End-stage Prostate Cancer Research Articles

Seven-Year Experience of Intramural Surgery in the Middle East: A Safety and Feasibility Analysis.

Background: Intramural surgery techniques, particularly esophageal peroral endoscopic myotomy (E-POEM), gastric peroral endoscopic myotomy (G-POEM), and peroral endoscopic myotomy for Zenker's (Z-POEM), have emerged as forefront minimally invasive endoscopic procedures. While several studies have reported on the outcomes in North America and Asia, evidence in the Middle East and North Africa remains limited. This study aims to evaluate the feasibility and safety of intramural surgery techniques within this region. Methods: This retrospective cohort study was conducted with approval from the institutional review board. All patients who underwent esophageal peroral endoscopic myotomy, gastric peroral endoscopic myotomy, and peroral endoscopic myotomy for Zenker's from January 2016 to August 2023 were included. Results: In total, 119 patients underwent intramural surgery procedures during this period. The esophageal peroral endoscopic myotomy group had 81 (68%) patients, the gastric peroral endoscopic myotomy had 34 (28.6%) patients, and the peroral endoscopic myotomy for Zenker's had 4 (3.4%) patients. The full cohort was 48.7% female, with a mean overall age of 40.5 years. The mean overall body mass index was 27.5 kg/m2. The chief complaint was dysphagia (n = 80, 67.2%). All cases were successfully completed endoscopically. During the first 30 days, the most common complications were nausea/vomiting requiring admission (n = 4, 4.76%) and pneumomediastinum (n = 2, 2.38%). At a follow-up of 19 months, there were four mortalities; the causes of death were cardiac arrest (three cases) and end-stage prostate cancer (one case). Conclusions: Intramural surgery techniques are safe and technically feasible with low complication rates. Our study suggests that clinical success in the Middle East and Northern Africa population is comparable to larger international series.

Comparison of PET/CT-based eligibility according to VISION and TheraP trial criteria in end-stage prostate cancer patients undergoing radioligand therapy.

Two randomized clinical trials demonstrated the efficacy of prostate-specific membrane antigen (PSMA) radioligand therapy (PSMA RLT) in metastatic castration-resistant prostate cancer (mCRPC). While the VISION trial used criteria within PSMA PET/CT for inclusion, the TheraP trial used dual tracer imaging including FDG PET/CT. Therefore, we investigated whether the application of the VISION criteria leads to a benefit in overall survival (OS) or progression-free survival (PFS) for men with mCRPC after PSMA RLT. Thirty-five men with mCRPC who had received PSMA RLT as a last-line option and who had undergone pretherapeutic imaging with FDG and [68Ga]Ga-PSMA I&T or [18F]PSMA-1007 were studied. Therapeutic eligibility was retrospectively evaluated using the VISION and TheraP study criteria. 26 of 35 (74%) treated patients fulfilled the VISION criteria (= VISION+) and only 17 of 35 (49%) fulfilled the TheraP criteria (= TheraP+). Significantly reduced OS and PFS after PSMA RLT was observed in patients rated VISION- compared to VISION+ (OS: VISION-: 3 vs. VISION+: 12months, hazard ratio (HR) 3.1, 95% confidence interval (CI) 1.0-9.1, p < 0.01; PFS: VISION-: 1 vs. VISION+: 5months, HR 2.7, 95% CI 1.0-7.8, p < 0.01). For patients rated TheraP-, no significant difference in OS but in PFS was observed compared to TheraP+ patients (OS: TheraP-: 5.5 vs. TheraP+: 11months, HR 1.6, 95% CI 0.8-3.3, p = 0.2; PFS: TheraP-: 1 vs. TheraP+: 6months, HR 2.2, 95% CI 1.0-4.5, p < 0.01). Retrospective application of the inclusion criteria of the VISION study leads to a benefit in OS and PFS after PSMA RL, whereas TheraP criteria appear to be too strict in patients with end-stage prostate cancer. Thus, performing PSMA PET/CT including a contrast-enhanced CT as proposed in the VISION trial might be sufficient for treatment eligibility of end-stage prostate cancer patients.

An Update to the Pilot Study of 177Lu-PSMA in Low Volume Hormone-Sensitive Prostate Cancer.

