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Controversies in Prostate Diseases

Controversies in Prostate Diseases. Europa Uomo Masterclass L. Denis Krakow, February 6, 2009. Understanding Prostate Diseases. Prostate Cancer is a chronic Disease. Purpose of this Chat Session. Highlight the uncertainty in prostate diseases. 2. Address overdetection / overtreatment.

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Controversies in Prostate Diseases

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  1. Controversies in Prostate Diseases Europa Uomo Masterclass L. Denis Krakow, February 6, 2009

  2. Understanding Prostate Diseases Prostate Cancer is a chronic Disease

  3. Purpose of this Chat Session • Highlight the uncertainty in prostate diseases. 2. Address overdetection / overtreatment. 3. Address undertreatment OCA 2009

  4. Europa Uomo Strategy and Aims • Protect the patient with focus on quality of life & solidarity. • Inform and educate evidence based care and values our business. • Collaborate and understand optimal medical care. OCA 2009

  5. The Way Forward • Individual prevention and treatment according to optimal treatment and care. • Reduce over- and undertreatment. OCA 2009

  6. The lost patient Tsunami information (Professionals, media, friends) Outcome results Statistics The medical labyrinth PANIC EBM Guidelines Nomograms Loss of personality OCA 2009

  7. Request of a Patient • Professional expertise specialist • Expertise and guidance general practitioner • Support from his environment Cure or Control Quality of Life We want our place in Society OCA 2009

  8. Uncertainties Prostate Cancer • Early prostate cancer has no symptoms • DRE not much help • PSA non specific, variable • Imaging TRUS, MRI not perfect • Biopsy techniques / pathology reports • Treatment choice We need: - Marker for Progression - % of trifecta OCA 2009

  9. Uncertainty with the Doctor • Limits of knowledge & training • Feels secure in his own specialty • Never enough time to communicate with the patient OCA 2009

  10. Localized Prostate Cancer

  11. Do we have time for a secure diagnosis / find rest with the idea. • PCa begins at age 30, present in half of men age 50 and increasing with age. • These cancers need 20 year (38 doublings) to be detected. • From diagnosis to death 15 years. With PSA 5 year survival obsolete. OCA 2009

  12. Relativity of Prostate Cancer in BelgiumKCE (knowledge) Of 100 Belgian men before 75 years of age - 64 have latent cancer - 2 to 6 are diagnosed - 1 died of PCA OCA 2009

  13. Overdetection is a fact Incidence en Mortality 2004 - 2006 Europa 25 * thousands, IARC

  14. Indolent Cancer is a Fact PCa and HGca (>7 Gleason) by PSA level (>4 ng/ml) in the Prostate Cancer Prevention Trial study.

  15. Bowery Series: Arbitrary Open BiopsyAge, frequency, and diagnosis of prostatic disease in 300 patients P. Hudson, Cancer 1954

  16. Primary Treatment according to Specialist Consult (N-85.088) T. Jang, NCI, 2007

  17. Primary Treatment according to Specialist Consult (N-85.088) T. Jang, NCI, 2007

  18. Active Surveillance vs. Watchful Waiting OCA, 2008

  19. Mismatch • Organ dysfunction increases toxicity / side-effects • Out of 438 patients, 389 (89%) with known dysfunction. • More than 1/3 received inappropriate treatment • Communication problems ? Chen 2008

  20. New Technology • Not the necessity but availability defines frequent use. • Good treatment not supported by industry fails. • Replacement ‘old’ treatments by new ones. • The learning curve of technology. W. Oosterlinck 2008

  21. Choice of Curative Treatment • Surgery: Anatomic Prostatectomy in T1, T2 and T3 cases • Radiatation: EBRT / Brachytherapy in T1, T2 well and intermediate risk in T3 combination hormones 3. Active Surveillance OCA 2009

  22. Avoid Undertreatment • Treatment decision based on SIOG evaluation • Salvage treatment after RP (ECE, rising PSA) EBRT or reverse • A double negation in watchful waiting (no symptoms, less than calculated life expectancy) OCA 2009

  23. Castration Resistant Prostate Cancer • About 20% of diagnosed, advanced PCa has diminished lowering PSA below 4 ng/ml • After secondary hormonal treatment: AA withdrawal – DES – MAB – Abiraterone seen as resistant • Docetaxel & combinations first choice • Experimental: Immunotherapy, growth factors, gen therapy • Lifestyle in all cases OCA 2009

  24. Close Communication Problems Knowledge Reality Prevention Treatment Rich Poor Collaboration Olympic stand Transparant Obscure OCA, 2009

  25. Life Expectancy • Age • Health • Activity • Address • Social Status OCA 2009

  26. Partnerships Europa Uomo EPPOSI OECI ESU ESOP – ESMO EAU – EONS – ECCO ECPC Eurocan+Plus Europa Donna PROCABIO WWPCC TRANSMARK Europa Uomo - ESO Europa Uomo 2009

  27. Thank you for not sleeping. Don’t shoot the pianist. OCA, 2009

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