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Screening or not screening? prostate cancer - 吳俊德醫師 The Preliminary Report of External-Beam Radiotherapy for Localized Prostate Cancer at KL-CGMH - 陳彥超醫師

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  • Screening or not screening? prostate cancer- The Preliminary Report of External-Beam Radiotherapy for Localized Prostate Cancer at KL-CGMH-Treatment of hormone refractory prostate cancer-

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    57018743M6320080220Stage II

    67115157M6320080220Stage II

    7311213M6520080314Stage II

    84025828M662008

    94110891M6620080422Stage IV

    104295952/M6620080513Stage IV

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    124026401M6720080512Stage III

    134325598M6720080516Stage II

    141426305M6820080517Stage IV

    154803486M7020080529Stage IV

    164252208M7020080331Stage II2008212008242009(1-5)5

    174324917M7620080804Stage IV809026

    184278371M7620080811Stage II724

    194332824M7620080804Stage II8.752.2215.3

    204547517M7620080823Stage III000

    214395349M7620080905Stage II000

    224294275M7720080915Stage II909026

    234384916M7720080923Stage I100100100

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    264189335M7820081021Stage II413511

    274836529M7820081023Stage IV

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    291869304M7920081027Stage II21245

    304879163M7920080902Stage II

    314097376M7920081112Stage I200720082009

    324109414M8120081203Stage III182410

    334051267M8320081208Stage II

    347050334M8320081203Stage II

    354078244/M8420080908Stage III

    97PROSTATE

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    97

    97 KIDNEY

    KIDNEY case list97

    NONameChart Nosexage123456789101112

    13924053M752008010810101303242118

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    34938117M392008518

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    97 KIDNEY

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    97

    98 PROSTATE

    prostate case list2008

    NONameChart NoSexAge123456789101112

    84242108M6920090421Stage I

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    114116638M7520090609Stage I

    234082143M8220091019Stage I7

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    294033026M8520090923Stage II100

    284028404M8720091107Stage II90

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    301058155M9420091116Stage II

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    34550155M622009123Stage II

    54368668M622009325Stage II

    10493185M6720090606Stage II

    24924143M722009122Stage II

    14550795M742009121Stage II30132243363535

    324839989M6220091202Stage III

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    134036421M6820090731Stage III

    184539164M6920090706Stage III200824

    194169306M6120090920Stage IV200831

    74397999M6520090515Stage IV

    224868045M6520091030Stage IV90

    68926803M682009413Stage IV

    204048073M7520090901Stage IV

    94127170M7620090515Stage IV

    244068739M7720091019Stage IV

    314177872M7720091212Stage IV

    47186238M932009426Stage IV

    98 PROSTATE

    2008

    98 KIDNEY

    KIDNEY case list98

    NONameChart NoSexAge123456789101112

    14109853F842009010812442325123231

    24278266F6020090217

    34938923F5020090225

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    98 KIDNEY

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    98

    98BLADDER

    BLADDER case list98

    NONameChart NoSexAge123456789101112

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    98BLADDER

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    98

    99PROSTATE

    NONamesexageChart No

    1M68450954220100109Stage III

    2M81303615201003Stage IV

    3M80415673320100106Stage I

    4M71485452120100125Stage IIA

    5M812092650720100123Stage IV

    6M74211496820100130Stage III

    7M74483037620100212Stage I

    8M63431018620100312Stage IIA

    9M83423493220100305Stage IIB

    10M70403867220100426Stage IIA

    11M84483968120100420Stage I

    12

    99BLADDER

    NONamesexageChart No

    1M92427998520100212

    2M83455883820100121

    3F52406830520100212

    4M642134647620100327

    5M80715668120100422

    99KIDNEY

    NONameChart Nosexage

    12084872569F20100111

    22133172061M20100114

    3990077260F20100209

    4299036951M20100126

    538782275F20100119

    61054454153M20100206

    7713636559M20100317

    8407550370M20100309

    9480736056M20100419

    102035186060M20100408

    96 PROSTATE

    prostate case list

    NONameChart NoSexage

    14357963M7820071224Stage III

    2142520M7120071126Stage II

    31245751M7520071119Stage IV

    44061157M6820071122Stage II

    54050566M86Stage IV

    64831656M7820071120Stage I

    74340650M8120070901Stage II

    84111493M7720071015Stage II

    96332768M5420070924Stage II

    104366134M8320070913Stage IV

    114037323M7320070629Stage III

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    132247695M7720070714Stage IV

