People in Partnership Meeting (PIP)

Are you living with

Prostate Cancer?

And want to know how to

manage it?

Mr Alvan Pope, Consultant Urologist at Hillingdon and Mount Vernon Hospitals speaking to patients and members of the public on:

Tuesday 4 March 2014, 5.30 – 8pm Committee Room 5, Civic Centre

Uxbridge, UB8 1UW

All Welcome

Other speakers:

Plans for Delivering High Quality Care in Hillingdon Jacqueline Walker, Deputy Director of Nursing

News Headlines from the Hospitals Trust

Shane DeGaris – Chief Executive

Refreshments from 5.30pm Parking available in the Chimes Shopping Centre (opp Civic Centre)

Incidence

0

5000

10000

15000

20000

25000

30000

35000

40000

ProstateLung

Large Bowel

Bladder

Stomach

Prostate cancer is the most

commonly diagnosed cancer in

men in the UK

New diagnoses

of cancer

annually in males

Prostate Cancer Facts

• >10,000 deaths a year in UK - 34,000 new cases

• Commonest male cancer death in non-smokers

• Can only reliably cure localised disease

• No agreed screening programme

• A lot of low-risk disease

• Risk of over-treatment is substantial

How do you know?

PSA

• Protein produced by prostate cells

• Raised by:

• Cancer

• Benign enlargement

• Inflammation

• Not very good for screening

• Much better for follow-up

Diagnostic

Tests

Prostate Specific Antigen

Digital Rectal Exam

TRUS guided biopsy

Role of MRI

How do you know?

• Most patients will need a prostate biopsy to

diagnose and grade, followed by an MRI

and sometimes a bone scan to stage their

disease

Clinical presentation

• Localised disease (65%)

• Locally advanced disease (25%)

• Advanced (metastatic spread) (10%)

Three stages of prostate cancer

Treatment of Prostate Cancer

• Early, localised tumours

• Low risk – monitoring (delay treatment)

• High risk - radiotherapy or surgery

• Locally advanced tumours

• Hormones +/- radiotherapy

• Advanced tumours

• Hormones, then chemotherapy

What’s important to Patients

• Treatment Choices

• Consequences of Treatment

• PSA and PSA relapse

• What’s new?

Prostate cancer – low risk

Men with low-risk localised prostate

cancer who are considered suitable for

radical treatment should first be offered

active surveillance.

NICE Feb 2008

Active surveillance

• Regular blood tests (PSA)

• Multi-parametric MRI at entry

• Regular examinations to feel the prostate

• Repeat biopsies and/or MRI scans to

check nothing changed

• Avoid the side effects of treatment

• Plan treatment for when it suits you

IMRT – intensity modulated

Fiducial markers

Brachytherapy – LDR (seed)

Da Vinci Robotic Prostatectomy

CyberKnife at Mount Vernon

CyberKnife

Multiple beams from many directions

Consequences of radical

treatments

• Bladder control issues (esp. with surgery)

• Bowel problems (esp. with radiotherapy)

• Sexual dysfunction (with both)

• Long-term effects (eg: second cancers)

Prostate Cancer (advanced)

Metastatic

Disease to

bones

Dr Charles Huggins (1901 – 1997)

Described the use of

oestrogens to control

prostate cancer

Nobel Prize 1966

Hormone treatment

• Block either the production or action of

testosterone required for prostate growth

• Prostate cancer cells are starved

• Cancer shrinks into remission

• Standard care for metastatic cancer

• Improves efficacy of radiotherapy

• Commonly given as a 3-monthly implant

Decapeptyl, Prostap or Zoladex

Side effects of hormones

• Lethargy, sweats, hot flushes

• Lack of sexual interest/loss of erections

• Loss of muscle mass/gain fat

• Loss of physical capacity

• Gynaecomastia (mild/mod)

• Osteoporosis/fractures-long term/elderly

• Subtle memory impairment long-term

Intermittent Hormones

Diet and Prostate Cancer

Diet and Prostate Cancer

• Lycopenes (processed tomato products & selenium

supplements) help reduce risk of prostate cancer

by up to 20%

• Red meat and fat not conclusive

• Inconsistent findings for green tea, fruit &

vegetables, soya products may protect

Can diet reduce the risk of

my cancer coming back?

• Lots of research!

• No clear or precise

recommendations

• Combination of lifestyle

factors

• YOU CONTROL THESE

Weight Diet

Physical

Activity

HEALTH

What happens when my PSA

starts to rise again?

• This will happen to many men after radical

treatment (eg. surgery or radiotherapy)

• only to a minority of men on monitoring

• and to all men treated by hormones alone

What is the definition of PSA recurrence?

• After radiotherapy – nadir (lowest value) +2

• After surgery – 3 progressive increases above 0.2

Salvage Treatments

• After surgery • Radiotherapy for PSA relapse (3 rises)

• Observation & hormones for clinical relapse

• After radiotherapy

• Observation & hormones for clinical relapse

• Cryotherapy and possibly HiFU

• After hormones

• Chemotherapy & clinical trials

What’s new?

• Low risk – Surveillance with MRI

• Localised - New treatments reducing trauma

• Surgery – Robotics, focal HiFU, Cryotherapy

• Radiotherapy – Cyberknife

• Advanced - New drugs

• Chemotherapy (eg: Docetaxel, Carbazitaxel)

• Hormonal - Abiraterone, Enzalutamide

• Intermittent Hormone Therapy

Priorities for Prostate Cancer Care

at Hillingdon

• Improved information and support

• Rehabilitation - the first year after treatment

• Supported self-management

Prostate cancer in Hillingdon prevalence around 920 patients

Diagnosis and

treatment

120

Rehabilitation

50

Monitoring

600

End of life care

35

Progressive

care

118

Monitoring could potentially be for 10 years

35% no treatment; 45% after radical treatment; 20% hormones

Rehabilitation: year after radical treatment – includes recovery from or

management of acute effects of treatment

Progressive care: metastatic disease, anticipate palliative care needs

End of life includes all those in the last year of life

Why is information important ?

• Empowers Patients

• Enables Patients to make informed decisions

• May reduce anxieties

• Promotes confidence in the service

• May reduce unnecessary GP/ Hospital visits

Cancer Information Centre

Hillingdon Hospital

37

• Cancer Information Centre

• Return to work models

• Exercise models

• Self-management models

• Health & Wellbeing/education days

Ongoing work to develop

rehabilitation packages

Supported self-management

• Realisation that many men have routine

hospital follow-up for prolonged time

• Stable patients don’t need to come to hospital

• GP’s were anxious about taking back (survey)

• Remote monitoring of PSA

• Holistic needs assessment

• Clear point of contact (CNS) for concerns

• Rapid access back into service without seeing GP

Risk Stratification and models of care

Moving towards self-directed follow-up

Concerned?

• Come and talk afterwards

• Patient support groups

National • Macmillan – helped fund the new cancer

information centre at Hillingdon Hospital

• Prostate Cancer UK

Local • Community Cancer Centre, Yiewsley

• Lynda Jackson Centre (MVH)