Comprehensive Management of Prostate Cancer 20150821

Comprehensive Management of
Prostate Cancer
Agus Rizal A. H. Hamid
Department of Urology
“Cipto Mangunkusumo” Hospital /
Faculty of Medicine, University of Indonesia
Jakarta
• INCIDENCE
• DIAGNOSIS
• MANAGEMENT
– Resource-stratified
Indonesia’s most frequent cancer
Men
Both Sexes
Incidence : 6.6% (2008)  9.8% (2012)
Globocan 2012
Risk Factors
• Age
• Race (Afro-American)
• Family history of prostate cancer
• Diets (red meat, fats, alcohol)
• Smoking
Prostate Cancer Staging (2006-2010):
Stage Jakarta Bandung Yogyakarta Total (n= 781)
1 1 2 20 23 (2.9%)
2 127 103 12 242 (31%)
3 19 9 0 28 (3.5%)
4 269 92 98 459 (58.8%)
NA 16 12 1 29 (3.7%)
(Safriadi F et al, 2012)

Courtesy of K. Fizazi & R. Umbas
Natural history of prostate cancer
DIAGNOSIS
Clinical manifestation (1)
• No symptoms (was detected during annual check up

or screening due to familial history of prostate
cancer)
• LUTS / urinary retention

• Hemospermia
• Hematuria
• Bone pain / pathologic fracture
• Neurological symptoms
Clinical manifestation (2)
• Abnormality on DRE:
- hard consistency
- uneven surface
- nodule
- asymetrical enlargement
• High PSA level
• Abnormality on trans-rectal ultrasonography (TRUS)

Prostate cancer in Asia: Diagnostic methods (%)
Author Country Biopsy TUR-P Open Others
Ahmad Z et al, 2009 Pakistan 26 74 n.a n.a
Peyromaure M et al 2005 China 68 5 1 26
Umbas R, 2008 Indonesia 74 22 2 2
Akaza H et al, 2003 Singapore 75 20 0 5
Akaza H et al, 2003 Taiwan 77 17 0 6
Nayyar R & Gupta N, 2009 India 82 18 0 0
Cancer Reg JUA, 2005 Japan 89 n.a n.a n.a

MANAGEMENT
Treatment modalities
As stated in guidelines from many

institutions/organizations worldwide including from
Asia, treatment options for prostate cancer were
depend on several factors
Treatment option Consideration Factors
Active surveilance Life expectancy at diagnosis
Radical Prostatectomy Tumor grade, PSA
Radiotherapy Tumor stage
Androgen deprivation therapy Co-morbidity
Chemotherapy Patient’s preverence

LOCALIZED PROSTATE CANCER
Panduan Praktik
Klinis
Kanker Prostat
Komite Nasional
Penanggulangan
Kanker 2015
Treatment modalities in stage I-III Prostate cancer
(year 1995-2013)
250 N=226
(53.8%)
200
RP = 87
(20.7%)
150
N=108
(25.7%)
100 Orchy=31
(7.4%)
RT = 139
(33.1%) N=58 (13.8%)
50
LHRH=77
N=28 (6.7%) (18.3%)
0
Active Surv Radical Tx Hormonal Tx Refused
Figure 1: Treatment modalities in T1-3, N0, M0 (n=420)
(Unpublished data. Umbas R et al, 2015)

Radical prostatectomy modalities
(1995-2015) from 2 tertiary hospital in Jakarta
Radical
prostatectomy
N = 96
Open retropubic Laparoscopic radical Robotic radical

radical prostatectomy prostatectomy* prostatectomy**
N = 69 N = 22 N=5
(71,8%) (22,9%) (5,3%)
*starting from 2007 **done at foreign country
(Unpublished data, Umbas R et al, 2015)

ADVANCED PROSTATE CANCER
Androgen Deprivation Therapy
• Surgical castration
Equally effective
• Medical castration
– LHRH agonist
– LHRH antagonist
– Estrogen
• Antiandrogen
IAB vs Orchydectomy
p = 0.35
Skeletal related event
• Radiotherapy
– Localized constant or breakthrough pain not sufficiently
controlled by analgesia,
– Pathological fractures following surgical fixation (postoperative
radiotherapy) or Inoperable pathological fractures
• Surgery
– to provide stabilization, to restore function and ambulation,
and to relieve pain that does not respond to any nonoperative
methods
• Spinal Cord Compression
– an oncological emergency
– Surgical decompression with tumor debulking followed by
radiotherapy is the procedure of choice
CASTRATION RESISTANT
PROSTATE CANCER
Palliative approach
Androgen deprivation therapy (orchiectomy or LHRH analogue/agonist)
should be maintained
Multidiscipline team approach should be done especially in patients with

metastatic disease or progression
• Urinary incontinence
• Toxicities related to ADT
• Pain treatment
• Bone protection agents (zoledronate or denosumab)
• Urinary tract obstruction: Palliative surgical intervention such as
channel TUR-P or ureteric stenting/nephrostomy
• Anxiety and other psychological problems
RESOURCE-STRATIFIED BASED
MANAGEMENT
Multidisciplinary team approach
• Is a substantial effect on patient management to
optimize therapeutic decisions and clinical
outcomes
• Key members : urological, medical, and radiation
oncologists, pathologists, radiologists, urological
nurses, and allied health-care staff.
• Decisions at multidisciplinary meetings must also
encompass a strong understanding of local-
population life expectancies and comorbidities.
Resource- stratified based management
(Williams S et al, Lancet Oncol 2013)

Take home messages
• Prostate cancer becomes a burden disease in
Indonesia
• Comprehensive evaluation and treatment is
needed in each prostate cancer cases.
• Multidisciplinary approach in prostate cancer
management will optimize treatment outcome
• Resource-stratified based management is
appropriate for prostate cancer management in
Indonesia
Acknowledgement
• Prof. Rainy Umbas, M.D., PhD
• Chaidir A. Mochtar, M.D., PhD
• Widi Atmoko, M.D.
• Adistra, M.D.

Comprehensive Management of Prostate Cancer 20150821

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Comprehensive Management of

Agus Rizal A. H. Hamid

Incidence : 6.6% (2008)  9.8% (2012)

• Family history of prostate cancer

• Diets (red meat, fats, alcohol)

Stage Jakarta Bandung Yogyakarta Total (n= 781)

2 127 103 12 242 (31%)

4 269 92 98 459 (58.8%)

(Safriadi F et al, 2012)

• No symptoms (was detected during annual check up

• LUTS / urinary retention

• High PSA level

• Abnormality on trans-rectal ultrasonography (TRUS)

Ahmad Z et al, 2009 Pakistan 26 74 n.a n.a

Peyromaure M et al 2005 China 68 5 1 26

Umbas R, 2008 Indonesia 74 22 2 2

Akaza H et al, 2003 Singapore 75 20 0 5

Akaza H et al, 2003 Taiwan 77 17 0 6

Nayyar R & Gupta N, 2009 India 82 18 0 0

Cancer Reg JUA, 2005 Japan 89 n.a n.a n.a

As stated in guidelines from many

Active surveilance Life expectancy at diagnosis

Radical Prostatectomy Tumor grade, PSA

Radiotherapy Tumor stage

Androgen deprivation therapy Co-morbidity

Chemotherapy Patient’s preverence

Figure 1: Treatment modalities in T1-3, N0, M0 (n=420)

(Unpublished data. Umbas R et al, 2015)

Open retropubic Laparoscopic radical Robotic radical

(Unpublished data, Umbas R et al, 2015)

Multidiscipline team approach should be done especially in patients with

(Williams S et al, Lancet Oncol 2013)

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