    144192947M7720070611Stage III

    157111000M5420070626Stage IV

    164814563M982007Stage IV

    17287627M7220070315Stage IV

    184041042M8220070406Stage I

    1921008671M5820070411Stage IV

    204292961M8020070414Stage III

    214090677M8020070416Stage IV

    224023123M5920070511Stage I

    237075450M7420070122Stage I

    244300647M8520070122Stage II

    2510056431M8220070209Stage IV

    261157039M6420070209Stage II

    274155631M8520070309Stage II

    284850855M8320070317Stage I

    297065567M6920070312Stage III

    304071908M8520070406Stage II

    314071908M7820070413Stage II

  • 96 511 51016%36 %16 %32 %

    97 220486%59%12%23%

    98 5174914%49%11%26%

  • 9616%36 %16 %32 %976%59%12%23%9814%49%11%26%

    Chart1

    0.160.060.14

    0.360.590.49

    0.160.120.11

    0.320.230.26

    96

    97

    98

    --

    (2)

    96

    511 510

    16%36%16%32%

    97

    9616%36%16%32%

    22048976%59%12%23%

    6%59%12%23%9814%49%11%26%

    98

    51749

    14%49%11%26%

    (2)

    000

    000

    000

    000

    96

    97

    98

    --

    (1)

    --

    96979800~3940~4950~5960~6970~7980

    3134359600441112

    9700311174

    980121589

    (1)

    000

    001

    432

    41115

    11178

    1249

    96

    97

    98

    --

    963196

    9734

    9835511 510

    16%361632

    96

    97

    00~3940~4950~5960~6970~7980

    0044111222048

    6%59%12%23%

    97

    98

    00~3940~4950~5960~6970~7980

    0031117451749

    14%49%11%26%

    98

    00~3940~4950~5960~6970~7980969798

    0121589313435

    --

    00~3940~4950~5960~6970~7980

    9600441112

    9700311174

    980121589

    97 BLADDER

    bladder case list97

    NONameChart NoSexAge123456789101112

    14147242/M812008012112312203202321

    24210441M7120080221

    34913434M8620080220

    410397596M4920080320

    54130940M5420080318

    610397596M4920080324

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    187058960M6820080918

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    204844982M7020081203

    214055005M6320081217

    97 BLADDER

    1

    2

    3

    1

    2

    2

    0

    3

    2

    0

    2

    3

    97

    97PROSTATE

    prostate case list97

    NONameChart NoSexAge123456789101112

    14357963M5620080109Stage II53256004753141

    24542694M5720080102Stage IV

    3309402M5820080116Stage II

    44259089M6020080428Stage IV

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    67115157M6320080220Stage II

    7311213M6520080314Stage II

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    94110891M6620080422Stage IV

    104295952/M6620080513Stage IV

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    141426305M6820080517Stage IV

    154803486M7020080529Stage IV

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    174324917M7620080804Stage IV809026

    184278371M7620080811Stage II724

    194332824M7620080804Stage II8.752.2215.3

    204547517M7620080823Stage III000

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    234384916M7720080923Stage I100100100

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    274836529M7820081023Stage IV

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    291869304M7920081027Stage II21245

    304879163M7920080902Stage II

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    324109414M8120081203Stage III182410

    334051267M8320081208Stage II

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    354078244/M8420080908Stage III

    97PROSTATE

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    97

    97 KIDNEY

    KIDNEY case list97

    NONameChart Nosexage123456789101112

    13924053M752008010810101303242118

    2311213M772008321

    34938117M392008518

    44032439M522008618

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    97 KIDNEY

    1

    0

    1

    0

    1

    3

    0

    3

    2

    4

    2

    1

    97

    98 PROSTATE

    prostate case list2008

    NONameChart NoSexAge123456789101112

    84242108M6920090421Stage I

    154201011M6920090807Stage I

    114116638M7520090609Stage I

    234082143M8220091019Stage I7

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    294033026M8520090923Stage II100

