68th Annual Scientific MeetingUrological Society of Australia and New Zealand (USANZ)16–19 April 2015, Adelaide, SA

2015TOLMAR

CONGRESSSERIES

TO SCREEN OR NOT TO SCREEN? THE PSA TESTING DEBATE STILL RAGES

This topic, which has been causing controversy in the prostate cancer arena for the last few years is clearly still up for discussion, with different respected international bodies offering sometimes widely differing opinions on the place of PSA testing in the preventative health repertoire (see table on page 4).1–12 Prof. Vickers was absolutely clear that he was not arguing the case for mass screening programs, “No mass screening! PSA testing is not like vaccination … not something we should be doing for everyone,” he stated, adding that all testing should be done in the context of a fully informed decision on behalf of the patient – a statement that echoes the one solidly consistent theme across most PSA screening guidance documents.1–12

No mass screening! PSA testing is not like vaccination... not something we should be doing for everyone.Prof. Andrew Vickers

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“Should we screen? Yes! How? Differently to how we’ve been doing it so far,” was the opening comment from Prof. Andrew Vickers (Memorial Sloan-Kettering Cancer Center, New York, USA) in his state-of-the-art plenary session lecture.

The controversy, Vickers suggested, stems from the debate about the risk:benefit ratio of screening programs and the well-reported risk of overdiagnosis and overtreatment.6,13 But he believes that the way screening is approached can have a real impact on that ratio and the proportion of overtreatment that may result. As an example of this, he presented data from his 2014 analysis of the US Surveillance, Epidemiology and End Results (SEER) database, which records US-population-based cancer statistics.14 After the PSA test became widely used in the 1980s, prostate cancer incidence increased sharply. By comparing the observed incidence of prostate cancer between 1987-1995 with the predicted incidence during that time, he quantified the number of ‘excess’ prostate cancer cases that resulted from PSA screening. Stratifying this data by age showed that only 15% of excess cases occurred in men less than 60 years of age, and by restricting PSA testing to a cohort of men <70 years of age, almost 42% of those excess cases could have been be avoided.14

Furthermore, he presented data from his recent BMJ paper showing that continued PSA screening in men aged 60 years who have a low PSA level (<2 ng/mL) increases the number of cases (767 in every 10,000) with no decrease in prostate cancer mortality.15 Conversely, in men with PSA ≥2 ng/mL at 60 years, there was a large reduction in mortality that translated to only 23 men needing to be screened and 6 diagnosed to avoid 1 death from prostate cancer by 15 years. Leading his group to recommend that men with a PSA level <1 ng/mL at 60 years should stop being screened; those with a PSA >2 ng/mL should continue screening; and for those with PSA 1–2 ng/mL, continued screening needs to be an individualised decision between the patient and the doctor.15

So, he ultimately suggested that we should be changing the way we approach screening in urology and radiation oncology by following his ‘Five Golden Rules for Transforming Prostate Cancer Screening’:16

• Get consent: PSA tests should not be ordered without a full and frank discussion about the potential consequences of the results.

• Don’t screen men who won’t benefit: screening in men over 70 years or with low life expectancy is likely to do more harm than good. And stop screening at 60 years if PSA is <1 ng/mL as you are at considerable risk of overdiagnosis.

• Don’t biopsy without a compelling reason: don’t biopsy men with only moderately elevated PSA unless there are other indicators, use risk stratification tools (such as his own 4KscoreTM test or the Prostate Health Index,17–19 which are available in the US) to help make the decision.

• Don’t treat low-risk disease: don’t treat men with Gleason 6 prostate cancer.

• If you have to treat, do so at a high-volume centre: experienced surgeons have higher cure rates, lower complication rates, and better outcomes for urinary and erectile function.

Who says what about PSA testing?

Publishing body Abbreviated summary of PSA testing guidance

ACS (2010)1 • Asymptomatic men with ≥10-year life expectancy should make an informed decision with their healthcare professional after appropriate counselling. (No screening advised in men with <10-year life expectancy based on age and health status).

• Men should receive this information at: 50 years for average risk; 45 years for higher risk (family history, African American); 40 for very high risk (multiple family members diagnosed before 65 years).

AUA (2013)2 • No screening in men <40 years.• No routine screening in men 40–54 years unless at higher risk (family history,

African American) in which case, testing decisions should be individualised.• Shared decision making for PSA screening in men aged 55–69 (recognising greatest

benefit in this age group).• Routine screening interval of ≥2 years (but individualised by baseline PSA level).• No routine screening in men >70 years or any man with life expectancy <10–15 years.

