Treatment Of Early Prostate Cancer Research Articles

The place of radical prostatectomy in the treatment of early localized prostate cancer

Today a number of treatment options exist for men diagnosed with early localized prostate carcinoma, of which the most important are radical prostatectomy, external beam radiotherapy and brachytherapy. New advances in brachytherapy using the implantation of iodine-125 and palladium-103 seeds have significantly altered its place in the treatment of localized disease and provided an alternative to external beam radiotherapy and potentially radical prostatectomy. Drawing on recently published data and our own experiences of retropubic radical prostatectomy in 100 consecutive men with localized disease, we review the place of radical prostatectomy in the treatment of early prostate cancer today. For many urologists radical prostatectomy remains the treatment of choice for men aged 70 years or less, with localized disease, a life expectancy of over 10 years and no co-morbidity. However, this has to be balanced against recent advances in brachytherapy, which now provides a minimally invasive alternative therapy for some patients with organ-confined disease and for those in whom surgery is contraindicated.

The role of active treatment in early prostate cancer

The dramatic increase in the number of patients diagnosed with localized prostate cancer in the last decade presents a difficult challenge for physicians. Because the window of opportunity for cure is short it is vital to begin treatment before the cancer cells invade neighbouring tissues and organs or metastasise to other sites. This pressure of increased patient numbers provided clinicians with the opportunity to investigate other treatment options. New surgical techniques including laparoscopic radical prostatectomy, improving therapeutic radiation by the introduction of conformal radiotherapy, neutron radiation, cryosurgery, high intensity focussed ultrasound (HIF) and the revival of brachytherapy with or without external beam radiation are currently being investigated. The goal of these techniques is to treat localized prostate cancer based on the endpoints of disease specific mortality, no evidence of disease, absent or low levels of prostate-specific antigen (PSA), reduced side-effects, improved quality of life and importantly increased cost-efficacy. It is important to remember however, that watchful waiting and endocrine therapy are still valid therapy options in certain patient groups. The lack of randomized, prospective trials on local treatment of prostate cancer, makes it difficult to compare the efficacy of the different treatments, especially in terms of disease-specific survival. Trials are now in progress but it will be several years before results are available. In the meantime, we need to focus on surrogate endpoints, side effects, quality of life and the cost-efficacy of each treatment. It is also important to ensure that patients are kept informed and up-to-date with any new therapeutic developments.

BENIGN AND MALIGNANT NEOPLASMS OF PROSTATE

No AccessJournal of UrologyUROLOGICAL SURVEY1 Oct 2000BENIGN AND MALIGNANT NEOPLASMS OF PROSTATE Patrick C. WalshM.D. Patrick C. WalshPatrick C. Walsh More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(05)67211-4AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail References 1 : Screening and early treatment of prostate cancer are accumulating strong evidence and support (Editorial Comment). Prostate2000; 43: 223. Google Scholar © 2000 by American Urological Association, Inc.FiguresReferencesRelatedDetails Volume 164Issue 4October 2000Page: 1428-1435 Advertisement Copyright & Permissions© 2000 by American Urological Association, Inc.MetricsAuthor Information Patrick C. Walsh More articles by this author Expand All Advertisement PDF DownloadLoading ...

Binary data with two, non-nested sources of clustering: an analysis of physician recommendations for early prostate cancer treatment.

A prospective cohort study of men with newly diagnosed early prostate cancer was undertaken Talcott et al. (1998) in order to evaluate both the patient-level and the physician-level determinants of physician recommendations for radical prostatectomy (surgery) versus radiation therapy. Each patient sought recommendations from as many as six physicians, and each physician provided recommendations for as many as 113 patients. Thus, the recommendations are clustered within physician and within patient. While methods have been developed for binary data with multiple-nested sources of clustering, they have not been fully explored for binary data with non-nested sources of clustering, such as the treatment recommendations. Here we propose reclustering the data to form binary data with one source of clustering. Because the reclustered data result in one very large cluster and several clusters of size one and two, marginal logistic regression models for the probability of a recommendation of surgery fit using a generalized estimating equation approach would produce unreliable estimates of uncertainty for the parameters. Thus, in addition to the mean model, we attempt to model the associations in as much detail as possible. We compare this model to a mixed-effects model that implicitly adjusts for both sources of clustering and to models based on the assumption of conditional independence with regard to one source of clustering.

Screening and early hormonal treatment of prostate cancer are accumulating strong evidence and support.