    284028404M8720091107Stage II90

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    301058155M9420091116Stage II

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    34550155M622009123Stage II

    54368668M622009325Stage II

    10493185M6720090606Stage II

    24924143M722009122Stage II

    14550795M742009121Stage II30132243363535

    324839989M6220091202Stage III

    144882052M6420090810Stage III

    134036421M6820090731Stage III

    184539164M6920090706Stage III200824

    194169306M6120090920Stage IV200831

    74397999M6520090515Stage IV

    224868045M6520091030Stage IV90

    68926803M682009413Stage IV

    204048073M7520090901Stage IV

    94127170M7620090515Stage IV

    244068739M7720091019Stage IV

    314177872M7720091212Stage IV

    47186238M932009426Stage IV

    98 PROSTATE

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    2008

    98 KIDNEY

    KIDNEY case list98

    NONameChart NoSexAge123456789101112

    14109853F842009010812442325123231

    24278266F6020090217

    34938923F5020090225

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    98 KIDNEY

    0

    0

    0

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    0

    0

    0

    0

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    0

    98

    98BLADDER

    BLADDER case list98

    NONameChart NoSexAge123456789101112

    14308700M722009011311251120322424

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    98BLADDER

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    98

    99PROSTATE

    NONamesexageChart No

    1M68450954220100109Stage III

    2M81303615201003Stage IV

    3M80415673320100106Stage I

    4M71485452120100125Stage IIA

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    12

    99BLADDER

    NONamesexageChart No

    1M92427998520100212

    2M83455883820100121

    3F52406830520100212

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    NONameChart Nosexage

    12084872569F20100111

    22133172061M20100114

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    96 PROSTATE

    prostate case list

    NONameChart NoSexage

    14357963M7820071224Stage III

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    44061157M6820071122Stage II

    54050566M86Stage IV

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    157111000M5420070626Stage IV

    164814563M982007Stage IV

    17287627M7220070315Stage IV

    184041042M8220070406Stage I

    1921008671M5820070411Stage IV

    204292961M8020070414Stage III

    214090677M8020070416Stage IV

    224023123M5920070511Stage I

    237075450M7420070122Stage I

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    2510056431M8220070209Stage IV

    261157039M6420070209Stage II

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    314071908M7820070413Stage II

    MBD001F08ED.xls

    Chart3

    31

    34

    35

    969798

    313435

    0

    0

    0

    963196

    9734

    9835511510

    16361632

    96

    97

    00~3940~4950~5960~6970~7980

    0044111222048

    6%59%12%23%

    97

    98

    00~3940~4950~5960~6970~7980

    0031117451749

    14%49%11%26%

    98

    00~3940~4950~5960~6970~7980969798

    0121589313435

    97 BLADDER

    bladder case list97

    NONameChart NoSexAge123456789101112

    14147242/M812008012112312203202321

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    97 BLADDER

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    0

    97

    97PROSTATE

    prostate case list97

    NONameChart NoSexAge123456789101112

    14357963M5620080109Stage II53256004753141

    24542694M5720080102Stage IV

    3309402M5820080116Stage II

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    57018743M6320080220Stage II

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    174324917M7620080804Stage IV809026

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    291869304M7920081027Stage II21245

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    98 KIDNEY

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    99BLADDER

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    prostate case list

    NONameChart NoSexage

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    314071908M7820070413Stage II

  • The Preliminary Report of External-Beam Radiotherapy for Localized Prostate Cancer at KL-CGMH 2010-8-13RTO

