Archive | Prostate Treatment

HIFU Treatment looks Promising for Localized Prostate Cancer

Data from a large clinical registry showed that over 80 percent of men with localized prostate cancer had negative biopsies for as long as 10 years after treatment with high-intensity focused ultrasound (HIFU).

The negative biopsy rate ranged from 78.3% of patients with high-risk prostate cancer to 89.3% for men with low-risk disease. The 10-year biochemical failure-free survival was 56% by a U.S. definition of biochemical failure and 42% by a German definition.

As reported at the American Urological Association meeting, the most common adverse events were urinary incontinence (mostly grade I) and urethral stenosis (bladder outlet obstruction) occurring in 20.6% and 18.5% of patients, respectively.

HIFU is available throughout Europe but not in the U.S., and it has appealed to many men as a noninvasive therapeutic option for early prostate cancer.  Whole-gland application of high-intensity ultrasound produces thermal and mechanical effects.  HIFU energy rapidly heats tissue to a temperature of greater than 80° C.  The ultrasound also generates gas bubbles that cause cavitation when they collapse, leading to the rupture of cell walls.

Roman Ganzer, MD, of the University of Regensberg in Germany. presented data on 2,552 prostate cancer patients treated with the Ablatherm HIFU system.  The mean age of the study population was 70.1 years.  Eight hundred twenty (32.1%) of patients received short-term hormonal therapy prior to HIFU treatment.  On average, the patients were followed for 3.3 years and as long as 16 years.  Overall, 83% of the patients had negative biopsies at follow-up, including 89.3% of low-risk patients, 81.2% of intermediate-risk patients, and 78.3% of high-risk patients.

In addition to incontinence and urethral stricture, the most common adverse events were infection and urinary retention, both at 11%.

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Pre-op Counseling For Prostate Surgery Not Effective

Researchers have found that over half of men undergoing radical prostatectomy have unrealistic expectations about some of the outcomes.

Daniela Wittmann, MSW, and colleagues at the University of Michigan Comprehensive Cancer Center in Ann Arbor, Michigan found that despite a pre-operative education program, 61 percent of men expected the same or better sexual function a year after surgery as they had before.  Sixty percent of men expected difficulties with urinary incontinence to be the same or better.  These findings were published in the Journal of Urology.

Wittmann and colleagues found that a substantial proportion of patients, 17 percent and 12 percent, respectively for both effects, expected better performance a year after surgery than before even though they had been told that such an outcome was improbable.  The researchers argued that this finding suggests that pre-op education should be followed up with post-surgery support for prostate cancer survivors.

The research team asked men undergoing radical prostatectomy to fill out the short form of the Expanded Prostate Index Composite questionnaire, both before and a year after surgery to get an idea of their urinary, bowel, hormonal, and sexual function.

The men were also asked, after pre-op counseling but before surgery, to fill out the Expanded Prostate Index Composite-Expectations questionnaire, which detailed what level of function they expected a year later.  Both questionnaires assess five domains: incontinence, urinary irritative symptoms, bowel function, hormonal function, and sexual function.

Analysis of the 152 participants showed that 36 percent and 40 percent expected the same function at one year as at baseline in urinary incontinence and sexual function, respectively, while 12 percent and 17 percent expected better function.  Forty-seven percent and 44 percent of patients had lower than expected function for urinary incontinence and sexual function, respectively.  Expectations matched or were better than outcomes for 78 percent of patients for urinary irritative symptoms.  Expectations of bowel and hormonal function largely matched outcomes, with 92 percent and 86 percent, respectively, having outcomes that were the same as or better than expected.

Wittmann said that these differences may arise from the way that the pre-op counseling is given.  The research tem cautioned that the study had a low response rate.  Out of 526 patients who signed consent forms, only 152 completed all the questionnaires.  This makes it difficult to generalize the findings.  Also, while the counseling on sexual matters was standardized, the information provided by surgeons on other outcomes was not.

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Saturation Biopsy Detects More Cancers

According to a new report, analysis of 20 to 24 biopsy cores is superior to analysis of 12 to 14 cores for detecting prostate cancer in men who’ve had a normal prostate biopsy in the past.