Canadian Task Force on Preventative Health (2014)3,4

• Summary recommendations state that for men of any age “…we recommend not screening for prostate cancer with the prostate-specific antigen test.”

• However, the accompanying publication states: “The PSA test should not be used for screening without a detailed discussion with the patient, ideally with the use of decision aids to facilitate comprehension.”

Cancer Council Australia & Prostate Cancer Foundation (Draft published December 2014)5

For men informed of the benefits and harms of screening: • Offer PSA testing every two years from age 50–69, with further investigation when

PSA >3.0 ng/mL. • For men <50 years, testing should not begin until age 45, offer testing every 2 years

with further investigation if PSA >95th percentile for age, but no further testing until 50 years if initial PSA at or below the 75th percentile for age. NB: currently in draft format.

EAU (March 2015)6 • An individualised risk-adapted strategy for early detection might be offered to a well-informed man with a good performance status and at least 10–15 years of life expectancy.

• Early PSA testing should be offered to men at elevated risk for PCa (high risk groups are: >50 years; >45 years with a family history of PCa; African-Americans; PSA >1 ng/mL at 40 years; PSA level >2 ng/mL at 60 years).

Melbourne consensus statement (2014)7

• For men 50–69 years, level 1 evidence shows PSA testing reduces the incidence of mPCa and PCa-specific mortality rates.

• PCa diagnosis must be uncoupled from PCa intervention. • PSA testing should not be considered on its own, but rather as part of a multivariable

approach to early PCa detection.• Baseline PSA testing for men in their 40s is useful for predicting the future risk of PCa

and its aggressive forms.• Older men in good health with a >10-year life expectancy should not be denied PSA

testing based on their age.

NCCN8 • PSA testing should be offered in combination with DRE after a risk:benefit discussion.• 45–49 years: DRE normal, PSA >1 ng/mL then testing every 2 years; DRE normal

PSA ≤1 ng/mL then repeat testing at 50 years.• >50 years: DRE normal, PSA <3 ng/mL, no other indications for biopsy then repeat

testing at 1–2 year intervals (testing in men >70 years done with caution and only if very healthy and little/no comorbidity).

RACGP Redbook 8th edition (2012)9

GPs need not raise the issue and PSA screening is not recommended unless:1. the man specifically asks for it; and2. he is fully counselled on the pros and cons.When a patient chooses screening, both PSA and DRE should be performed.

USANZ (2009–2011)10,11 • Men 55–69 years should be offered PSA and DRE after providing information on risks and benefits.

• Men <55 years (and over 40) could have a single PSA/DRE to estimate 10–20 year risk and intensity of subsequent testing adjusted accordingly.

USPSTF (2012)12 • Recommends against PSA-based screening.

ACS, American Cancer Society; AUA, American Urological Association; EAU, European Association of Urology; DRE, digital rectal examination; mPCa, metastatic prostate cancer; NCCN, National Comprehensive Cancer Network; NHMRC, National Health and Medical Research Council; NHS, National Health Service; PCa, prostate cancer; PSA, prostate-specific antigen; RACGP, Royal Australian College of General Practitioners; USANZ, Urological Society of Australia and New Zealand; USPSTF; United States Preventive Services Task Force.

PERSPECTIVES FROM A PROSTATE CANCER SPECIALIST NURSE

The Prostate Cancer Foundation of Australia (PCFA) Prostate Cancer Specialist Nursing Service opened its doors in 2012 to fund 12 nurses as part of a national pilot program. This was enabled by the generous financial support of The Movember Foundation. Since then, the Federal Government has acknowledged the importance of the program and provided a further funding, helping to grow the service to encompass 27 nurses.20

