016. Since its upload, it has received 92 views. For similar materials see Cancer: Perspectives and Controversies in Health Professions at Wichita State University.
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Date Created: 10/06/16
October 6, 2016 Dr. Joudi Presentation **All Notes Quoted from Dr. Joudi • From Wichita urology group • Focusing on perspectives & controversies • 2016 statistics: o Most common (non-skin) cancer in men in U.S. § 2 leading cause of death in men in the US o Majority of men diagnosed with prostate cancer will die from other causes o Autopsy results show 30% of men older than 50 years of age and 70% of men older than 70 year s have occult prostate cancer o 10 year risk of death from prostate cancer is 8% for well differentiated cancer (less aggressive) and 26% for poorly differentiated cancer (more aggressive) • Early detection o Digital Rectal Exam (DRE) o Prostate Specific Antigen Blood Test • Prostate biopsy o Any abnormality in the PSA or DRE will require • Biopsy results o Prostate cancer graded on appearance of cancer cells o Gleason grading system § Ranges from 1 (least aggressive) to 5 (most aggressive) o Gleason score (2-10) § Most common cell grade (first) added to second most common cell grade o New grading system (2016) § Grade group 1: Gleason <=6 § Grade Group 2: Gleason 3+4 § Grade Group 3: Gleason score 4+3 § Grade Group 4: Gleason score 8 § Grade Group 5: Gleason score 9/10 • Prostate cancer o Localized vs. locally advanced vs. metastatic o Clinical stage T1c: diagnosed by biopsy done for elevated PSA o cT2: firmness felt on rectal exam! • PSA Screening (controversial) o PSA is a protein produced by the prostate and can be tested with a simple blood test o Specific to the prostate but not to prostate cancer, as other factors like infection, instrumentation, or inflammation of he prostate can cause an elevated PSA o Therefore, not all men need a prostate biopsy, and the urologist takes these factors into consideration before recommending a prostate biopsy October 6, 2016 o Prostate cancer that is felt by rectal exam represents a higher stage than one diagnosed by biopsy done due to elevated PSA o Prostate cancer does not cause any symptoms in early stages and thus the importance of the screening PSA test • Improving diagnostic accuracy of PSA (because PSA is controversial) o PSA velocity o % Free PSA o PSA density o Age adjusted PSA • Does screening save lives? o EORTC Trial (Europe): YES o PLCO trial (US): NO? o Because PSA is controversial they did the clinical trials § One group is screened, one group is not § PLCO: Contamination during the trials, so the groups are actually not equal § USPSTF: says that screening PSA causes more harm than good. • So people are not going to get screened as much. • So yes, the amount of people diagnosed is less, but that is not accurate because some people are not getting the test • Recent PSA Controversy o In October 2011, the US preventative services task force has issued a recommendation of not using it o No urologist on this trial panel • Factors overlooked by USPSTF o Opposed PSA testing regardless of age o Expected lifespan span for a man aged 75 years is approx. 10 years but reaches 30 year for men at age 45 to 50 o Opposing screening for young men can result in delayed diagnosis of curable cancer o ERSPC trial, higher-grade cancer (Gleason sore >7) was more common in the control group (45.2%) versus the screened group (27.8%) with a 40% greater incidence of locally advanced and metastatic cancer o The Task Force did not take into consideration high risk patients, like African American patients and those with family history of prostate cancer • Practical point (Urologist’s Perspective) o Not all patients get treatment (watchful waiting and active surveillance) o “Treatment or non-treatment decisions can be made once a cancer diagnosis is made, but not knowing about it in the first place surely burns bridges” Joseph Smith, MD, Vanderbilt University § Always look at the life expectancy – if the lifespan is not l • Impact of PSA o In 1990, 21% of men at diagnosis had bone metastases o Compare to 4% in 2012 October 6, 2016 o Without PSA, men will present when they become symptomatic which is too late of a stage to cure • PSA screening o The American Urological Association (AUA) recommended annual screening with digital rectal exam and prostate specific antigen for all men with 10-15 year lie expectancy starting at the age of 54 o Screening is important in high risk African American and patient with family history (start at age 40) o PSA test has limitations, the fact that we are seeing the stage migration and • Treatment options o Dependent on: § Stage of disease § Age and health § Personal preference o Active surveillance/watchful waiting o External Beam Radiation Therapy o Brachytherapy (radioactive seed) o Cryosurgery (freezing prostate) § Not mainstream o Surgery (radical Prostatectomy) § Open surgery § Da Vinci • Prostate cancer is slow growing – which is why a longer lifespan is necessary, so someone who is 90 years old would more than likely not need treatment • First urologic robot , PROBOT 1989 • Da Vinci surgical system o Robotic technology o Surgeon is in control and operates at the consul o Surgeon is immersed in 3-D image of the surgical field o Surgeon directs the instruments o Surgeon’s hands are place in special devices called EndoWrist § Allows increased dexterity § Can use several instruments to cut, sew, dissect o Benefits § Decreased blood loss § Shortened length of hospital stay § Decreasing pain § Less scarring § Shorter urinary catheter time o 95% of urologists use this method now • Conclusions o Prostate cancer screening with DRE and PSA decreases prostate cancer mortality o PSA test has limitations and has to be interpreted appropriately to avoid unnecessary biopsies and over diagnosis October 6, 2016 o Research is ongoing to identify a biomarker that helps identify patients art risk of dying from the disease o Treatment options for prostate cancer has to be tailored to the patient considering comorbidities, life expectancy and patient preferences o Minimally invasive surgery decreases the morbidity of surgery o With screening, discussion is not made between the patient and the family position, which makes the physician not liable. However, it has not been found that insurance will not pay for the screening. Physicians are just making the call on whether or not the PSA is needed § Physicians are sued because the PSA was not called for or the results were not communicated to the patient. Not because of overtreatment.
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