177Lu-PSMA-617 radioligand therapy is a novel treatment for end-stage prostate cancer, which could also be applied to patients with hormone-sensitive prostate cancer with high expression levels of prostate-specific membrane antigen (PSMA). In this perspective, we review the recent results of toxicity, radiation doses, and treatment effect of 177Lu-PSMA in patients with low volume metastatic hormone-sensitive prostate cancer. Moreover, we present long-term follow-up data, such as toxicity and time without androgen deprivation therapy (ADT), of the patients who participated in this trial. Overall, 177Lu-PSMA appeared to be a feasible and safe treatment modality in this setting, as well as in long-term follow-up. We observed that men with a prostate-specific antigen (PSA) response of more than 50% seemed to especially benefit from this therapy by postponing ADT and thus preserving the quality of life.

Regulation of CEACAM5 and Therapeutic Efficacy of an Anti-CEACAM5-SN38 Antibody-drug Conjugate in Neuroendocrine Prostate Cancer.

Neuroendocrine prostate cancer (NEPC) is an aggressive form of castration-resistant prostate cancer (CRPC) for which effective therapies are lacking. We previously identified carcinoembryonic antigen-related cell adhesion molecule 5 (CEACAM5) as a promising NEPC cell surface antigen. Here we investigated the scope of CEACAM5 expression in end-stage prostate cancer, the basis for CEACAM5 enrichment in NEPC, and the therapeutic potential of the CEACAM5 antibody-drug conjugate labetuzumab govitecan in prostate cancer. The expression of CEACAM5 and other clinically relevant antigens was characterized by multiplex immunofluorescence of a tissue microarray comprising metastatic tumors from 34 lethal metastatic CRPC (mCRPC) cases. A genetically defined neuroendocrine transdifferentiation assay of prostate cancer was developed to evaluate mechanisms of CEACAM5 regulation in NEPC. The specificity and efficacy of labetuzumab govitecan was determined in CEACAM5+ prostate cancer cell lines and patient-derived xenografts models. CEACAM5 expression was enriched in NEPC compared with other mCRPC subtypes and minimally overlapped with prostate-specific membrane antigen, prostate stem cell antigen, and trophoblast cell surface antigen 2 expression. We focused on a correlation between the expression of the pioneer transcription factor ASCL1 and CEACAM5 to determine that ASCL1 can drive neuroendocrine reprogramming of prostate cancer which is associated with increased chromatin accessibility of the CEACAM5 core promoter and CEACAM5 expression. Labetuzumab govitecan induced DNA damage in CEACAM5+ prostate cancer cell lines and marked antitumor responses in CEACAM5+ CRPC xenograft models including chemotherapy-resistant NEPC. Our findings provide insights into the scope and regulation of CEACAM5 expression in prostate cancer and strong support for clinical studies of labetuzumab govitecan for NEPC.

Total tumor volume reduction and low PSMA expression in patients receiving Lu-PSMA therapy.

Background: [177Lu]-PSMA-617 (Lu-PSMA) therapy is a promising therapeutic option for end-stage prostate cancer patients. Early treatment response at the first restaging after two therapy cycles might correlate with high treatment efficacy and long overall survival (OS). Therefore, the aim of this study was to evaluate whether early reduction in tumor volume is a positive prognosticator for OS. To this end, PSMA PET prior to therapy (baseline) and at first restaging after two therapy cycles (interim; i.e., 12 weeks) were compared.Methods: Patients with metastatic castration-resistant prostate cancer who received Lu-PSMA therapy were reviewed for this analysis. All patients with available baseline and interim [68Ga]-PSMA-11 PET/CT were included in this analysis (n = 33). All PSMA avid metastases in baseline and interim PETs were semi-automatically segmented. The average PSMA expression (mean SUVmax of all metastases), total tumor volume (PSMA-TV) and TLQ (quotients of tumor volume and SUVmean summed over all metastases) were quantified at baseline and interim timepoints. Response in PSMA-TV was assumed when a decline > 30% was present. OS and biochemical response were available for all patients.Results: Baseline PSMA-TV was a statistically significant prognosticator of OS (HR = 1.618 95%CI: 1.117 - 2.343, p = 0.011). Reduction in PSMA-TV was not a statistically significant positive prognosticator of OS in the total cohort (HR = 0.829 95%CI: 0.559 - 1.230, p = 0.352). Likewise, there was no statistical difference in survival time comparing patients with PSMA-TV response to those without (13.2 vs. 15.6 months, p = 0.1). In the subgroup of patients with PSMA-TV response, mean SUVmax was a statistically significant prognosticator of OS (binarized by median; HR = 0.15; 95%CI: 0.03 - 0.83; p < 0.05). If patients with low PSMA expression at baseline were excluded from the analysis, reduction in PSMA-TV became a positive prognosticator of OS in uni- and multivariable Cox regression (HR = 0.290; 95%CI: 0.108 - 0.782; p = 0.015).Conclusion: PSMA-TV reduction was a positive prognosticator of OS only if patients with low PSMA expression were excluded. This might indicate that the PSMA-PETs of patients with low PSMA expression may not be suited for assessing PSMA-TV reduction. Future studies investigating the interplay of PSMA-TV and low PSMA expression response are warranted.