The nurses follow a professional framework that includes clinical competencies specific to prostate cancer care. They are well supported by the PCFA and take part in an ongoing educational program that includes regular journal clubs. “One of the joys of the role is the collegial relationship that exists between the 27 nurses,” said Sally Sara, a Prostate Cancer Specialist Nurse from SA who presented at the conference. The aim of the service is to provide a point of contact for men and their families across the whole continuum of care from diagnosis through to long-term follow up, “…that’s what sets our role apart from many other cancer-related roles,” said Sally, “…we get many phone calls from men who are several years down the track and the feedback that I have received is that men really appreciate having a contact that will last through their whole journey.” Before they begin their role,

the nurses map the local care environment, and their focus is on collaboration and filling the gaps in prostate cancer care that are not already covered locally. They also spend significant time providing information and emotional support to newly diagnosed patients, liaising with multidisciplinary care teams and finding appropriate care solutions for individuals, such as contacting rural patients by phone. Sally herself is deeply involved in developing a care plan to support prostate cancer survivorship, in conjunction with the Flinders Centre for Innovation in Cancer. The plan aims to help provide a picture of what should be expected in terms of treatment follow up and side-effect management over the long term; allowing the men themselves to take ownership of the plan.For further information about the program please refer to the PCFA website; www.pcfa.org.au

We are setting the strategy that, in patients with high-risk disease, adding local care will improve outcomes.

Prof. James Eastman

SURGERY AND RADIOTHERAPY IN VERY HIGH-RISK PROSTATE CANCER

Radical prostatectomy has long been the mainstay of treatment in men with low–intermediate-risk disease, with metastatic disease commonly handled with systemic therapies such as ADT followed by chemotherapy.6 However, Prof. James Eastman (Chief, Urology Service and Chair of Urologic Oncology, MSKCC, New York, US) is one of a growing number of urologists who believe that addressing the primary tumour in metastatic disease should be explored. This makes theoretical sense: it removes a source of future metastatic clones, reduces endocrine factors and cytokines and enhances the immune response; and has been of proven benefit in other cancers such as renal cell carcinoma21 and ovarian cancer.22

Prof. Eastman’s group has completed a Phase 1 study showing that, in principle, men with low-volume metastatic disease (<10 bone metastases) can safely undergo radical prostatectomy. This was in combination with extensive pelvic and retroperitoneal lymph-node dissection plus irradiation of the bone, followed by hormonal therapy. The outcome was positive, with at least one patient (of the 26 in the study) benefitting to the point of needing no further therapy after two years follow up. His group plans to extend their studies in this setting to encompass a drug-screening strategy that will evaluate the worth of adding specific ADT and/or other systemic therapies to their

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multi-modal plan. Ultimately their aim is to progress to Phase III trials that will answer the question of whether combining ADT with systemic agent(s) and radical prostatectomy could potentially cure patients with metastatic non-castrate prostate cancer. However, Prof. Eastman also suggested that they would plan to distinguish whether radical prostatectomy or radiotherapy is the best way to address local therapy for the primary tumour.

Prof. Alberto Bossi (Head of the Urology and Prostate Brachytherapy Unit, Gustav Roussy Cancer Institute, Villejuif, France) followed Prof. Eastman’s discussion with a thoughtful presentation on the current evidence for using radiotherapy in high-risk prostate cancer. He pointed out that there is Level 1 evidence for using radiotherapy in combination with ADT in men with locally advanced disease.6 And given that the clinical trials that came to these conclusions were designed in the 1980s and run in the 1990s using 2D radiotherapy, he echoed the sentiments of a trial author23 in suggesting that with current techniques, including 3D radiotherapy, results could be

even further improved today. Furthermore, he showed that there is ample level 1 evidence that higher doses are better.6 Although he did caution that while accurate high-dose radiotherapy can be difficult to get right, the use of the latest imaging techniques – including methods such as regular CTs to take into account prostate movement within the pelvis – can provide significant benefits in terms of oncologic outcomes and side-effect reduction for patients. However, he showed that the current evidence available for radiotherapy in high-risk prostate cancer stems only from observational studies and prospective trials.6 And that such multi-modal combinations can result in significant side effects for patients, such as low levels of success at returning to continence.24 He therefore concluded that we need far more solid clinical trial evidence before changing current guidance, to which end there are clinical trials in progress. But he also cautioned that if and when radiotherapy is used in these patient groups, it should come with a full explanation of the possible downstream side effects.

A SURGICAL DEBATE: SHOULD SURGEONS’ RESULTS BE PUBLISHED?Hosted by Rick Sarre (Professor of Law and Criminal Justice at the University of South Australia) the ‘Dark Side of Surgery’ debate on the publishing of surgical results yielded a riveting discussion, which although characterised by largely differing opinions over interpretation of the data, seemed to end with the combatants in furious agreement: yes results should be ‘published’, but in a manner that is confidential to individual surgeons.