I review the data published during the last 5 years on the effects of early treatment of prostate cancer on survival. Data from prospective and randomized studies as well as from population-based studies are presented. Two studies (European Organization for Research and Treatment of Cancer and Radiation Therapy Oncology Group) in stage T3 disease have shown that long-term (3 years or indefinite, respectively) androgen blockade prolongs life in patients receiving androgen blockade in addition to radiotherapy compared to radiotherapy alone. In the UK Medical Research Council study, androgen blockade at diagnosis of locally advanced or asymptomatic patients decreased cancer-specific death by 21% compared to delayed treatment. A 69% decrease in prostate cancer death was observed in the Quebec Randomized Prostate Cancer Screening Study. Population-based studies in Sweden and Denmark have shown that 62% and 63%, respectively, of patients diagnosed with localized prostate cancer will die from the disease if not treated immediately. Decreases in prostate cancer death rate of 6.3-23% have been found between 1991-1997 in the US and Canada, respectively. Treatment of localized disease has been shown in all the available randomized studies to cause a marked decrease in prostate cancer death. Simple use of the available screening procedures and treatments for localized prostate cancer could cause a dramatic decrease in prostate cancer death.

Changes in quality of life following treatment for early prostate cancer

Objectives. To explore the effects of urinary, bowel, and sexual symptoms following treatment for early (nonmetastatic) prostate cancer on health-related quality of life through an examination of the responsiveness of the Medical Outcomes Study Short Form Health Survey (SF-36). Methods. We conducted a prospective observational cohort study of 125 men with early prostate cancer who underwent either radical prostatectomy or radical, external beam radiotherapy. Patients completed questionnaires, which included assessments of urinary, bowel, and sexual symptoms and the SF-36 at the time of their clinical consultation prior to deciding on primary therapy and at 3 and 12-month follow-up. Results. Although cross-sectional analysis showed substantial associations between symptoms and the eight scales of the SF-36 12 months after the initiation of treatment, longitudinal analyses of changes in these scales showed only modest effects. Three scales registered changes associated with the development of new symptoms: General Health Perceptions, Vitality, and Social Function. Role Performance with Emotional Limitations demonstrated a surprising response: slight improvements in men with new symptoms, compared with substantial gains in men who survived treatment without developing new urinary, bowel, or sexual symptoms. Overall, the SF-36 demonstrated a pattern of decline at 3 months and recovery to baseline at 12 months. Rather than registering declines in response to increasing symptoms, negative changes occurred primarily in men who presented symptoms prior to treatment and whose symptoms were unchanged 12 months later. Conclusions. The SF-36 is associated with the presence of physical symptoms but demonstrates a complicated pattern of change following treatment and the development of new urinary, bowel, and sexual problems. Multidimensional approaches to the outcomes of treatment for early prostate cancer help to clarify the magnitude of both gains and losses in quality of life.

Effect of early treatment of prostate cancer with the 5alpha-reductase inhibitor turosteride in Dunning R3327 prostatic carcinoma in rats.

Turosteride, a selective 5alpha-reductase inhibitor, was reported to be effective in inhibiting the growth of established tumors in the Dunning R3327 rat prostatic carcinoma model. We evaluated the preventive effect of turosteride when administered during the latency period in this prostatic tumor model. Turosteride was given orally, 6 days a week for 10-15 weeks, starting at different times: 1) 5 weeks after tumor implantation, when tumors were not yet palpable, or 2) 1 day after tumor implantation. In each experiment, one group of animals was castrated on the first treatment day. When treatment started 5 weeks after tumor implantation, neither turosteride (at 50 and 200 mg/kg/day) nor castration reduced tumor incidence (91-100%). Tumor growth was reduced in groups treated with the highest dose of turosteride and in castrated rats. When treatment started 1 day after tumor implantation, castration resulted in a 62% tumor incidence compared to 100% in controls, while turosteride at 200 mg/kg/day was not effective in reducing tumor incidence. However, as in the previous experiment, the compound was highly effective in reducing tumor growth. The antitumor activity profile of turosteride seems not to be related to the timing of treatment. Given either 5 weeks or 1 day after tumor implantation, the compound did not reduce tumor take, while it maintained effective tumor growth-inhibiting activity in both cases.

Conformal radiation approaches to the treatment of early prostate cancer: Techniques, outcomes & pitfalls

Conformal radiation approaches to the treatment of early prostate cancer: Techniques, outcomes & pitfalls

Quality of life in prostate cancer patients.

Quality of life in prostate cancer patients.