PSMA PET total tumor volume predicts outcome of patients with advanced prostate cancer receiving [177Lu]Lu-PSMA-617 radioligand therapy in a bicentric analysis

Introduction[177Lu]Lu-PSMA-617 (Lu-PSMA) radioligand therapy is an emerging treatment option for patients with end-stage prostate cancer. However, response to Lu-PSMA therapy is only achieved in approximately half of patients. It is clinically important to identify patients at risk of poor outcome. Therefore, the aim of this study was to evaluate pretherapeutic PSMA PET derived total tumor volume and related metrics as prognosticators of overall survival in patients receiving Lu-PSMA therapy.MethodsA total number of 110 patients form the Departments of Nuclear Medicine Münster and Essen were included in this retrospective analysis. Baseline PSMA PET-CT was available for all patients. Employing a previously published approach, all tumor lesions were semi-automatically delineated in PSMA PET-CT acquisitions. Total lesion number, total tumor volume (PSMA-TV), total lesion uptake (PSMA-TLU = PSMA-TV * SUVmean), and total lesion quotient (PSMA-TLQ = PSMA-TV / SUVmean) were quantified for each patient. Log2 transformation was used for regressions.ResultsLesion number, PSMA-TV, and PSMA-TLQ were prognosticators of overall survival (HR = 1.255, p = 0.009; HR = 1.299, p = 0.005; HR = 1.326, p = 0.002). In a stepwise backward Cox regression including lesion number, PSMA-TV, PSA, LDH, and PSMA-TLQ, only the latter two remained independent and statistically significant negative prognosticators of overall survival (HR = 1.632, p = 0.011; HR = 1.239, p = 0.024). PSMA-TLQ and LDH were significant negative prognosticators in multivariate Cox regression in contrast to PSA value.ConclusionPSMA-TV was a statistically significant negative prognosticator of overall survival in patients receiving Lu-PSMA therapy. PSMA-TLQ was an independent and superior prognosticator of overall survival compared with PSMA-TV.

Evaluating the clinical, environmental, genetic, and genomic profile of men with early-onset aggressive prostate cancer (PCa).

