Management Of Localized Prostate Cancer Research Articles

Local variation in primary treatment of localized prostate cancer

5126 Background: We aimed to characterize and quantify variation in the primary management of localized prostate cancer at the level of clinical practice sites. Methods: Data were abstracted from patients accrued to the CaPSURE national prostate cancer registry. Patients were accrued from the 36 clinical practice sites which contributed at least 30 patients to the registry, and represented all those diagnosed since 1990 with localized disease who received radical prostatectomy (RP), external beam radiation therapy (EBRT), brachytherapy, active surveillance / watchful waiting (WW), or primary androgen deprivation therapy (PADT) were included. Descriptive analyses were performed, and a random effects logit hierarchical model was constructed, controlling for year of diagnosis, age, comorbidity, PSA, Gleason score, clinical T stage, and percent of biopsy cores positive, to estimate the proportion of variation in primary treatment selection explicable by practice site. Analyses were conducted for all patients and for low-risk patients (Gleason score ≤6, PSA ≤10 ng/ml, clinical stage ≤T2a). Results: 10,080 men were analyzed. The distribution among primary treatments at each clinical practice site varied widely: use of RP, for example, ranged from 12% to 95% of enrolled patients. Patterns of treatment are not reliably explained by patient risk distribution at each site. The proportion of variation attributable to clinical practice sites was 10% for PADT, 19% for WW, 21% for EBRT, 28% for RP, 37% for brachytherapy, and 75% for cryotherapy. For low-risk patients only, this proportion was higher for all treatment types except brachytherapy and cryotherapy. Only a small amount of the variation attributable to practice site can be explained by measured sociodemographic factors such as ethnicity, income, education, and geographic region. There are significant trends in treatments over time, including more use of PADT for intermediate- and high-risk patients, and more use of RP and WW for low-risk patients. Conclusions: These data do not represent a random sampling of the United States population. However, the significant variation in practice patterns across individual clinical sites suggests that factors other than patient clinical and sociodemographic factors may be driving selection of primary treatment. [Table: see text]

Management of localized prostate cancer in men over 65 years

With the pervasive use of prostate-specific antigen-based screening, many men in the US are now diagnosed with prostate cancer in their 50s or earlier. However, the majority of tumors are still detected among men over 65-years-old. The appropriate management of localized disease among these older men is controversial. The US Preventive Services Task Force recently strengthened its recommendation against screening men over 75 years old. To date, however, screening among older patients remains common, and does not adequately reflect patient life expectancy. Older men are more likely to be diagnosed with higher-risk tumors, but are less likely to receive curative local therapy, and are more likely to be managed with primary androgen deprivation therapy. Careful active surveillance is an increasingly viable option for selected older men with low-risk tumors; focal therapy and low-intensity medical therapy may be emerging alternatives in the near future. Decisions regarding both screening and treatment should consider patient comorbidity, life expectancy, and treatment preferences rather than chronologic age. Treatment also must be tailored to the level of tumor risk. Increased use of active surveillance, together with diet and lifestyle intervention, is appropriate for many older men with lower-risk tumors. Conversely, those with high-risk disease should not be denied the opportunity for curative local therapy on the basis of age alone.

Prostate-specific antigen bounce after external beam radiotherapy plus high-dose-rate brachytherapy boost for definitive management of localized prostate cancer

Prostate-specific antigen bounce after external beam radiotherapy plus high-dose-rate brachytherapy boost for definitive management of localized prostate cancer

Actualités concernant la prise en charge non chirurgicale du cancer de la prostate localisé

During the last decade, several new non-surgical treatments have emerged for the management of localized prostate cancer. External radiotherapy and radical prostatectomy are still gold-standard and effective treatments but often associated with morbidities and side-effects. Consequently, less invasive treatments such as high-intensity focused ultrasound and brachytherapy have been progressively developed in order to decrease the complication rate associated with standard therapies as well as developing an effective oncological treatment. Later on, concepts of << watchful waiting >> and/or << active surveillance >> have been proposed to decrease overtreatment for patients with indolent disease. Despite promising results, further studies with long term follow up are strongly needed to better evaluate the cancer control and the quality of outcomes afforded with theses new therapeutics and before considering to alter the current guidelines for localized prostate cancer.

