Tag Archive | "prostate cancer"

Radiotherapy And Androgen Deprivation More Beneficial Than Radiotherapy Alone in Some Prostate Cancer Patients


In a recent study funded by grants from the National Cancer Institute and published in the New England Journal of Medicine, it was reported that short-term androgen-deprivation therapy improves survival in men with intermediate-risk, localized prostate cancer.  From 1994 to 2001, one thousand seventy nine men with localized prostate cancer and prostate-specific antigen levels of 20 ng/mL or less were randomized to receive radiotherapy alone (992 patients) or radiotherapy plus four months of androgen-deprivation therapy (987 patients).

The overall ten-year survival rate was significantly higher with combination therapy than with radiation alone, and combination therapy decreased disease-specific deaths.  The median follow-up period was 9.1 years, and the ten-year rate of overall survival was 62% among patients receiving radiotherapy plus short-term ADT (the combined-therapy group), as compared with 57% among patients receiving only radiotherapy.  The addition of short-term ADT was associated with a decrease in the 10-year disease-specific mortality from eight percent to four percent. Biochemical failure, distant metastases, and the rate of positive findings on repeat prostate biopsy at two years were significantly improved with radiotherapy plus short-term ADT.  In the two groups, acute and late radiation-induced toxic effects were similar.

The study was carried out because it had not been known whether short-term androgen-deprivation therapy (ADT) before and during radiotherapy improves cancer control and overall survival among patients with early, localized prostate adenocarcinoma.

It was found in a post-hoc analysis that the benefits of combination therapy were limited to men with intermediate-risk disease rather than men with low-risk cancer.

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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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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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Simple Postage Stamp Test Objectively Assesses ED


According to the results of a small clinical study at Fox-Chase Cancer Center in Philadelphia, a simple, inexpensive home test for erectile dysfunction showed a good correlation with prostate cancer patients’ and partners’ subjective assessments of their sex life.

Objective measures of nocturnal tumescence, erectile dysfunction (ED), and overall sexual function had significant associations for up to a year with the “stamp” test, a do-it-yourself nocturnal penile tumescence assessment.  This test supplements subjective information provided by patients and their sexual partners.  The findings were presented by Lanea Keller, MD, at the American Society for Radiation Oncology.  Dr. Keller found that after high-dose IMRT (intensity-modulated radiation therapy), both the patient’s and the partner’s perception of their overall sex life was reflected by a positive stamp test as well as their own perception of erectile dysfunction.

After radiation therapy for localized prostate cancer, men often have concerns about sexual function.  According to Keller, the information clinicians use to assess erectile and other aspects of sexual function comes mainly from standardized questionnaires, which elicit responses that may be subjective.

Adding the results of an objective test, which involves a strip of postage stamps, could help in the assessment and decision making related to sexual function.  The test involves a man wrapping a strip of postage stamps around the base of the penis.  If he has a normal nocturnal tumescence response, the stamps separate at one or more of the perforations, resulting in a positive test.  Ninety-four prostate cancer patients were evaluated using this test.  The men completed the Expanded Prostate Cancer Index Composite (EPIC) and International Index of Erectile Function (IIEF) questionnaires at baseline and at six, 12, and 24 months after treatment. During the weeks that they completed the questionnaires, the patients also performed stamp tests on various nights.  Their partners also completed an IIEF partner questionnaire at the same time intervals.  The correlation between patients’ and partners’ questionnaire responses and the stamp test was analyzed.

The median age of the patients was 62.5.  Ninety-seven percent of the patients had stage T1c or T2a cancer.  Keller reported that 68 patients had positive stamp tests at baseline. The number of positive tests declined to 33 at six months, 32 at 12 months, and 30 at 24 months.  A positive stamp test at baseline had no relationship with patients’ or partners’ overall satisfaction with their sex life. At all of the follow-up periods, the stamp test had one or more significant or borderline-significant associations with the subjective assessments of sexual function and satisfaction.

At all three time intervals after IMRT, a positive stamp test was associated with patients’ overall satisfaction with their sex life, the partner’s perception of the patient’s erectile dysfunction, and partners’ overall satisfaction with their sex life.  A positive stamp test’s correlation with subjective measures tended to be strongest at one year.

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Urine Test Can Help Detect and Sort Prostate Cancer


Researchers report that an investigational urine test can detect and stratify prostate cancer in men with elevated prostate specific antigen (PSA).  According to Arul Chinnaiyan, MD, PhD, of the University of Michigan Medical School in Ann Arbor and colleagues, the test is based on the detection of a gene fusion that is specific to prostate cancer combined with another marker.  Stratifying patients by the combined marker identified groups with markedly different risks of cancer, high-grade cancer, and clinically significant cancer on biopsy.

This noninvasive test may allow some men with elevated PSA to avoid a needle biopsy.  Although many more men have elevated PSA than actually have cancer, the test could be an intermediate step before getting a biopsy.

The fusion that doctors look for in the test involves the genes transmembrane protease, serine 2 (TMPRSS2), and v-ets erythroblastosis virus E26 oncogene homolog (avian) (ERG).  This fusion appears in roughly half of all prostate cancers, but when it does appear, it is almost 100% specific for malignancy.  Through a series of experiments, the research team showed that the fusion gene was associated with indicators of clinically significant cancer at biopsy and prostatectomy.  The indicators included tumor size, high Gleason score at prostatectomy, and upgrading of Gleason grade at prostatectomy.

Because this fusion gene is not always present, the team created a model that combined it and the prostate cancer antigen 3 (PCA3) gene.

The researchers use the model to stratify 1,065 men who underwent biopsy into three groups – lowest, intermediate, and highest levels of the combined genes.

These tests, however, remain investigational.  Additionally, the researchers note that most of the men studied thus far have been Caucasian.  More studies are needed to see if the results can be generalized.

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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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