  • 1. Prostate cancer:1) Long nature course2) Old age (median age= 75 y/o, rarely
  • 3. According to Tx aggressiveness1) Active monitoring (low-risk group and life expectancy
  • RT +- H/TAccording to the risk group1. Low-risk: no H/T is needed2. Intermediate-risk or only single high-risk factor(PSA>20) high-risk: 4-Ms short-term ADT(TAB): 2Ms neoadjuvant + 2Ms concurrent H/T3. High-risk or very high-risk(T3b/T4): at least 2-y long-term ADT (short-term + 20 Ms adjuvant H/T) 1. LHRH antagonist + oral antiandrogen2. Orchiectomy (T3b or N+; old age without sexual desire)

  • 2007-1 ~2010-654 PCa patients received RT at KL-CGMH

    NumberDose21Palliative intent3Curative post-op dose(60-66.6 Gy)30Curative Intent (>75 Gy)

  • Localized PCa27T4N0M1, GS= 8-9, PSA=20+ 78 Gy/39fx3: long-term palliation all rapid biochemical failure after RT

  • Biochemical FailureIf patients received definitive RT +- H/TNadir +2 ng/ml biochemical failure (End-point surrogate)2006-7 IJROBP

  • NCCN guidelines: (2010 V2)Low risk: 75.6 -79.2 GyOthers:78 - 80+ Gy

    CMGH guidelines(Linkou/KL): 7560 cGy/42fx (before 2009-3)78.4 Gy/42fx (Linkou+KL-CGMH)

  • HDR+EBRT 79.6 Gy vs IMRT 75.6 Gy 3-Y BC= 91.7% vs 73.7% (-18%)2009-3-10

  • Characteristics N=27Median age 70 y/o (range= 60-80)Median f/u interval12 Ms (range=1-38)Risk Group Very-high High Intermediate Low7 (26%)15 (56%)3 (11%)2 (7%)T-stage T1c T2a-c T3a-b T42 (7%)11 (41%)13 (48%)1 (4%)Gleason Score2-678-108 (30%)5 (18%)14 (52%)iPSA204 (15%)11 (41%)12 (44%)

  • RT technique IMRT RapidArc ()21 (78%)6 (22%)Median RT total dose78.4 Gy/42fxMid-pelvic RT No Yes22 (82%)5 (18%)Hormone Therapy None Not per-protocol Per-protocol4 (15%)13 (48%)10 (37%)Referral Hospital KL-CGMH Linkou-CGMH 12 (44%)2 (7%)13 (48%)

  • Acute Adverse Effects

    GI Gr0 Gr1 Gr211 (41%)12 (44%)4 (15%): mild diarrheaGU Gr0 Gr1 Gr2 Gr3 7 (26%)11 (41%)7 (26%)2 (7%): acute urine retention, RT interruption)Perianal skin Gr0 Gr1 Gr220 (74%)(15%)3 (11%)

  • , 30 -> 350 cc IMRT () / Rapid Arc () = 7840 cGy/ 42

  • Chronic Adverse Effects

    GI Gr0 Gr1 Gr224 (89%)2 (7%)1 (4%) (mild rectal bleeding)GU Gr0 Gr1 Gr2 Gr322 (81%)1 (4%)3 (11%)1 (4%) (urethral stricture: Hx of TURP x3)

  • Sexual function

    Pre-Tx 0 1 2 3 ?21 (78%)01 (4%)05 (18%)Post-Tx 0 ?22 (82%)5 (18%)

  • Nadir Achieved3 patients(+) Time to nadir achieved: 12Ms, 15Ms, 29Ms

  • Biochemical ControlFor all these 27 patientsno biochemical failure at present

  • 100%91%81%25%2007-7 UrologyCGMH-Linkou HDR+EBRT(~79.6 Gy) : 4-y Biochemical-Free Survival

  • Overall Survival 1. 1 died of lung cancer and 1 died of liver cirrhosis.