INFLAMMATION IS ASSOCIATED WITH MORE AGGRESSIVE PROSTATE CANCER

waiting was seen (36% to 9%). Combination therapy was utilized with increasing frequency (6.6% to 14.3%), with the largest increase found with the combination of radiation and hormones (3.4% to 12.25%). When compared to the non-VA published reports, these results demonstrate significant differences in pattern of initial management for localized prostate cancer. CONCLUSIONS: The number of patients diagnosed and treated at the VA medical centers has more than doubled over the last 10 years. This is of particular importance in terms of allocating additional resources and personnel to manage the increasing number of patients. While there was an increase in low risk prostate cancer which corroborated national data trends, the mode of treatment varied significantly from other national data.

The role of magnetic resonance imaging in targeting prostate cancer in patients with previous negative biopsies and elevated prostate‐specific antigen levels

In the past 20 years, magnetic resonance imaging (MRI) has developed rapidly, along with the management of localized prostate cancer. We summarize current data on the efficacy of MRI for targeting cancer, compared with biopsies, in patients with previous negative prostate biopsies and persistently elevated prostate-specific antigen (PSA) levels. The key clinical question is how many men benefit by having had prostate cancer detected purely because of the MRI-targeted, as opposed to standard scheme, biopsies. We reviewed all available databases for prospective studies in patients having MRI and prostate biopsy with previous negative biopsies and persistently elevated PSA levels. Six studies fulfilled the selection criteria, with 215 patients in all; in these studies, the cancer-detection rate at repeat biopsy was 21-40%. For MRI or combined MRI/MR spectroscopy, the overall sensitivity for predicting positive biopsies was 57-100%, the specificity 44-96% and the accuracy 67-85%. In five studies, specific MRI-targeted biopsies and standard cores were taken, with a significant proportion (34/63, 54%) having cancer detected purely because of the MRI-targeted cores. The value of endorectal MRI and MR spectroscopy in patients with elevated PSA levels and previous negative biopsies to target peripheral zone tumours appears to be significant. Although more data obtained with current technologies are needed, published results to data are encouraging. A comparison study and cost-benefit analysis of MRI-targeted vs saturation biopsy in this group of patients would also be ideal, to delineate any advantages.

Asystolic Cardiac Arrest during Balloon Insufflation for Endoscopic Extraperitoneal Radical Prostatectomy

Hemodynamic changes during abdominal laparoscopic procedures have been described as multifactorial phenomena. We report the possible occurrence of bradycardia and asystolic cardiac arrest during insufflation of the balloon trocar as a rare and serious but reversible complication during endoscopic extraperitoneal radical prostatectomy (EERP) for management of localized prostate cancer. Between 2003 and 2006, 430 patients underwent EERP for localized prostate cancer. The anesthetic protocol was standardized. The EERP was started with creating a preperitoneal space by insufflation of air through a balloon trocar inserted tangentially to the cutaneous plane toward the pubis. Review of the intraoperative data of our patient population revealed the occurrence of bradycardia and/or asystolic cardiac arrest during insufflation of the balloon trocar in three patients. The overall incidence of this complication in our population was therefore 0.7 per 100 patients. Further, during the insufflation of the balloon, a maximum pressure of 120 mm Hg has been measured. Severe vagal reaction triggered by manipulation of pelvic structures or nerves by the insufflated balloon trocar resulted in asystolic cardiac arrest in three patients. The life-threatening nature of this phenomenon should be understood by all anesthesiologists and urologists engaged in laparoscopic procedures.

Prostate Cancer: To Treat or Not to Treat?

To treat or not to treat is one of the most difficult dilemmas facing prostate cancer patients, especially elderly men with early prostate cancer or small cancer that is contained within the prostate. The primary objective of this review is to analyse the treatment options for patients with localised prostate cancer. This information can be considered alongside other important factors like natural history of disease and diagnostic tests. Several randomised and nonrandomised clinical trials published in the literature investigating the natural history of the disease, diagnostic tests, and treatment options for localised prostate cancer have been reviewed for this paper. Analysis of prostate-specific antigen (PSA) kinetics should play a major role in the management of localised prostate cancer. Trials investigating long-term outcomes of active surveillance are under way. Taking all these factors into consideration, the data support active surveillance as an appropriate choice for patients with well-differentiated or moderately differentiated, low-volume prostate cancer who have a life expectancy of <10 yr. Men with higher grade tumours and longer life expectancy may be at excess risk of death from prostate cancer if managed with active surveillance. Treatment options for localised prostate cancer can be considered in the treatment decision-making process alongside other important factors, such as the individual patient's values and situation as well as the potential impact of treatment on his quality of life.