e17517 Background: Although PCa incidence has stabilized/decreased in most age groups, the incidence of metastatic disease has increased among men 50-69 years-old. The incidence of fatal PCa has decreased for most age groups, it has remained unchanged in men under 55 years-old. Studies have described genetic abnormalities in aggressive localized or end-stage PCa, but early-onset cases are not included or are under-represented. The primary objective of this study is to characterize the clinical, environmental, genetic and genomic features of high-risk advanced PCa. Methods: Study cohort includes men with PCa ≤ 60 years old with N1 or M1 stage at diagnosis or who develop metastases in 5-years after local therapy. Clinical (race, family history (Hx), environmental exposure), laboratory,/pathology, cell-free DNA germline analysis were collected. Primary/metastatic tumor tissue tested via the Tempus-Xe platform (DNA sequencing, whole transcriptome expression profiling, copy number analysis, comprehensive fusion gene analysis and calculation of tumor mutational burden). We report interim analysis. Results: Study completed accrual with 30 pts. Median age 55 years (41-60), 87% are white, 13% are black, 77% had a family Hx of malignancy in 1-6 family members, including 40% with family hx of PCa. Only 33% had Hx of smoking. Median Gleason score 9. Only 27% had nodal disease, and 73% had metastatic disease at diagnosis. Molecular data are available in 25 pts. Most common germline mutations: BRCA2 (12%), ATM (12%), RB1 (8%), MSH3 (8%) and MYBPC3 (8%). Most common somatic mutations:TP53 (40%), TMPRSS2-ERG fusion (32%), MUC4 (16%), PTEN (12%), C2CD4D (12%), SPOP (12%), OBSCN (12%), MXRA5 (12%), and MYO15A (12%). Microsatellite stability status was available in 15 pts and all were stable. Tumor mutational burden was low in all pts, ranging between 0.7 to 2.7 mutations/megabase. Conclusions: Our preliminary data suggest high rates of germline mutations in early onset lethal PCa. This aggressive subset of disease requires further studying to better characterize the underlying clinical/genomic factors driving this disease.

Hormone -Refractory Prostatic Adenocarcinoma Mimicking Basal Cell Carcinoma: A Case Report

Abstract Prostate cancer is an androgen-driven malignancy. Patients with late-stage prostate cancer often receive androgen-deprivation therapy to suppress the disease progression. Under the selection pressure, some prostate cancers transform to androgen-independent cancers. Treatment-induced small cell neuroendocrine carcinoma is one of the examples. In the last decade, patients with disseminated prostate cancer frequently received second-generation androgen-deprivation agents, such as abiraterone, enzalutamide, and apalutamide. Those more potent drugs have led to an emergence of a novel type of androgen-independent carcinoma named “double-negative” prostate cancer, which is immunohistochemically negative for both neuroendocrine markers and androgen targets. In this report, we present a typical case of “double-negative” end-stage prostate cancer that morphologically resembled basal cell carcinoma of prostate, basaloid large nest type.

Pretreatment PSA as Predictive Factor for Outcome with 177Lu-PSMA-617 Radioligand Therapy for Men with Lymph Node-Positive Prostate Cancer: A Retrospective Cohort Study

The 177Lu-PSMA-617 radioligand therapy (RLT) is a treatment of patients with end-stage prostate cancer but preliminary studies found a better response for patients with lymph node-positive prostate cancer (LNM). The present study aimed to analyze pretreatment PSA as predictive factor for the outcome of 177Lu-PSMA-617 RLT for LNM patients. A retrospective cohort study examined 32 patients with positive sites in lymph nodes with PSMA PET/CT with or without one or two bone metastases (10 and 22 patients). The two groups received cycles of 177Lu-PSMA-617 RLT with similar cumulative 177Lu activity: median 14.5 GBq (IQR 11.95-19.3) and 14.8. GBq (IQR 12.4-19.8). After 177Lu-PSMA-617 RLT, the 22 patients with LNM had a maximal PSA decline of median 95% (IQR 72-99). Maximal PSA decline of ≥50% was found for 19 patients (86%, 95% CI 70-100).). PSA nadir <0.2 μg/L was found for three patients (14% (95% CI 0-30). Patients with LNM and PSA before 177Lu-PSMA-617 RLT of <2 μg/L had a PSA nadir of <0.2 μg/L more often than patients with a higher pretreatment PSA (p = 0.001). Ten patients with LNM and one or two bone metastases had a maximal PSA decline of median 56% (IQR 21-97). Maximal PSA decline was significantly higher for the 22 patients with LNM than for the 10 patients with LNM and one to two bone metastases (p = 0.03). None of the patients had grade 3 or 4 hematologic adverse effects. 177Lu-PSMA-617 RLT for patients with LNM and pretreatment PSA <2 μg/L gave a post-therapy nadir PSA <0.2 μg/L as often as has previously been reported for salvage lymph node dissection or salvage radiotherapy of patients with recurrent LNM. A pretreatment PSA <2 μg/L was associated with the lowest posttreatment PSA nadir following 177Lu-PSMA-617 RLT for patients with LNM.