J. Stephen Jones, M.D., from Cleveland Clinic, Ohio said, “We have shown that transrectal saturation biopsy is as easy and safe to perform as standard biopsy while detecting almost 1/3 more cancers. With these findings, we are confident that this approach offers benefit with negligible downside.”

Jones did however caution that it would be premature to suggest that this should be made universal for a number of reasons.  First, this has only been shown in one study.  Second, this must be balanced against the potential to detect clinically insignificant cancers that we might be better not knowing about even though saturation biopsy detected almost a third more cancers and had equivalence complication rates.

Jones and colleagues compared the results of extended and saturation prostate biopsy protocols in a first repeat prostate biopsy population of 1056 men (393 with a 12 to 14-core extended biopsy and 663 with a 20 to 24-core saturation biopsy.  The authors reported their findings in the Journal of Urology. The detection rate was significantly higher in the saturation biopsy group than in the extended biopsy group.  Over a third of the positive biopsies (37.8%), however, met predetermined criteria for clinical insignificance, and there was a trend toward increased detection of clinically insignificant cancer in saturation compared to extended biopsies (40.1 percent compared to 32.6 percent).

For higher-risk populations, detection rates were higher for saturation biopsy than for extended biopsy, but the differences did not reach statistical significance.  The increased detection with saturation biopsy was significant for men whose initial biopsy was completely normal.

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Alpha Blocker Improves Symptoms of Chronic Prostatitis

Recent findings show that treatment with a specific alpha blocker helps reduce symptoms and improve quality of life for men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).  This alpha-blocker, called silodosin, works by selectively relaxing the muscles in the neck of the urinary bladder and prostate.  It has been approved in Canada, the United States, the EU and Japan to treat symptoms of another prostate gland condition, benign prostatic hyperplasia, which is commonly referred to as an enlarged prostate.

Although CP/CPPS is the most common form of prostatitis, it is the most misunderstood and difficult to treat because the symptoms are very similar to other conditions and requires a significant amount of testing and screening to identify.

Curtis Nickel, a professor in the Department of Urology, practicing urologist at Kingston General Hospital and Canada Research Chair in Urologic Pain and Inflammation, emphasized that antibiotics are commonly used as a treatment, but they are not typically effective.  This could be because CP/CPPS does not seem to be caused by a bacterial infection.

CP/CPPS is a debilitating condition; patients with this condition suffer from discomfort in the lower pelvic area including the bladder area, testicles, and penis.  Symptoms may be severe and can include painful and frequent urination and difficult or painful ejaculation.  The cause of CP/CPPS is not known.

In Dr. Nickel’s study, about 60 percent of men reported feeling better after treatment with silodosin as opposed to 30 percent of participants who were given a placebo.  These results for patients feeling better is higher than a similar study he conducted several years ago that tested the effects of a different alpha blocker.

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New Technology May Encourage Doctors to Recommend Prostate Surgery

A new study finds that after hospitals in Wisconsin received robotic surgery technology, the number of prostate removals there doubled within three months.  In contrast, the number of prostate surgeries remained the same at hospitals that did not purchase this new two-million dollar technology.

This finding was published in the peer-reviewed journal Cancer. It comes just months after a Johns Hopkins report showing that hospital websites often hype robotic surgery without considering the risks and play up the benefits leading the study authors to worry that the new technology is encouraging doctors to recommend surgery to patients.

Each robot, in addition to the initial cost of nearly $2 million, requires more than $100,000 per year for maintenance.  Jim Hu, MD, director of urologic robotic surgery at Brigham and Women’s Hospital in Boston, who was not involved in the new study, suggested that hospitals that acquire this expensive technology might feel pressure to cover its costs by performing more surgeries.    The new technology is now used in almost three-quarters of all prostate removals nationwide.  Yair Lotan, MD, from the University of Texas Southwestern Medical Center at Dallas, who was not involved in the study, said that The bulk of evidence, however, does not show it to be more effective in saving lives than traditional surgery.