Mr Glenn McCulloch (Clinical Director of the South Australian Audit of Perioperative Mortality) in the Pro position put forward his argument that surgical result publication is not only necessary, but inevitable. He stated that, “Patients want some form of assessment. Health departments are demanding it. Audits show the benefits of it. And it has been shown to save futile surgery.” He cited positive outcomes from the New York State Cardiac Registries,25 and the UK NHS; both of which currently support publically accessible and searchable websites that report on hospital performance down to the level of surgeon- specific mortality rates.26,27

His own self-described ‘hobby horse’ of surgical mortality audits in Australia he claimed, has seen mortality decreases of 5% per year in SA over the last 2 years, and 9% in VIC over the last 3 years: but it should be noted that this is a system which releases confidential performance reports to individual surgeons, and reports de-identified data publically, rather than making the individual surgeons’ results available online. He ended his speech by calling for adequate funding and the proactive involvement of surgical societies and surgeons themselves in setting up the reporting environments and procedures, as without this, he cautioned “…what we are heading for is a train wreck. Don’t let that happen.”

Prof. Andrew Vickers in the Con position highlighted some of the many issues that come

along with this kind of result publication. This included him questioning whether the current use of statistical analysis can potentially look better than it should for low-volume surgeons, and worse than it should for some very good high-volume surgeons; as well as whether the public can properly interpret the data they are being given in the context of national or state-wide performance, rather than hospital-specific performance. Furthermore, he cited evidence that surgeons changed their medical decisions in fear of result publication repercussions.28 He also cited various papers on the impact of result publication on patient outcomes, including a systematic review of 45 studies from the Annals of Internal Medicine that showed that “the effect of public reporting on effectiveness and safety remains uncertain.”29

In his own institution (Memorial Sloan-Kettering Cancer Center, New York, USA) Prof. Vickers is pioneering a surgical results database that returns confidential performance data to individual surgeons. The interactive environment allows them to analyse their own performance and surgical outcomes in comparison to their peers. He concluded that currently, publication of surgical results is “…a great idea that has gone horribly wrong,” and urged that there needs to be significant checks and balances in place and thoughtful conversations with both patient advocates and surgeons themselves before the truly public ‘publication’ of surgical results occurs, to guard against surgeons ‘gaming the system’.

Social media (or SoMe) is revolutionising the way we communicate, both personally and professionally, and the world of healthcare is certainly not being left behind. Reports suggest that up to 40% of adults in both the UK and the US use Facebook to search for health information.30,31 And up to 90% of healthcare professionals were found to be using social media in their personal lives, with 65% of a group of 4000 surveyed physicians also using it professionally.32

HAVE YOU JOINED THE SoMe REVOLUTION?

If you haven’t made the leap yet, or even if you have, the SoMe session at USANZ15 was a great overview of how to use SoMe in your professional life. Dr Imogen Patterson (Queensland Health) began the session with an interesting discussion of the dos and don’ts of professional SoMe interactions. The key thing to remember, she believes, is that anything you post online is there permanently, and is permanently searchable, no matter what SoMe platform you choose to operate within. The repercussions of a badly thought through post or tweet can also follow you around even if you delete it. A famous example being the #HasJustineLandedYet story in which a London PR professional sent out a ‘joke’ tweet that had racist connotations just before boarding a plane to South Africa. By the time the plane landed, enough of a media firestorm had erupted to ensure she lost her job. She is still having trouble finding employment, and

What not to do on professional SoMe

Considered grievous violations

Misleading claims (e.g. exaggerated claims of ‘cure’)

Misrepresenting credentials

Using patient images without consent

Inappropriate communication with patients (e.g. of a sexual nature)

Narrative of your day that may give away who your patients were

Anything suggestive of discrimination

Less grievous but still unacceptable

Posting social photos looking less than professional (read inebriated)

Narrative that is disrespectful to patients even with no possible identifiers

On-line journal clubs using social media platforms such as the “International Urology Journal Club on Twitter” (#urojc), lend themselves well to the discussion of the most recently published research. Unlike traditional journal clubs, there is global participation and frequently the participation of study authors.