Lu-177-PSMA treatment for metastatic prostate cancer: case examples of major responses

Prostate-specific membrane antigen (PSMA) is expressed in high-risk prostate cancer (PCa). PSMA has potential as a basis for new diagnostics and theragnostics. 177Lu-PSMA radioligand therapy is mainly used for patients with end-stage prostate cancer. This report describes seven PCa patients: one patient with extensive metastatic bone and bone marrow disease during the first visit, one patient with his fifth recurrence during 15 years, one patient with extensive metastatic disease in liver, one patient with multiple lung metastases, one patient with metastatic disease where 177Lu-PSMA was used as first-line treatment and one patient with extensive metastatic disease in the lymphatics and skeleton. All these patients were treated with 177Lu-PSMA radioligand therapy with major response, i.e. major (up to complete) response by imaging and substantial (> 90%) reduction of PSA. 177Lu-PSMA radioligand therapy gave only mild adverse effects. In conclusion, in patients with metastatic prostate cancer, 177Lu-PSMA radioligand therapy had an attractive therapeutic profile, showing efficacy in the prostate, in lymph nodes, in lungs, in the liver and also in bones. The therapy had to be adjusted according to the patients’ needs.

LU-177-PSMA TREATMENT FOR METASTATIC PROSTATE CANCER – CASE EXAMPLES OF MIRACLE RESPONSES

Prostate specific membrane antigen (PSMA) is expressed in unfavorable prostate cancer. PSMA is basis for new diagnostics and theranostics. 177Lu-PSMA radioligand therapy is mainly used for patients with endstage prostate cancer. This report describes two patients: one patient with a multiple recurrences and one with extensive metastastic disease during the first visit. Both these patients were treated with 177Lu-PSMA radioligand therapy with major response, i.e. complete response by imaging and substantial reduction of PSA. 177Lu-PSMA radioligand therapy gave only mild adverse effects. In conclusion, patients with metastatic prostate cancer, 177Lu-PSMA-617 radioligand therapy had an attractive therapeutic profile which had to be adjusted according to the patient´s need.

177Lu-PSMA-617 radioligand therapy for a patient with lymph node metastatic prostate cancer.

Prostate specific membrane antigen (PSMA) is expressed in unfavorable prostate cancer. PSMA is basis for new diagnostics and theranostics. PET/CT using PSMA is more sensitive than choline PET/CT. 177Lu-PSMA radioligand therapy is mainly used for patients with end-stage prostate cancer. This report describes a patient with a third recurrence in lymph nodes. The recurrence was treated with 177Lu-PSMA radioligand therapy instead of chemotherapy with docetaxel. The effect was in part evaluated relative to that of two established salvage treatments. Prior salvage radiotherapy and abiraterone of the first and second recurrence in lymph nodes had given only a partial reduction of PSA. Nevertheless within five months of follow-up, 177Lu-PSMA radioligand therapy of the third recurrence in lymph nodes reduced PSA for a period to unmeasurable levels. 177Lu-PSMA radioligand therapy gave only mild adverse effects. In conclusion, for a patient with lymph node metastatic prostate cancer, 177Lu-PSMA-617 radioligand therapy had an attractive therapeutic profile. A follow-up study of similar patients is being planned.

Abstract A56: Physician consultations, prostate cancer knowledge, and PSA screening in African American men: Are the conversations effective?