THE SOCIOECONOMIC IMPLICATIONS OF PROSTATE-SPECIFIC ANTIGEN SCREENING

Widespread PSA screening will increase overall health care costs. This increase will not result from the detection of clinically insignificant prostate cancer, but rather from the stage migration caused by prostate cancer screening. This stage migration will result in a larger percentage of men with prostate cancer undergoing early treatment options, which are more expensive than treatment of late disease. More importantly, early detection of prostate cancer will lead to treatment several years earlier than would have occurred otherwise. Because treatment then will be paid for in current rather than future dollars, the opportunity costs of money will make treatment costs resulting from PSA screening greater than treatment costs resulting from traditional detection. The critical question is what benefits will be obtained by the expenditure of these additional health care dollars. If early treatment of clinically localized cancer has little or no effect on cause-specific survival, the additional health care costs will have been spent only to limit eventual treatment of local symptoms in the screened men. If early treatment of prostate cancer can increase survival, the added expense is more worthwhile. Because there are not adequate data available to address this issue, several approaches have been used to develop models to estimate cost-effectiveness. Decision analysis models have been used to evaluate the effectiveness of prostate cancer screening and treatment and have found little or no benefit. The current review has demonstrated how assumptions used in the models can influence the results. Benoit et al also have constructed a model of the effectiveness and cost-effectiveness of prostate cancer, but in this study only concrete parameters such as cost, published complication rates, and survival data were used. This quantitative analysis demonstrated that prostate cancer screening is an effective and cost-effective health care intervention compared with currently accepted medical interventions. Although men aged 50 to 70 years will potentially benefit the most from PSA screening, this benefit will not be realized until these men are in their seventh and eighth decades of life. Society must decide if the years of life saved in these men warrants the use of its limited health care resources. This decision will be easier when randomized, controlled trials are available to quantify the costs and benefits of PSA screening.

Best treatment in early prostate cancer - do nothing

Best treatment in early prostate cancer - do nothing

Conformal static field radiation therapy treatment of early prostate cancer versus non-conformal techniques: A reduction in acute morbidity

Patients with early prostate cancer have been definitively treated using our previously described technique of CTbased 3D treatment planning and beam's eye view techniques with patients immobilized in alpha cradle casts. An average of 14% bladder (range 6–31%) and 14% rectal (range 7–25%) volume receiving a given dose was eliminated using four conformally blocked fields, with a 1.5 cm margin around the prostate contour, when compared to stage matched controls. Treatment-related acute morbidity was compared for 26 patients treated by the conformal techniques (CG) since April 1989 and 20 consecutive patients treated immediately prior to the conformal techniques with prostate only fields from May 1985-March 1989 (NCG). Acute urinary symptoms (frequency, dysuria, hematuria) or acute rectal symptoms (diarrhea, tenesmus, blood) occurred in 77% ( 20 26 ) of the CG versus 80% ( 16 20 ) of the NCG patients. Only 31% ( 8 26 ) of the CG versus 60% ( 12 20 ) of the NCG patients ( p < .05) experienced symptoms to a degree which prompted physician intervention (medication and/or interruption of treatment). Two of 26 CG patients (8%) required medication for both bladder and rectal symptoms compared to 5 20 (25%) NCG patients ( p = .09). Symptoms persisted for an average of 2.5 weeks versus 3.5 weeks in the CG and NCG groups, respectively. Persistent symptoms at or beyond the 1 month follow-up were present in 3 26 (11%) CG patients (average duration 1.5 months) and were present in 4 20 (20%) of the NCG patients (average duration 2.5 months). Thus, although the percentage of patients who experience acute irritation of the bladder and/or rectum is similar in the two groups, it appears that the percentage requiring medication and/or interruption of treatment is significantly less when 313 treatment planning, rigid immobilization, and conformal blocks are used. The amount of bladder and rectal tissue that is eliminated by our conformal technique is important as shown clinically by the lesser severity and shorter duration of acute symptomatology.

Decreased acute morbidity with conformal static field radiation therapy treatment of early prostate cancer as compared to non-conformal techniques

Decreased acute morbidity with conformal static field radiation therapy treatment of early prostate cancer as compared to non-conformal techniques

What is the Optimal Treatment for Early Prostatic Cancer? Summary of the Discussion

There was agreement at the end that prospective studies are necessary to solve the problems touched upon in this panel discussion. Screening studies and studies of the cancer cases detected as a result of such studies could be useful in this respect and treatment studies could be organized in this conjunction. There is little doubt that both radical prostatectomy and radiotherapy can cure some patients. Excellent local control is achieved especially with radical prostatectomy. the side-effects of radiotherapy and radical prostatectomy have decreased during recent years due to improvement of treatment techniques. Further improvment, however, seems to be necessary to justify a purely palliative use of these methods. It was also suggested that the risk of these treatment modalities in the future might become so low that the question of treatment or no treatment of early prostate cancer may become irrelevant.

Treatment of early prostate cancer.

For the treatment of locally advanced prostate cancer, agents that induce androgen deprivation might be given several months prior to radical prostatectomy with the hope of reducing the size and extent of tumour prior to surgery.