Assoc. Prof. Henry Woo, Associate Professor of Surgery, Sydney Adventist Hospital Clinical School of the University of Sydney and Editor in Chief, BJUI Knowledge.

even starting a relationship, despite the fact that she deleted her entire social media presence shortly afterwards.33 Thankfully, many healthcare organisations are recognising the potential of social media for professional harm as well as good, and guidelines for online conduct for healthcare professionals are beginning to emerge – the BJUI having one of the more robust examples, which can be viewed in abbreviated form on their blog (www.bjuinternational.com/bjui-blog).34 Dr Patterson pointed out that it is important to remember that whatever you post can, and often will, be commented on by others, so even if you are careful to remove patient identifiers (for example) – would all your colleagues and friends who may join the discussion be as thoughtful? Ultimately, the best advice in the session was that anything you post becomes part of your ‘digital professional identity’, and you should take care that it is in line with your professional practicing goals.

Despite the potential for pitfalls however, it appears that urology, and Australian urologists in particular, are leading the way in professional social media. Dr Henry Woo gave an insightful introduction to using Twitter as well as presenting his first-of-its-kind Twitter-based journal club #urojc. The beauty of this is that there are no international or time boundaries for joining the discussion, and commentary from and interactions with key opinion leaders and paper authors are available to interested followers who may never get the chance to meet the other participants in person. The journal club discussions run for 48 hours on the first

Sunday/Monday of each month, depending on your time zone, and recently published papers are crowd-sourced through recommendations from colleagues and participants. “When you’re on Twitter its all about now, and knowing that you are discussing the latest and greatest research,“ said Professor Woo. With over 378 users, the popularity of the journal club is growing and although many people follow and don’t necessarily participate, the discussion is open to everyone. You can join by searching the hashtag #urojc on Twitter, and you might even win one of the regular prizes for participation that, in the past, have included journal subscriptions and international meeting fees.

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CONCLUSIONSThe Adelaide Convention Centre venue for this 68th USANZ Annual Scientific Meeting was situated in prime position on North Terrace just opposite the famous Adelaide Oval, which played host to the impressive Monday night gala dinner. The meeting began with a fascinating Harry Harris Oration from Dr Corey Bradshaw, a well-known conservation ecologist who spoke about the climate and population changes we are facing as a planet and a country. With over 800 delegates, including 20 prestigious international faculty members, the ASM hosted both cutting-edge scientific discussions and unique national and international networking opportunities. Innovation abounded, with Australian Urologists continuing to lead the way in the online world, including the exciting introduction of BJUI Knowledge – a web-based platform for continuing medical education, which its Editor in Chief, A/Prof Henry Woo, says will be closely linked to social media. Next year, the meeting will be heading to the Gold Coast, with the theme being ‘Bringing out the best!’ So remember to put April 16–19th in your diaries for 2016.

Minimum Product Information: INDICATIONS: Palliative treatment of advanced prostate cancer. DOSAGE: One subcutaneous injection of Eligard® every one/three/four/six months. Do not inject in the arm. CONTRAINDICATIONS: Hypersensitivity to GnRH, GnRH agonist analogues or any excipients. Pregnancy (Category D) and lactation. Paediatric patients. Previous orchiectomy. Sole treatment in patients with spinal cord compression or evidence of spinal metastases. PRECAUTIONS: Increase in serum testosterone causing bone pain, neuropathy, haematuria, urinary tract obstruction, spinal cord compression or ureteral obstruction; metastatic vertebral lesions, diabetes, cardiovascular disease, QT interval, convulsions; elderly. INTERACTIONS: No reports. ADVERSE EFFECTS: Flare phenomenon, skin reactions; malaise, fatigue, dizziness, alopecia, pruritis, myalgia, arthralgia, atrophy, or pain of testes, decreased libido, gynaecomastia; nervous system disturbances, depression, hot flashes/sweats; haematologic disorders; urinary disorders; gastrointestinal disorders; decreased bone density, cardiovascular disorders, pituitary apoplexy. Based on PI Jan 2015.