  • Thanks for your attentionRed Meat RR=2.64

  • HRPCProgressive prostate cancer disease despite a castrate testosterone level (
  • Treatment of HRPC1.Continue androgen suppression2.Palliative chemotherapy3.Radiotherapy4.Other supportive treatment

  • Androgen suppression1.Alternate hormone therapyCheck testosterone level first If serum testosterone not at castration level Additional hormone manipulation or orchiectomy If at castration level, response to 2nd line hormone therapy
  • ChemotherapyNo indication or benefit of palliative chemotherapy in the past until 1996. Mitoxantrone Plus Prednisolone was as first approved by FDA.In 2004, Docetaxel in combination with Prednisolone showed superior survival, improvement of QOL and pain control as compared with Mitoxantrone Plus Prednisolone in several randomized studies.Other active chemotherapy regimen included VP-16, CDDP, Carboplatin, Estramustine, Atrasentan etc.Target therapy: Sunitinib, Bevacizumab also showed clinical effect in HRPC pts.

  • Chemotherapy with Mitoxantrone plus Prednisolone or Prednisolone after for Symptomatic Hormone-Resistant Prostate Cancer. Tannock. J Chin Oncol 1996

    590 HRPC pts RandomizedResult: M+P P Decrease in pain 29% 12% Duration of pain relief 43 weeks 18 weeks Palliative response 38% 21%Mitoxantrone 12mg m2 Q3W, +Prednisolone (5) 1#Bid Prednisolone (5) 1#Bid

  • Two large pivotal Phase III trials with docetaxel-based therapy (TAX 327 and SWOG 9916) have demonstrated a survival benefit with docetaxel chemotherapy for patients with metastatic CRPC

    CRPC: Taxane-based chemotherapyTannock I, et al. N Engl J Med 2004;351:15021512Petrylak D, et al. N Engl J Med 2004;351:15131520

  • TAX327 trial 1006 metastatic HRPC ptsTannock I, et al. NEJM 2004Berthold DR, et al. J Clin Oncol 2008 ResultMedian survival : 19.2M (D3P);17.8M (D1P);16.3(MP)(P=0.004)Pain control: HR ratio in favour of Docetaxel (0.78)Decline of PSA level: HR ratio :0.75

  • Berthold DR, et al. J Clin Oncol 2008;26:242245 Docetaxel q3wDocetaxel qwMitoxantrone Median survival Hazard (months) ratio p-valueDocetaxel q3w: 19.20.790.004Docetaxel qw: 17.80.870.086Mitoxantrone16.3 0.00.20.40.60.81.001234567YearsProbability of survivingTAX 327: 3 years survival analysis updated

  • Tannock I, et al. NEJM 2004: 351: 15021512Berthold DR, et al. J Clin Oncol 2008;26:24245 17.4 (15.719.0)Mitoxantrone (n = 337) 201 (60%) 16.5 (14.418.6) 297 (88.1%) 16.3 (14.317.9) Docetaxel q3w (n = 335) Docetaxel weekly (n = 334)Original data 2003 n (%) dead 166 (50%) 190 (57%) Median survival* 18.9 (17.021.2) Hazard ratio* 0.76 (0.620.94) 0.91 (0.751.11)pvalue 0.009 0.36 Updated data 2007 n (%) dead 285 (85.1%) 285 (85.4%) Median survival* 19.2 (17.521.3) 17.8 (16.219.2)Hazard ratio* 0.79 (0.670.93) 0.87 (0.741.02) 0.004 0.09 pvalueTAX 327: initial vs updated analysis

  • Berthold DR, et al. J Clin Oncol 2008;26:24245 TAX 327: Survival benefit across all subgroups

  • Summary of treatment of metastasis prostate Ca Androgen suppression using bilateral orchiectomy or LHRH agonist should be the first line treatment . Two weeks course of antiandrogen treatment should be used to prevent disease flare on starting LHRH agonist. Pts with HRPC should hold androgen suppression temporally. After observation of androgen withdrawal syndrome, 2nd-line hormone therapy (Different antiandrogen), 3rd-line (e.g. corticosteroid, vit D,) even 4th-line hormone therapy (e.g. DES) should be considered. Docetaxel (Q3W schedule) is the standard palliative chemotherapy for HRPC, 2nd line chemotherapy or target therapy are optional if failure of Docetaxel, but pts performance status is the first consideration. Palliative radiotherapy or radioisotope therapy (e.g. strontium-89)may be offered for painful bone metastasis from HRPC.Bisphosphonates may decrease the risk of complication for bone metastasis.

  • Thank You

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