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CONTINUING EDUCATION EDITORIAL BOARD
PROGRAM TOP3 • RELEASE DATE: JUNE 15, 2010 • EXPIRATION DATE: JUNE 15, 2011
Scott E. Eggener, MD
ESTIMATED TIME TO COMPLETE: 1.0 HOUR
Assistant Professor of Surgery/Urology University of Chicago Medical Center 5841 South Maryland Ave, MC6038 Chicago, IL 60637
Active Surveillance as a Management Strategy for Low-risk Prostate Cancer
David Frame, PharmD Clinical Hematology/ Oncology/BMT Specialist Assistant Professor of Pharmacy University of Michigan 428 Church Street Ann Arbor, MI 48109
By Scott E. Eggener, MD Assistant Professor of Surgery/Urology, University of Chicago Medical Center, Chicago, Illinois STATEMENT OF NEED
With the introduction and widespread use of prostatespecific antigen screening, the number of men being diagnosed with prostate cancer has increased. Almost 50% of these cancers, however, have biological characteristics associated with a low risk of cancer progression. As a result, clinicians are interested in management strategies that offer the possibility of delaying, obviating, or minimizing the impact of treatment to avoid having patients undergo unnecessary treatment. Oncology nurses and pharmacists should be aware of the most recent data regarding one such strategy, active surveillance with selective delayed intervention, so that they may discuss it with patients diagnosed with various types of prostate cancer.
PLANNING COMMITTEE Gloria Mui Medical Director Veritas Institute for Medical Education, Inc. 611 Route 46 West Hasbrouck Heights, NJ 07604 Julie Ann Tagliareni CME Director Veritas Institute for Medical Education, Inc. 611 Route 46 West Hasbrouck Heights, NJ 07604
TARGET AUDIENCE
Registered pharmacists and other interested healthcare professionals, especially those caring for cancer patients
Anne L. Finger President Veritas Institute for Medical Education, Inc. 611 Route 46 West Hasbrouck Heights, NJ 07604
LEARNING OBJECTIVES
After completing this activity, the reader should be better able to: • Discuss active surveillance with selective delayed intervention with patients diagnosed with prostate cancer
Dawn Lagrosa Associate Editor Green Hill Healthcare Communications, LLC 241 Forsgate Drive Monroe Twp, NJ 08831 Karen Rosenberg Editorial Director Green Hill Healthcare Communications, LLC 241 Forsgate Drive Monroe Twp, NJ 08831 Eileen Koutnik-Fotopoulos 77A Beers Street Keyport, NJ 07735
• Appropriately select candidates for active surveillance based on disease characteristics at diagnosis • Evaluate patient progress to determine if, and, when treatment may be warranted
T
he number of American men dying of prostate cancer has decreased 30% over the past 25 years, but it remains the second leading cause of cancer death. In 2009, an estimated 192,280 new cases of prostate cancer were diagnosed and 27,360 men died of the disease.1 There is no universally accepted strategy for screening, diagnosis, and treatment of prostate cancer.2 The introduction and widespread use of prostate-
specific antigen (PSA) screening, however, has led to an increasing number of men being diagnosed with prostate cancer each year. Almost 50% of these cancers have biological characteristics associated with a low risk of cancer progression.3 The challenge facing patients and physicians is accurately determining which men have cancers with a significant risk of progression or metastases whom would benefit from treatment, compared with those unlikely to be impacted by the cancer during their natural lifespan. Although radical prostatectomy (RP) and radiation therapy are effective treatments, they can result in serious long-term side effects such as urinary problems and erectile dysfunction. As a result, clinicians are interested in management strategies that offer the possibility of delaying, obviating, or minimizing the impact of treatment to avoid having patients undergo unnecessary treatment.3 One strategy is active surveillance (AS) with selective delayed intervention.3 AS involves characterizing the cancer using all available tools, determining whether the patient is a good candidate for AS, and frequently evaluating the cancer and overall health of the patient to determine if, and, when treatment may be warranted.2 Current clinical practice guidelines Because many prostate cancers detected through PSA screening may not require immediate treatment, the American Urological Association and National Comprehensive Cancer Network (NCCN) recommend that during discussion of treatment approaches for cancer clinicians include AS as an option for men with low-risk prostate cancer who have a life expectancy of less than 10 years.4,5 In addition, a new “very low risk” category has been added to the
CONTINUING PHARMACY EDUCATION ACCREDITATION AND CONTACT HOURS STATEMENT
Veritas Institute for Medical Education, Inc is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This program (UPN 0394-0000-10-004-H01-P) is acceptable for 1.0 Contact Hours. Initial release date: June 15, 2010. A statement of credit will be available online to participants who successfully complete the program, learning assessment (>70%), and program evaluation form. There is no registration or processing fees. METHOD OF PARTICIPATION
1. Read the article in its entirety 2. Log on to www.TheOncologyPharmacist.com 3. Click on “CE Credits” 4. Click on “Click here to complete the posttest and obtain a CE certificate online” 5. Register to participate 6. Enter program number TOP3 7. Complete and submit the CE posttest and CE Activity Evaluation and Request for Credit Form online 8. Print your Statement of Completion This activity is provided free of charge to participants.
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June 2010 I VOL 3, nO 4
updated NCCN guidelines using a modification of the Epstein criteria for clinically insignificant prostate cancer (Table). AS is offered and recommended for men in this category when life expectancy is less than 20 years.5 Multicenter study examines active surveillance Studies have assessed the safety and efficacy of AS for low-risk localized prostate cancer.2,3,6 One multicenter, retrospective study evaluated the actuarial rates and predictors of remaining on AS, the incidence of disease progression, and the pathologic findings of delayed RP.3 Patient criteria Each man in a cohort of 262 men from four institutions was offered multiple options but ultimately chose AS. All patients met the following criteria for eligibility3: • 75 years of age or younger • PSA 10 ng/mL or less • Clinical stage T1 to T2a • Biopsy Gleason sum 6 or less • Three or fewer positive cores at diagnostic biopsy • No single core with >50% cancer • Repeat biopsy before AS (restaging) • No treatment for 6 months following the repeat biopsy. Patient assessment AS was defined as starting on the date of the second biopsy. Evaluation of patient progress included office visits, review of general health and urinary symptoms, digital rectal examinations, and PSA screenings every 6 to 12 months. Biopsies were routinely recommended within 18 months of starting AS and subsequently every 1 to 3
FINANCIAL DISCLOSURES
Veritas Institute for Medical Education, Inc. is required to disclose to the activity audience the relevant financial relationships of the planners and faculty involved in the development of CE content. An individual has a relevant financial relationship if he or she has a financial relationship in any amount occurring in the last 12 months with a commercial interest whose products or services are discussed in the CE activity content over which the individual has control. In addition, all faculty are expected to openly disclose any unlabeled/unapproved/investigational uses of drugs or devices discussed in this activity. Disclosures are as follows: • Scott E. Eggener, MD, has nothing to disclose. • David Frame, PharmD, has nothing to disclose. The staffs of Veritas Institute for Medical Education, Inc. and Green Hill Healthcare Communications, LLC have nothing to disclose. DISCLAIMER
The opinions expressed in this activity are those of the presenters and do not necessarily reflect the opinions or recommendation of Veritas Institute for Medical Education, Inc. Copyright © 2010 Veritas Institute for Medical Education, Inc. All rights reserved.
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