References: 1. Wolf AMD et al. CA Cancer J Clin 2010; 60:70–98. 2. American Urological Association. Early detection of prostate cancer: AUA guideline. Available at https://www.auanet.org/education/guidelines/prostate-cancer-detection.cfm accessed April 2015. 3. Canadian Task Force on Preventative Health Care. Can Med Assoc J 2014; 186(16):1225–34. 4. Canadian Task Force on Preventative Health Care. Screening for prostate cancer (2014). Website, available at http://canadiantaskforce.ca/ctfphc-guidelines/2014-prostate-cancer/ accessed April 2015. 5. Cancer Council Australia. Public consultation – Draft Clinical Practice Guidelines PSA Testing and Early Management of Test-Detected Prostate Cancer. Available at http://www.cancer.org.au/health-professionals/clinical-guidelines/prostate-cancer.html accessed April 2015. 6. Mottett N et al. Guidelines on prostate cancer March 2015 update. Available at uroweb.org accessed April 2015. 7. Murphy DG et al Br J Urol Int 2014; 113: 186–8. 8. NCCN Clinical Practice Guidelines in Oncology. Prostate Cancer Early Detection. Version I.2014. Available at nccn.org accessed April 2015. 9. RACGP Red Book Guidelines. Guidelines for preventative activities in general practice, 8th edition. Section 9.8, Prostate cancer. Available at http://www.racgp.org.au/your-practice/guidelines/redbook/early-detection-of-cancers/prostate-cancer/ accessed April 2015. 10. USANZ PSA testing policy. Available at http://www.usanz.org.au/uploads/29168/ufiles/USANZ_2009_PSA_Testing_Policy_Final1.pdf accessed April 2015. 11. USANZ Early prostate cancer testing saves lives. Media release available at http://www.usanz.org.au/uploads/65337/ufiles/110602EarlyTestingMediaRelease.pdf accessed April 2015. 12. Moyer VA on behalf of the USPSTF. Ann Intern Med 2012; 157:120–134. 13. Ilic D et al. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD004720. DOI: 10.1002/14651858.CD004720.pub3. 14. Vickers A et al. BMC Medicine 2014; 12:26. 15. Carlsson S et al. Br Med J 2014;348. 16. Vickers A et al. Eur Urol 2014; 66:188–190. 17. OPKO Lab, 4Kscore test. Available at http://clinical.opko.com/how-does-4kscore-test-work accessed April 2015. 18. Vedder MM et al. Eur Urol 2014; 66:1109–15. 19. Loeb S Catalona WJ. Ther Adv Urol 2014; 6:74–7. 20. Movember Foundation. Prostate Cancer Specialist Nurses. Available at http://au.movember.com/programs/prostate-cancer accessed April 2015. 21. Sankin A et al. Front Oncol 2015; 5:67. 22. Raja FA et al. Ann Oncology 2012; 23(Suppl. 10):x118–x127. 23. Bolla M et al. Lancet 2002; 360:103–6. 24. Suardi N et al. Eur Urol 2014; 65:546-51. 25. Hannan EL et al. J Am Coll Cardiol 2012; 59:2309–16. 26. MyNHS. Performance information to support transparency and drive equality. Website, available at https://www.nhs.uk/Service-Search/performance/search accessed April 2015. 27. New York State, Department of Health, Physician profiles. Available at https://www.health.ny.gov/health_care/consumer_information/physician_profile/about.htm accessed April 2015. 28. Narins CR et al. Arch Intern Med 2005; 165:83–87. 29. Fung CH et al. Ann Int Med 2008; 148: 111–123. 30. Moorhead SA et al. J Med Internet Res 2013; 15:e85. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636326/ accessed April 2015. 31. IMS Institute For Health Care Informatics Engaging patients though social media. January 2014. Available at www.slideshare.net accessed April 2015. 32. Ventola CL. Pharm Therapeutics 2014; 39:491–499. 33. Has Justine landed yet. http://www.independent.co.uk/news/people/news/pr-executive-justine-sacco-apologises-after-losing-job-over-racist-aids-joke-provoked-hasjustinelandedyet-twitter-storm-9020809.html 34. BJUI guidelines http://www.bjuinternational.com/bjui-blog/engaging-responsibly-with-social-media-the-bjui-guidelines/

Congress Series report prepared for Tolmar Therapeutics, Inc. Tolmar Australia Pty Ltd. ABN 53 162 640 708. Level 2/20 Bridge St, Pymble, NSW 2073. Medical Information: 1800 TOLMAR (865 627). inCeptiv July 2015. TOL150110

Please review full Product Information before prescribing. Product Information is available on request from TOLMAR (1800 865 627).

PBS Information: Authority Required (STREAMLINED) Locally advanced (equivalent to stage C) or metastatic (equivalent to stage D) carcinoma of the prostate.

THE POWER OF CHOICE7†‡

2015TOLMAR

CONGRESSSERIES30th Annual EAU Congress 20–24 March 2015, Madrid, Spain.

68th Annual Scientific Meeting (USANZ) 11–14 April 2015 Adelaide, Australia.

AUA Annual Meeting 15–19 May 2015 New Orleans, LA, USA.

Tolmar Uro-Oncology Symposium June 13–14 2015 Sydney, Australia.