Qual o melhor tratamento para o Câncer de Próstata de Risco Baixo ou Intermediário?

Gustavo Franco Carvalhal

PG em Medicina e Ciências da Saúde, PUCRS

Declaration of Conflict of Interest

Over the last 12 months I participated in clinical trials sponsored by: Novartis, Astra Zeneca Over the last 12 months I have received honoraria for speaking engagements from: Novartis, Astra Zeneca, Sanofi-Sinthelabo, GSK, Bayer, Pfizer I am member of Advisory Boards for the following companies: Bayer I do not have any pertinent financial interests to disclose

Rule 1595/2000 of the Federal Medical Council Resolution RDC 102/2000 of ANVISA

Ca de Próstata

D’Amico’s Risk Groups

• Low-risk: PSA < 10 ng/ml, Gleason <6, <cT2a

• Intermediate-risk: PSA 10-20 ng/ml, Gleason 7, cT2b

• High-risk: PSA > 20 ng/ml, Gleason 8-10, cT2c

• Biochemical recurrence imperfect proxy for long-

term outcomes

D'Amico, A. V., Whittington, R., Malkowicz, S. B. et al.: Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA, 280: 969, 1998

Observação

Albertsen, P. C., Hanley, J. A., Fine, J.: 20-year outcomes following conservative management of clinically localized prostate cancer. JAMA, 293: 2095, 2005

Bill-Axelson, A., Holmberg, L., Ruutu, M. et al.: Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med, 364: 1708, 2011

Scandinavian RCT – 1A, 15 anos Seguimento

Vigilância Ativa

Klotz, L., Zhang, L., Lam, A. et al.: Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer. J ClinOncol, 28: 126, 2010

•Mortalidadeespecífica Foi de 5/452 pacientes

Vigilância Ativa

Klotz, L., Zhang, L., Lam, A. et al.: Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer. J ClinOncol, 28: 126, 2010

Vigilância Ativa

Klotz, L., Zhang, L., Lam, A. et al.: Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer. J ClinOncol, 28: 126, 2010

RRP @ MSKCC 2000-2010

Silberstein, JL, etalCancer, 2011

Proportion of radical prostatectomy cases classified by NCCN risk stratification. Solid line indicates low-risk. Dashed line indicates intermediate-risk. Grey line indicates high-risk.

Cirurgia

Catalona, W. J., Ramos, C. G., Carvalhal, G. F.: Contemporary results of anatomic radical prostatectomy. CA Cancer J Clin, 49: 282, 1999

Cirurgia

Bianco Jr F, etalUrology, 2005

• Clinically localized, potentially life-threatening tumor • Life expectancy of 10 years •No serious co-morbid condition that would preclude a major operation

Catalona, W. J., Ramos, C. G., Carvalhal, G. F.: Contemporary results of anatomic radical prostatectomy. CA Cancer J Clin, 49: 282, 1999

Complications

Goluboff et al. Radical prostatectomy for the treatment of prostate cancer. In: Movsas B, Hudes G, Olsson C (eds.), Atlas of Genitourinary Oncology, W.B.Saunders, 2002..

Potência

• Discrepância entre séries acadêmicas e comunitárias (70% vs 30%)

• Causa comum de alteração da qualidade de vida

• Causa incomum de insatisfação com o tratamento Carvalhal GF, Smith DS, Ramos, et al. Correlates of dissatisfaction with

treatment in patients with prostate cancer diagnosed through screening. J Urol 162, 1999.

Smith DS, Carvalhal GF, Schneider K, et al. Quality-of-life outcomes for men with prostate carcinoma detected by screening. Cancer 88, 2000.

Potência

• Preservação Bilateral X Unilateral (68% X 47%; p<0.001)

• Idade < 70 anos (71% X 48%; p < 0.001) 90% nos quarenta 80% nos cinqüenta 60% nos sessenta 47% nos setenta • Número de prostatectomias (<500: 61%; 500-1000:

78%; 1000-1500: 70%; p = 0.03) Catalona WJ, Carvalhal GF, Mager DE, Smith DS. Potency, continence and

complication rates in 1870 consecutive radical retropubicprostatectomies. J Urol162, 1999.

Continence

•In academic series, 92% freeofpads • Age wasonlysignificantfactor; p < 0.0001) 92% for men in fourties 97% for men in fifties 92% for men in sixties 87% for men in seventies • Is mostcommon cause for dissatisfactionwithtreatment •In community series results are somewhatworse, butnotmuch

Catalona WJ, Carvalhal GF, Mager DE, Smith DS. Potency, continence and complication rates in 1870 consecutive radical retropubicprostatectomies. J Urol 162, 1999.

Learning Curve

CANCER CONTROL DOES NOT REQUIRE SACRIFICE OF FUNCTIONAL OUTCOMES AFTER RADICAL PROSTATECTOMY: ANALYSIS OF HETEROGENEITY BETWEEN SURGEONS AT A SINGLE CANCER CENTER Andrew Vickers*, Caroline Savage, New York, NY, Fernando Bianco, Miami Beach, FL, John Mulhull, JaspreetSandhu, Bertrand Guillonneau, Angel Cronin, Peter Scardino, New York, NY