Abstract African American (AA) men are more likely to develop and die from prostate cancer (PCa) yet less likely to receive information about screening from physicians. Although guidelines espouse shared decision-making regarding PCa screening and PSA testing, studies reveal lack of consistency. Several studies demonstrate that PCa knowledge strongly influences informed decisions, and that engaging interactions are especially important for AA men who are more likely to progress from early stage to aggressive end-stage PCa at an earlier age and faster rate than other populations. This study evaluated the frequency of physician-patient conversations among AA men and whether this translated into increased PCa knowledge and PSA testing. In this study, self-identified Black men ages 21-85 donated blood and completed a health survey (n=414) via Project C.H.A.N.G.E. (Changing Health in Adult Men with New and Great Experiences), a transdisciplinary cross-sectional study conducted at Loma Linda University. PCa knowledge following physician conversations in light of socio-economic and health care variables was evaluated using univariate, bivariate, and multiple regression analyses. PSA values were measured with ELISA. Our results revealed that 52.7% of participants had never discussed the pros and cons of PCa screening with their physicians. The likelihood of physician-patient conversations increased with age (p.001), and health insurance positively predicted these discussions (p.001). Multiple regression analysis indicated ethnicity and high school education as predictors of improved PCa knowledge (p.001). We found that 38.5% of men who had discussed PCa screening with a physician and 28.5% who had not discussed PCa screening had PSA values that could be considered high-risk for PCa diagnosis. These findings expose a remaining deficiency in physician compliance regarding national guidelines for shared decision-making conversations with high-risk men. This is problematic as a large group of AA men at evident risk for PCa have not ever discussed this disease with their physicians and may be harboring undetected PCa. Encouraging more effective interactions between AA men and their physicians concerning PCa screening and PSA testing has the potential to reduce PCa health disparities. Citation Format: Leanne Woods-Burnham, Laura Stiel, Colwick Wilson, Susanne Montgomery, Carlos A. Casiano. Physician consultations, prostate cancer knowledge, and PSA screening in African American men: Are the conversations effective? [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A56.

Racial Disparities in End-of-Life Care Among Patients With Prostate Cancer: A Population-Based Study.

To examine racial disparities in end-of-life (EOL) care among black and white patients dying of prostate cancer (PCa). Relying on the SEER-Medicare database, 3789 patients who died of metastatic PCa between 1999 and 2009 were identified. Information was assessed regarding diagnostic care, therapeutic interventions, hospitalizations, intensive care unit (ICU) admissions, and emergency department visits in the last 12 months, 3 months, and 1 month of life. Logistic regression tested the relationship between race and the receipt of diagnostic care, therapeutic interventions, and high-intensity EOL care. Overall, 729 patients (19.24%) were black. In the 12-months preceding death, laboratory tests (odds ratio [OR], 0.51; 95% CI, 0.36-0.72), prostate-specific antigen test (OR, 0.54; 95% CI, 0.43-0.67), cystourethroscopy (OR, 0.71; 95% CI, 0.56-0.90), imaging procedure (OR, 0.58; 95% CI, 0.41-0.81), hormonal therapy (OR, 0.53; 95% CI, 0.44-0.65), chemotherapy (OR, 0.59; 95% CI, 0.48-0.72), radiotherapy (OR, 0.74; 95% CI, 0.61-0.90), and office visit (OR, 0.38; 95% CI, 0.28-0.50) were less frequent in black versus white patients. Conversely, high-intensity EOL care, such as ICU admission (OR, 1.27; 95% CI, 1.04-1.58), inpatient admission (OR, 1.49; 95% CI, 1.09-2.05), and cardiopulmonary resuscitation (OR, 1.72; 95% CI, 1.40-2.11), was more frequent in black versus white patients. Similar trends for EOL care were observed at 3-month and 1-month end points. Although diagnostic and therapeutic interventions are less frequent in black patients with end-stage PCa, the rate of high-intensity and aggressive EOL care is higher in these individuals. These disparities may indicate that race plays an important role in the quality of care for men with end-stage PCa.

Analysis of urological procedures in men who died from prostate cancer using a population‐based approach

What's known on the subject? and What does the study add? Very few studies have examined end-of-life urological studies in men with prostate cancer. These studies reported fewer procedures in men who received primary therapy for prostate cancer. However, these studies were typically single institution or had a short follow-up period. The present study is the first population-based study examining end-of-life urological procedures and uses a geographic region encompassing 385 000 patients. Furthermore, this study incorporates both hospital- and office-based procedures. This approach has not been previously undertaken. To determine using a population-based approach whether men with end-stage prostate cancer who had definitive primary therapy might require fewer urological interventions. Repeated urological procedures can impact health-related quality of life in patients dying from prostate cancer. Using the Marshfield Epidemiological Study Area (MESA) database and tumour registry, we compared end-of-life interventions in men who died from prostate cancer between 1991 and 2009. Patient charts were queried for urological procedures using International Classification of Disease Modification, 9th edition (ICD9) codes for 3 years before death. Clinicopathological information was examined including whether the patient had a history of primary therapy (radiation or radical prostatectomy). Among 280 patients dying from prostate cancer, 52 (19%) required 153 urological procedures during the last 3 years of life. The frequency of procedures increased closer to death. The most common procedures involved nephrostomy tube (56%), Foley catheter (24%) and transurethral resection of the prostate (10%). Clinicopathological features did not predict the need for an end-of-life urological procedure. There was no difference in the frequency of upper or lower tract procedures in surgery or radiation patients compared with patients without primary therapy (P = 0.556 and P = 0.508). Using a Kaplan-Meier analysis, there were no differences between groups in the proportion of patients not requiring a procedure (n = 280; P = 0.179). This is the first population-based study to examine the frequency of urological procedures in patients with end-stage prostate cancer. A minority of patients (19%) required urological procedures during the final 3 years of life. A history of surgery or radiation did not influence the overall risk for urological intervention.