Joan Neuner, MD, MPh, of the Medical College of Wisconsin and colleagues found that between 2002 and 2008, Wisconsin hospitals performed more than 10,000 prostate removal surgeries. Almost one in four hospitals purchased surgical robots in that period.  Although fewer men had prostate cancer in 2007, there were 1,760 prostatectomies in 2007 compared to 1,400 in 2002.

Dr. Neuner and colleagues attribute these findings partly to patient demand, driven by aggressive marketing by manufacturers and hospitals.  Dr. Lotan reports that patients often request the robotic surgery without knowing the risks involved.  While shorter recovery times, less blood loss, and smaller scars are benefits of the robotic system, the technology extends the operation time. Dr. Hu emphasizes that the safety of surgeries depends more on the skills of the surgeon than on the technology involved.

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Hormone Therapy Used to Treat Prostate Cancer Increases Vertebral Fractures

A recent study found that androgen deprivation therapy (ADT), a hormone therapy that is used to treat prostate cancer, speeds up loss of bone mineral density and increases vertebral fractures, particularly in white men.  The study was published in the Journal of Urology.

The men in the study were enrolled in a fracture prevention trial for prostate cancer patients receiving ADT and were at least 70 years old or had low bone mineral density at the lumbar spine or total hip.

Lead author of the study, Philip J. Saylor, MD, of Boston’s Massachusetts General Hospital, and his colleagues studied 1244 men, including 162 (13%) who had a vertebral fracture at baseline.  Although white race, osteoporosis and low bone density were significantly associated with this finding, age, country of residence and body mass index were not.  According to Saylor, older age, low bone mineral density, and white race prompt patients and doctors to discuss preventative therapy.

The duration of ADT was also not linked to prevalent vertebral fractures, perhaps because the effect on bone mineral density is most apparent in the first year of therapy and the average duration at study entry was four years.

The authors concluded the article by stating that these observations should inform the assessment and management of fracture risk among such men.  Also, in a related editorial, Paul Maroni and E. David Crawford, MDs, of the University of Colorado Health Sciences Center in Denver emphasized the importance of assessing bone health before ADT given the frequency and urgency of the condition.

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Surgery Improves Longevity and Quality of Life for cT3 Prostate Cancer Patients

Researchers at the Mayo Clinic, a leading nonprofit institution providing medical care, research and education for people from all walks of life based in Rochester, Minnesota, have found that long-term survival rates for patients with advanced prostate cancer suggest that they can be good candidates for surgery.  The research team found a twenty-year survival rate for 80 percent of patients diagnosed with cancer that has potentially spread locally from inside the prostate to immediately outside of it, known as cT3 prostate cancer, and who had been treated with radical prostatectomy, which is surgery to remove the prostate gland.  These findings were presented at the annual meeting of the American Urological Association in Washington.

Previously, patients who had cT3 prostate cancer were offered radiation or hormone treatment but not radical prostatectomy.

R. Jeffrey Karnes, MD, an Assistant Professor at the Mayo Clinic’s Department of Urology said that the identification and expansion of candidates for surgery that results in improved and longer outcomes for patients has improved. Other study investigators from the Mayo Clinic include Christopher Mitchell, M.D., Eric Umbreit, M.D., Rachel Carlson and Laureano Rangel.

The 80 percent survival rate for cT3 diagnoses at 20 years is compared to 90 percent for cT2, which is cancer confined to the prostate.  The study included patients with cT3 diagnoses and who were operated on between 1987 and 1997.  Ongoing research will continue to examine the current data.  This long-term follow-up is an important advance in understanding the quality outcomes for these cT3 patients.

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Rectal Injuries During Treatment for Prostate Cancer Reduced by Tissue Spacers

Recent research has found that injecting a tissue space in the prostate-rectal inter-space is an effective way to reduce the rectal dose for prostate cancer patients receiving radiation therapy.  These results were presented at the Cancer Imaging and Radiation Therapy Symposium in Atlanta, sponsored by the American Society for Radiation Oncology (ASTRO) and Radiological Society of North America (RSNA).