Barry, M. J., Gallagher, P. M., Skinner, J. S. et al.: Adverse Effects of Robotic-Assisted Laparoscopic Versus Open Retropubic Radical Prostatectomy Among a Nationwide Random Sample of Medicare-Age Men. J ClinOncol, 2012 PURPOSE Robotic-assisted laparoscopic radical prostatectomy is eclipsing open radical prostatectomy among men with clinically localized prostate cancer. The objective of this study was to compare the risks of problems with continence and sexual function following these procedures among Medicare-age men. PATIENTS AND METHODSA population-based random sample was drawn from the 20% Medicare claims files for August 1, 2008, through December 31, 2008. Participants had hospital and physician claims for radical prostatectomy and diagnostic codes for prostate cancer and reported undergoing either a robotic or open surgery. They received a mail survey that included self-ratings of problems with continence and sexual function a median of 14 months postoperatively. Results Completed surveys were obtained from 685 (86%) of 797 eligible participants, and 406 and 220 patients reported having had robotic or open surgery, respectively. Overall, 189 (31.1%; 95% CI, 27.5% to 34.8%) of 607 men reported having a moderate or big problem with continence, and 522 (88.0%; 95% CI, 85.4% to 90.6%) of 593 men reported having a moderate or big problem with sexual function. In logistic regression models predicting the log odds of a moderate or big problem with postoperative continence and adjusting for age and educational level, robotic prostatectomy was associated with a nonsignificant trend toward greater problems with continence (odds ratio [OR] 1.41; 95% CI, 0.97 to 2.05). Robotic prostatectomy was not associated with greater problems with sexual function (OR, 0.87; 95% CI, 0.51 to 1.49). CONCLUSION Risks of problems with continence and sexual function are high after both procedures. Medicare-age men should not expect fewer adverse effects following robotic prostatectomy

Reducing blood loss in open radical retropubic prostatectomy with

prophylactic periprostatic sutures

Gustavo F. Carvalhal, Christopher R. Griffin, Donghui Kan, Stacy Loeb* and William J. Catalona

Department of Urology, Northwestern University Feinberg School

of Medicine, Chicago, IL, and *Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins, Baltimore,

MD, USA

Introduction

• Betterunderstandingofpelvicanatomy: widespreadacceptabilityof RRP

• Bleeding still anissue in open RRP • Jurczoket al. Open vs.Robotic RRP - Mean EBL: 500 ml vs. 200 ml; (transf. 9% vs. 3%) • Farnhamet al. Open vs. Robotic RRP - Mean EBL: 664 ml vs. 191 ml (transf. NS)

Objective

• To determine if modifications of open RRP technique could reduce intraoperative blood loss

• Use of rapidly absorbed “prophylactic” catgut sutures before mobilization of the prostate

Patients & Methods

• Routine placement of 4/0 catgut in the apex (immediately after transecting the urethra)

• Routine placement of running 3/0 catgut lateral to the NVBs

• Compared EBL, non-autologous transufions, postop Hb in 100 men before and 100 men after the adoption of the technique, in 2007

• Student’s t test and Chi-square tests

Surgical Technique

Placementof 4/0 catgut sutures Placementof 3/0 catgut sutures

Results

Conclusions

• Routine use of periprostatic “prophylactic”catgut sutures reduced significantly intraoperative blood loss in open RRP

• Further studies are needed to ascertain impact on potency and continence rates

HOW LONG CAN SURGERY BE SAFELY DELAYED IN MEN WITH LOW RISK PROSTATE CANCER?

Gustavo F. Carvalhala, Stacy Loebb, Donghui Kana, Matthias D. Hoffera, Jessica T. Caseya, Brian T. Heflanda,

and William J. Catalonaa

From the Division of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, and the James Buchanan Brady Urological Institute, Johns Hopkins University, Baltimore, MD

* Supported in part by the Urological Research Foundation, Prostate SPORE grant (P50CA90386-05S2) and the Robert H. Lurie Comprehensive Cancer Center grant (P30 CA60553)

• Men with low-risk prostate cancer (PCa) have multiple options, including radical prostatectomy (RP), radiation therapy and active surveillance

• Increased acceptance of surveillance,

scheduling issues, etc. may lead to extended time from biopsy to surgery

• Determine impact of the delaying RP on biochemical recurrence rates in a contemporary series of low-risk PCa patients

Objective

• 1,111 men from RRP cohort – All met D’Amico low-risk criteria (clinical

stage T1c/T2a, PSA <10 ng/ml, and biopsy Gleason < 6)

• Compared pathological tumor features and

biochemical recurrence rates (confirmed serum PSA > 0.2 ng/ml) in men treated within 6 months or after 6 months of diagnosis

Methods

Surgical Delay and Biochemical Recurrence

<6 months (n=1052)

≥6 months (n=59)

P Value

Follow-up 43 38 0.17

% Biochemical Recurrence

5% 12% 0.04

Progression-Free Survival and Surgical Delay

Multivariable Analysis for Biochemical Progression

Hazard Ratio

P value

PSA 1.2 0.02 Clinical stage > T1 1.9 0.03

Delay > 6 months 2.9 0.02

Conclusions

• With D’Amico low-risk PCa, delay in RP for >6 months after diagnosis a significant adverse association with outcomes – Significantly more high-grade disease and

biochemical recurrence

• Low-risk patients should be counseled about possibility of worse outcomes with delay in surgical treatment

AUA Guidelines

Active surveillance, brachytherapy, external beam radiotherapy and radical prostatectomy are all options for the low-risk prostate cancer patient Preferences regarding sexual, bowel and urinary function may influence treatment decision, since no option is clearly superior in this clinical scenario Active surveillance, brachytherapy, external beam radiotherapy and radical prostatectomy are all options for the intermediate-risk prostate cancer patient Preferences regarding sexual, bowel and urinary function may influence treatment decision, since no option is clearly superior in this clinical scenario

2007, revised 2011

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