British Association of Urological Surgeons

1. British Association of Urological Surgeons Metastatic Prostate Cancer Guidelines

2. Key Recommendations • Multi-faceted disease • Requiring a multi-disciplinary approach BAUS MPC Guidelines 2005.

3. Key Recommendations • MDT review • Best medical practice where evidence base is lacking • Two-way communication BAUS MPC Guidelines 2005.

4. Key Recommendations • Fully inform patients • Sensitivity and support • PSA is a critical measure in most cases • Disease progression • Response to therapy BAUS MPC Guidelines 2005.

5. Key Recommendations • Positive approach to HRPC therapies • Inform and discuss current clinical trials • Encourage participation BAUS MPC Guidelines 2005.

6. Management Algorithms

7. Assessment BAUS MPC Guidelines 2005.

8. First-line Therapy BAUS MPC Guidelines 2005.

9. Second-line Therapy BAUS MPC Guidelines 2005.

10. Metastatic Bone Disease BAUS MPC Guidelines 2005.

11. Obstructive Uropathy BAUS MPC Guidelines 2005.

12. Spinal Cord Compression BAUS MPC Guidelines 2005.

13. Palliative Care BAUS MPC Guidelines 2005.

14. Evidence Chapters Overview

15. Scope • Assessment • First-line therapy • Second-line systemic therapies • Management of metastatic bone disease • Radiotherapy • Obstructive uropathy • Spinal cord compression • Palliative care • Patient perspective

16. Assessment • Indications • Histological diagnosis in most cases • Determine presence of metastatic disease • Early recognition and accurate staging BAUS MPC Guidelines 2005.

17. Assessment • Initial appraisal • Biochemical • Imaging • Patient status determines assessment mode BAUS MPC Guidelines 2005.

18. First-line Therapy • Immediate hormone treatment with an LHRH analogue or orchidectomy • Choice discussed with the patient BAUS MPC Guidelines 2005.

19. First-line Therapy • Flare prevention • Liver toxicity • Liver function monitoring BAUS MPC Guidelines 2005.

20. First-line Therapy • Oestrogens are non-standard first-line therapies • CAB not recommended for routine use • Intermittent hormone treatment is experimental BAUS MPC Guidelines 2005.

21. Second-line Systemic Therapies • Chemotherapy - major part of management • Alternative therapies not recommended • Use should be discussed openly • Clinical trials - discuss and consider BAUS MPC Guidelines 2005.

22. Systemic Management of Metastatic Bone Disease • Metastatic Bone Disease (MBD) is common in prostate patients • Skeletal Related Events • Bone Pain • Fracture • Spinal Cord Compression BAUS MPC Guidelines 2005.

23. Systemic Management of Metastatic Bone Disease • In HRPC, evidence suggests a role for early bisphosphonate therapy to reduce risk and/or delay progression to SRE • Zoledronic acid is the only bisphosphonate proven to reduce this risk BAUS MPC Guidelines 2005.

24. Systemic Management of Metastatic Bone Disease • For established SREs • Treatment options also include: • Radiotherapy, surgery and analgesics BAUS MPC Guidelines 2005.

25. Radiotherapy • Early referral • External beam and Radionuclide therapy BAUS MPC Guidelines 2005.

26. Spinal Cord Compression • Consider in any prostate cancer patient presenting with back pain • Patient should be asked about • numbness • weakness and • bladder/bowel dysfunction BAUS MPC Guidelines 2005.

27. Spinal Cord Compression • Once confirmed • immediate action to prevent irreversible effects BAUS MPC Guidelines 2005.

28. Obstructive Uropathy • Regular monitoring of serum creatinine • Urinary tract US or CT to confirm diagnosis • Urgency of intervention determined by degree of renal failure and hyperkalaemia BAUS MPC Guidelines 2005.

29. Palliative Care • Identify and refer early on • Needs of the patient and their carers should be addressed • Pain must be assessed and treated • Access to specialist services BAUS MPC Guidelines 2005.

30. Patient Perspective • Good communication skills are key • Diagnosis is usually emotionally devastating • Men’s involvement in their own care should be assessed on an ongoing basis BAUS MPC Guidelines 2005.