Although prostate cancer is cured in over 90 percent of patients, reducing side effects from treatment complications remains an important concern.  A more common side effect is damaging the rectum during treatment.  For this reason, researchers wanted to determine if inserting an injectable tissue space would reduce the risks of radiation burns to the rectum.

Thirty-four prostate carcinoma patients were administered a tissue space compound to increase the separation between the prostate and the rectum in this study in addition to the radiation therapy they were receiving.  They were imaged by MRI pre-injection and every two weeks until the end of treatment to monitor changes.  The research tem found that the spacer produced an additional one centimeter on average separation between the prostate and rectum resulting in a significant reduction in the rectal dose administered, and it caused very little damage to the rectum.

Severe rectal radiation burns, the most serious risk of injury from the radiation were almost eliminated by injecting an absorbable material into the rectum.  This allows the radiation oncologist to increase the dose to the posterior prostate without concern of damaging the rectum.

Kenneth Tokita, MD, senior author of the study and the founder and medical director of Cancer Center of Irvine said that reducing the risk of rectal injury from the treatment makes radiation therapy the treatment of choice for prostate cancer.

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Prostate Cancer Vaccine Fights Tumors Without Damaging Healthy Tissue In Mice

Researchers have developed a vaccine that destroys even advanced prostate tumors without any side effects.  The vaccine has only been shown to work in mice, but the researchers from the Mayo Clinic in Rochester Minnesota and at the University of Leeds in England hope that the treatment can someday work in humans.

The researchers created a vaccine that tricks the immune system to think existing tumors are antigens by using DNA from healthy prostate cells, thus triggering its antibodies to destroy the tumors.  Eighty percent of prostate cancer cells were destroyed without harming healthy tissue in mice.

The findings were published in the peer-reviewed journal Nature Medicine.  The study’s author Richard Vile, Ph.D., professor of immunology at the Mayo Clinic said that it might take three to five years for their to be a human version of the vaccine.  More research is needed to clear some FDA hurdles.

Prostate cancer is one of the deadliest cancers.  It strikes about 220,000 men each year and kills about 32,000.  Existing conventional treatments include surgery, radiation therapy, and hormone therapy, which can damage surrounding prostate tissue.  For this reason, the researchers were pleased that the vaccine did not destroy healthy tissue in mice.

The researchers are, however, cautioning men to not get their hopes up.  Dr. Kate Holmes, research manager at England’s Prostate Cancer charity, said that even though they are hopeful that the results of this study could help to form the basis of a new cancer vaccine in the future, researchers have only studied this possibility in mice.

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Men’s Expections for Urinary and Sexual Function After Prostate Surgery Are Not Met

A recent study in the Journal of Urology, led by Daniela Wittmann at the University of Michigan, found that man’s expectations to have better urinary and sexual function a year after the surgery than before it went unmet.

The study used a survey of 152 men, recruited between June 2007 and November 2008, undergoing radical prostatectomy before the surgery after they had received counseling on the risks of the procedure.

Of the patients 36% and 40% expected the same as baseline function at one year in urinary incontinence and sexual function, respectively, and 17%, 45%, 39%, 15% and 32% expected worse than baseline function at one year in urinary incontinence, urinary irritable symptoms, bowel function, hormonal function and sexual function, respectively. One year after prostatectomy fewer than 22% of patients attained lower than expected urinary irritable symptoms, and bowel and hormonal function, but 47% and 44% of patients attained lower than expected function for urinary incontinence and sexual function, respectively. Twelve percent and 17% of patients expected better than baseline urinary incontinence and sexual function at one year after surgery.

Other recent studies have shown that about one in four men recovered the ability to have intercourse one year after surgery and that some amount of incontinence was common even though men were generally not significantly bothered by it.

Tracey Krupski of the University of Virginia, who wrote an editorial that was published with the study, said that a support network may help new cancer patients understand the realities of life after surgery, while Wittmann said that involving patients’ partners is important to successfully regaining sexual function.

Although the study did not examine whether men would make a different treatment decision given what they know after the surgery, Wittmann said that she thinks that only a small proportion of these men would choose not to have surgery given the cancer-related risks.

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March 2019
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