Operative Details and Oncological and Functional Outcome of Robotic-Assisted Laparoscopic Radical Prostatectomy: 400 Cases with a Minimum of 12 Months Follow-up

BackgroundRobotic-assisted laparoscopic radical prostatectomy (RALP) using the da Vinci® surgical system (Intuitive Surgical, Sunnyvale, CA) is increasingly used for the management of localised prostate cancer. ObjectiveWe report the operative details and short-term oncological and functional outcome of the first 400 RALPs performed at our unit. Design, setting and participantsFrom December 2003 to August 2006, 400 consecutive patients underwent RALP at our institution. A prospective database was established to record the relevant details of all RALP cases. Surgical procedureA six port transperitoneal approach using a 4-arm da Vinci® system was used to perform RALP. This database was reviewed to establish the operative details and oncological and functional outcome of all patients with a minimum of 12 months follow-up. MeasurementsPerioperative characteristics and outcomes are reported. Functional outcome was assessed using continence and erectile function questionnaires. Biochemical recurrence (prostate-specific antigen (PSA) ≥0.2ng/mL) is used as a surrogate for cancer control. Results and limitationsThe mean age±standard deviation (SD) was 60.2±6 years. Median PSA level was 7.0 (interquartile range (IQR) 5.3–9.6) ng/mL. The mean operating time±SD was 186±49 mins. The complication rate was 15.75% comprising Clavien grade I-II and Clavien grade III complications in 10.5% and 5.25% of patients respectively.The overall positive surgical margin rate was 19.2% with T2 and T3 positive margin rates of 9.6% and 42.3% respectively. The biochemical recurrence-free survival was 86.6% at a median follow-up of 22 (IQR=15–30) months. At 12 months follow-up, 91.4% of patients were pad-free or used a security liner. Of those men previously potent (defined as Sexual Health Inventory for Men [SHIM] score ≥21) who underwent nerve-sparing RALP, 62% were potent at 12 months. ConclusionsThe safety and feasibility of RALP has already been established. Our initial experience with this procedure shows promising short-term outcomes.

Brachytherapy for Prostate Cancer: A Systematic Review

Low-dose rate brachytherapy has become a mainstream treatment option for men diagnosed with prostate cancer because of excellent long-term treatment outcomes in low-, intermediate-, and high-risk patients. To a great extend due to patient lead advocacy for minimally invasive treatment options, high-quality prostate implants have become widely available in the US, Europe, and Japan. High-dose-rate (HDR) afterloading brachytherapy in the management of localised prostate cancer has practical, physical, and biological advantages over low-dose-rate seed brachytherapy. There are no free live sources used, no risk of source loss, and since the implant is a temporary procedure following discharge no issues with regard to radioprotection use of existing facilities exist. Patients with localized prostate cancer may benefit from high-dose-rate brachytherapy, which may be used alone in certain circumstances or in combination with external-beam radiotherapy in other settings. The purpose of this paper is to present the essentials of brachytherapies techniques along with the most important studies that support their effectiveness in the treatment of prostate cancer.

Hypofractionation for Prostate Cancer

Hypofractionation for prostate cancer was originally carried out in the pursuit of efficiency and convenience but has now attracted greatly renewed interest based upon a hypothesis that prostate cancers have a higher sensitivity to fraction size, reflected in a low alpha/beta ratio, than do late responding organs at risk such as the rectum or bladder. Tumor control and acceptable toxicity outcomes from several hypofractionation or brachytherapy analyses do in fact support an alpha/beta ratio for prostate cancer that is low, perhaps even lower that that for the normal organs that ordinarily constrain the delivery of radiation therapy. However, many of these studies lack sufficient patient numbers and follow-up, are clouded by dose inhomogeneity issues in the case of brachytherapy, or delivered effective doses that were too low by contemporary standards. Thus, the clinical efficacy of the approach has yet to be fully validated. However, a number of newer prospective trials, some randomized, are underway or have reached accrual but await sufficient follow-up for analysis. These studies, which cover a wide range of doses per fraction, should ultimately be capable of validating the utility of prostate hypofractionation and the models that predict its effects. With hypofractionation's significant potential for therapeutic gain, cost savings, and improved patient convenience, the future management of localized prostate cancer could be profoundly altered in the process.

