7. Benefits for all
• Patients
• care closer to home
• ↓appointment burden
• NHS
• ↑efficiency
• ↓ 2° care tariffs
• Optimisation of LHRH
injections, PSA testing
& follow ups
9. Prostate examination
▪ Prostate
▪ Size
▪ Normal – golf ball
▪ > 50 cm3 – tennis ball
– Consistency
▪ Nodule/asymmetric? Cancer
– Anatomical limits
▪ Should be able to feel median sulcus,
lateral and cranial borders
▪ Seminal vesicles impalpable
– Normal anal tone and sensation
T1: feels benign
T2: hard but mobile
T3: hard, not mobile
T4: fixed
10. DRE unnecessary if PSA normal
for age in watchful waiting
Age Range PSA Threshold
40 to 49 years 2
50 to 59 years 3
60 to 69 years 4
Over 70 years 5
11. PSA varies by 15% & affected by
many factors - best to avoid them
26. At 5 and 10 years, 24% and 36% have
come off active surveillance
26 Klotz 2015 JCO
27. Enhanced mpMRI
can “see” prostate
cancer that cannot
be felt or hit by
transrectal biopsy
The same part of the prostate examined by MRI in different
ways (“multiparametric MRI”) exposes cancer
Cancer in
prostate
Bladder
Rectum
Anus
28. Active Surveillance better now
with mpMRI & template biopsies
Back
Front
Prostate
Cancer Transrectal biopsies
many problems
Back
Front
Prostate
Cancer
``
``
Transperineal
biopsies hits the
significant cancer
Unlikely to miss
important cancer
29. Mulitparametric MRI: restricted diffusion
predicts failure of active surveillance
Henderson
2015 Eur Urol
Follow up 12 years
n=86
MRI results not available
to investigators
33. Hot flushes on androgen
deprivation therapy
• Medroxyprogesterone
• 20 mg per day
• for 10 weeks, [new 2014]
• Cyproterone acetate
• 50 mg bd for 4 weeks [new 2014]
• no good-quality evidence for the use
of complementary therapies to treat
troublesome hot flushes. [new 2014]
34. Exercise to fight fatigue from
androgen deprivation
• supervised resistance
and aerobic exercise
• at least twice a week
• 12 weeks [new 2014]
37. Welcome Letter: introduces
man to 1° care management
• Indicates date of check up
• Support information
• symptoms to look out for
• list of local support services
• definition of commonly used
terms
• holistic care plan
49. PSA Monitoring
• External Beam Radiotherapy
– PSA should be 50% its pre-treatment level 3 months post-treatment
– PSA should decrease to 0.2-0.5 ng/ml within 36 months
– PSA bounce
• Transitory rise of 0.4 ng/ml or 15% of previous PSA
• Spontaneously resolves
• Seen in 10-30% of people treated with EBRT
• Usually occurs within 9 months of treatment
• Can occur after 60 months
– PSA failure: Lowest PSA + 2.0 ng/ml
• Brachytherapy: PSA Monitoring unclear
– Assumed similar to EBRT
51. Patients With Incurable Disease
• Visits q6 months
– PSA testing, optional DRE
– BMD q2 yrs if on Androgen Deprivation Therapy (ADT)
– Bone scan if PSA >20 or clinically indicated
– Evidence of increased disease activity
• PSA > 10
• PSADT < 6 mo
• Symptomatic
• Consider ADT if not already receiving it
• Consider secondary hormonal therapy or chemo if already
receiving ADT