Smoking and prostate cancer survival and recurrence

Smoking and prostate cancer survival and recurrence

Management of a Request for Physician-Assisted Suicide

With the legalization of physician-assisted suicide (PAS) in several states, it remains controversial whether present guidelines take into account the complexity of identifying treatable sources of suffering, including underlying depression and other psychiatric disorders, in this high risk population. We present a case in which a patient with end-stage prostate cancer requested PAS; this request was in a state where PAS is not a legal option. He was evaluated psychiatrically and was not found to be depressed, but ample opportunities were found to improve his quality of life. With appropriate treatment, he lost interest in PAS as an option. We discuss the need for a comprehensive evaluation to properly assess and manage the untreated physical and emotional suffering that may influence a patient's decision to hasten death.

Age-related macular degeneration and its effect on quality of life

I was interested to read the review article on age-related macular degeneration (AMD) by Tariq Ayoub and Nishal Patel.1 While the article discussed in great detail the pathogenesis, diagnosis and management of AMD, the authors failed to mention the effect of all this on a patient's quality of life, thus supporting the findings of Stein et al.2 that clinicians undervalue or are not well aware of the broad impact of AMD on health-related quality of life. In fact, there is significant evidence that AMD reduces quality of life3 and that in severe forms of the disease this is comparable to a patient with end-stage prostate cancer.4 Furthermore, measures of quality of life, e.g. MacDQoL,5 can be (and have been) used as outcome measures to determine the effectiveness of various interventions, including many mentioned in the review article.

ETHICS FORUM

A 75-year-old man has end-stage prostate cancer with metastases to bone. He has received both external beam and parenteral isotope radiation therapy within the previous year. He now presents with increasing, severe pain, apparently in his spine and right hip, manifest by moaning, writhing, grimacing, and grunting. He is very restless and has very little capacity for verbal communication since suffering a hemispheric stroke within the last 6 months. His daughter has legal power of attorney for healthcare decisions, and he lives with her. The patient has been receiving hospice care at home for the last 3 weeks, and pain behaviors have been treated primarily with acetaminophen and naproxyn. He received an intravenous (IV) infusion of zolendronic acid (bisphosphonate) just prior to his admission to hospice. Oral intake is poor, and he has a diminished gag reflex. There is concern about absorption of oral analgesics and choking/gagging with pills and liquids, so parenteral morphine is recommended by the hospice team, and this is supported by his attending physician, a urological oncologist. The patient's daughter refuses subcutaneous (SQ) or IV morphine to be administered, stating, “Dad is going to be unconscious, may become addicted, may die from the drugs.” How shall the hospice team proceed?

Poster 38: The Use of Vertebroplasty in Improving Pain Control for End-Stage Prostate Cancer Patients: A Case Report

Setting: An acute inpatient cancer rehabilitation unit. Patient: A 74-year-old man with adenocarcinoma of the prostate with extensive bone metastasis. Case Description: The patient was admitted with intractable thoracic lumbar pain. Magnetic resonance imaging of the spine revealed metastatic involvement of every lumbar vertebral body with L2 being completely replaced with osteolytic metastasis, resulting in compression fracture of T12. Initially, patient received radiation therapy to T12-L3, corticoidsteroids, and patient-controlled analgesia (PCA) dilaudid with no significant pain relief.