High-Dose-Rate Brachytherapy in the Curative Treatment of Patients With Localized Prostate Cancer

High-dose-rate brachytherapy is a relatively new radiotherapeutic intervention that is used as a curative treatment for patients with many types of cancer. Advances in mechanical systems and computer applications result in a sophisticated treatment technique that reliably delivers a high-quality radiation dose distribution to the intended target. Patients with localized prostate cancer may benefit from high-dose-rate brachytherapy, which may be used alone in certain circumstances or in combination with external-beam radiotherapy in other settings. The authors comprehensively searched the MEDLINE database for clinical studies published from January 1, 2002, through December 31, 2007, using the key terms brachytherapy, high-dose-rate, and prostatic neoplasms. Criteria for study review were study design, English language, relevance to clinicians, and validity based on design and appropriateness of conclusions. The abstract proceedings of meetings sponsored by the American Brachytherapy Society and the American Society for Therapeutic Radiology and Oncology were reviewed to identify additional relevant material. These sources provided the basis for a concise review of the rationale and advantages of high-dose-rate brachytherapy in the management of localized prostate cancer, as well as the details of the clinical use and therapeutic outcomes of this treatment as observed in a contemporaneous time frame.

Prostate-Specific Antigen: A Misused and Maligned Prostate Cancer Biomarker

Prostate-Specific Antigen: A Misused and Maligned Prostate Cancer Biomarker

Changing times for the management of localised prostate cancer

AbstractWith recent NICE guidance emphasising the role of active surveillance for men with ‘low‐risk’ prostate cancer, the authors ask whether we can reliably identify those men with cancers that have a minimal risk of progression. While it is important for patients to be involved in treatment decisions, the diversity of opinion and the lack of high quality comparative data mean that there is no recommended ‘best practice’ for treatment of this disease. Copyright © 2008 Wiley Interface Ltd

Prevention and management of perioperative complications in laparoscopic and endoscopic radical prostatectomy

Laparoscopic transperitoneal radical prostatectomy (LRP) and endoscopic extraperitoneal radical prostatectomy (EERPE) are established techniques for the management of localized prostate cancer in numerous specialized urologic centers worldwide. The complication rates of LRP and EERPE are ranging between 2 and 17%. Rare but possible complications are vascular injuries, bowel injury, lymphocele formation, port-site hernia, anastomotic leakage, gas embolism and catheter obstruction and other rare events. Prevention and management of complications requires high surgical expertise and adequate standardization of the technique. We herein review our experience with the endoscopic extraperitoneal radical prostatectomy in a series of 1,800 consecutive patients regarding the appearance of complications and their management.

High dose rate brachytherapy for prostate cancer

High dose rate (HDR) afterloading brachytherapy in the management of localised prostate cancer has practical, physical and biological advantages over low dose rate seed brachytherapy. There are no free live sources used, no risk of source loss and since the implant is a temporary procedure following discharge no issues with regard to radioprotection use of existing facilities. Adequate coverage of extracapsular and seminal vesicle tumour is possible for advanced cases and HDR brachytherapy is the most efficient means of obtaining dose escalation in terms of biological dose based on a low α/β ratio. Selection for HDR brachytherapy includes patients with any prostate specific antigen (PSA) level provided there is no demonstrable metastasis, any Gleason score and stages T1B to T3B. The results of a randomised trial show that HDR brachytherapy is an effective means of dose escalation with a favourable therapeutic ratio when compared with standard external beam radiotherapy. Current studies are evaluating HDR brachytherapy as monotherapy delivering a radical dose in two to four fractions. The acute toxicity with HDR brachytherapy is short-lived and far less severe than seen with low dose rate brachytherapy and late toxicity rates are low.

Rationale, Conduct, and Outcome Using Hypofractionated Radiotherapy in Prostate Cancer

Hypofractionated radiation therapy for prostate cancer has become of increasing interest with the recognition of a potential improvement in therapeutic ratio with treatments delivered in larger-sized fractions. In addition, the associated reduction in fraction number produces attractive cost and patient convenience advantages as well. A still limited but growing number of hypofractionation trials have reported acceptable short-term levels of toxicity and biochemical control, but most have insufficient follow-up to ensure the long-term safety and efficacy of this approach. This situation will improve as many currently active trials mature, particularly several high-value randomized trials. In contrast, extreme hypofractionation, with schedules delivering only on the order of 5 fractions, is truly in its infancy for prostate cancer, with extremely limited tolerance and efficacy information currently available. Several uncertainties in the radiobiology of hypofractionation mitigate for an organized, cautious investigational approach. The fractionation response (alpha/beta ratio) of prostate cancers and, for that matter, late-responding normal tissues, has yet to be rigorously defined. Additionally, the linear-quadratic (LQ) model used in the design of hypofractionation schedules is subject to its own uncertainties, particularly with respect to the upper limit of fraction sizes for which it remains valid. Contemporary dose-escalated radiation therapy is already highly effective, making it imperative that ongoing and future studies of hypofractionation be performed in carefully designed, randomized clinical trials. Clinical validation permitting, the adaptation of hypofractionation as a standard of care could profoundly influence future management of localized prostate cancer.

Distant and local recurrence in patients with biochemical failure after prostate brachytherapy

Purpose To analyze the patterns of failure after the brachytherapy management of localized prostate cancer. Methods and materials From 1990 to 2008, 2869 patients underwent prostate brachytherapy and 213 experienced a prostate-specific antigen (PSA) failure by the Phoenix definition. Of these 213 patients, 33.5% were low, 18.5% intermediate, and 58% high risk. Results Of the 119 patients biopsied, 36 (30%) had a least one positive posttreatment biopsy. In univariate and multivariate analyses, PSA doubling time was the most predictive of a positive biopsy. Patients with doubling times ≤3, >3–6, ≥6–10, and >10 months had positive biopsy rates of 9%, 18%, 36%, and 42%, respectively ( p = 0.01). The actuarial rate of remaining free from distant metastases at 10 years was 73%. Patients with PSA doubling times of ≤3, >3–6, >6–10, and >10 months had freedom from distant metastases rates of 0%, 74%, 78%, and 94.5% at 10 years, respectively ( p < 0.0001). In multivariate analysis, PSA doubling time and time to PSA failure were the most significant predictors of developing distant metastases. Conclusions About one third of patients harbor a component of local failure and one fourth demonstrate clinical metastases. PSA doubling time can be used to help predict the source of a rising PSA.

Comparison of radical prostatectomy techniques: open, laparoscopic and robotic assisted

To review the current status of laparoscopic radical prostatectomy (LRP) and robotic assisted radical prostatectomy (RALP) in relation to radical retropubic prostatectomy (RRP) in the management of localized prostate cancer. Between 1982 and 2007 published literature was reviewed using the National Library of Medicine database and the following key words: retropubic, laparoscopic, robotic, robot-assisted, and radical prostatectomy. Special emphasis was given to the technical and cost considerations as well as operative, functional and oncologic outcomes. In particular, reports with pioneering work that have contributed to the evolution of the technique, presenting comparative outcomes and with large series encompassing intermediate/long term follow-up, were taken into account. After intermediate term follow-up, LRP and RALP achieved similar oncologic and functional results compared to RRP. However, LRP and RALP were associated with decreased blood loss, faster convalescence and better cosmetics when compared to RRP. The RALP technique is undoubtedly more expensive. The oncologic and functional outcomes for LRP and RALP are similar to RRP after intermediate term follow-up. Long term follow-up and adequately designed studies will determine the inherent advantages and disadvantages of the individual techniques in the management of localized prostate cancer.

Minimally invasive surgical modalities in the management of localized prostate cancer

Localized prostate cancer is one of the success stories of modern oncology, with radical treatments offering long-term cancer-specific survival for most patients. In fact, most men with this condition die from nonprostate cancer diseases rather than from their prostate cancer. Open radical prostatectomy has been the gold standard radical treatment for localized prostate cancer, but a new dawn is emerging. Novel minimally invasive modalities are now available, and include both minimally invasive prostatectomy as well as newer energy sources such as high-intensity focused ultrasound. This review summarizes these newer technologies, in terms of technique, as well as both oncological and functional outcomes to date. The ultimate goal of such novel minimally invasive modalities is to continue to improve on the functional outcomes without compromise to the oncological results of the gold standard.