Simpler Prostate Cancer Grading System Proposed

Tumors fall into 1 of 5 grade groups based on what pathologic findings indicate about prognosis.

Source: Simpler Prostate Cancer Grading System Proposed

I have been counseling men with prostate cancer on their treatment options for many years.  One of the most difficult parts of diagnosing prostate cancer is explaining to the patient and family what his “cancer” means.  I have started with the most important prognostic factors of gleason score and PSA to explain how their prostate cancer is compared to other men.

I’ve explained how the cancer scoring system goes from gleason 2 to 10, but really the least aggressive cancers have a gleason score of 6.  There have been less than a handful of patients that have been diagnosed with a score of 5 in my career.  For the thousands of men that I have counseled, I used to translate their gleason score from 1-4 with a 6 translating to a 1 and a 7 to either a 2 or 3.  Fortunately the urology field is adapting a similar scoring system.

The new grading system simplifies the scoring to a scale of 1-5, with 1 being the least aggressive and 5 the most aggressive.  The old gleason 7 was made of of 2 types, a less aggressive 3+4 and a more aggressive 4+3.  This should help men and their loved ones better understand the type of prostate cancer they have.

Surgery improves survival rates for men with prostate cancer if radiation treatments fail

Approximately 14 percent of men will be diagnosed with prostate cancer at some point in their lifetimes, according to the National Institutes of Health. Radiation therapy traditionally has been a primary treatment for the cancer, but one-fourth of men have a recurrence of prostate cancer within five years after the therapy. Now, a University of Missouri School of Medicine researcher has found that a complex procedure to remove the prostate achieves excellent long-term survival for men after radiation therapy has failed.

Source: Surgery improves survival rates for men with prostate cancer if radiation treatments fail

Men are often told that surgery can not be performed after radiation therapy.  This article shows how men can have surgery for prostate cancer after failed radiation therapy.

I have performed many davinci robotic prostatectomies after failed therapies.  Due to the effects of the radiation on the tissue surrounding the prostate, the risks of salvage surgery is much higher than surgery done as the original treatment.  The biggest change is that the risk of life long incontinence goes up significantly.

I have also performed salvage robotic prostate surgery for failed HIFU and cryosurgery patients.

Sexual function after prostate removal

I am frequently asked about the changes to fluid that comes out of the penis during sexual activity and about the ability to have children.

Many years ago I described the changes for men to expect after prostatectomy for cancer.

Normally the testicles make sperm that travels through the vas deferens to reach the prostate where it mixes with most of the fluid from the prostate to make the ejaculate.

male reproductive picture

If you have a vasectomy, the vas defers is clipped so that sperm can not enter the prostate area and you become sterile.  The amount of ejaculate during sexual activity remains the same.

With prostate removal, the ejaculate which is made from fluid from the prostate and seminal vesicles is also missing.  Men can have an orgasm, but there will be no fluid that comes out with the orgasm as normal.

There may be a small amount of fluid that is thick that comes out during the excitement phase as before.

Some men also experience leakage of urine that comes from the bladder during the excitement or orgasm stage of sexual activity.

Surgery Offers Prostate Cancer Patients Better Survival Odds

Prostate cancer patients with clinically localized tumors are more likely to die if they undergo radiotherapy rather than radical prostatectomy.

Radiotherapy for clinically-localized prostate cancer (PCa) is associated with an increased risk of overall and PCa-specific mortality compared with radical prostatectomy, according to a new systematic review and meta-analysis.

Dr. Nam’s group stated that, to their knowledge, their study represents the most comprehensive and up-to-date review of the literature comparing survival outcomes associated with radiotherapy and surgery.

Source: Surgery Offers Prostate Cancer Patients Better Survival Odds

 

This issue is frequently asked by patients.  In the short run, surgery and radiation are both effective at controlling prostate cancer.  Over time, most studies have shown that prostate cancer surgery is more effective than radiation at curing cancer.

Exercise Training May Delay PCa Progression – Renal and Urology News

PSA doubling time, a marker of cancer progression, increased from 28 to 76 months in prostate cancer patients performing exercise training.

“The exercise intervention resulted in marked physiological adaptations that aided weight regulation and increased fitness levels,” Dr. Hojman told Renal & Urology News. “PSA doubling time correlated with improved fitness, but not with weight loss. These findings suggest there is a fitness component that plays a role in the control of prostate cancer that is not related to weight.”

Source: Exercise Training May Delay PCa Progression – Renal and Urology News

I have been recommending exercise for my prostate cancer patients for many years.  I usually recommend 30 minutes of aerobic exercise 3 times a week.  In this study, 45 minutes of exercise 3 times a week led to the PSA going up slowly for patients that had regular exercise.

U.S. Food and Drug Administration Approval Summary: Enzalutamide for the Treatment of Patients With Chemotherapy-Naïve Metastatic Castration-Resistant Prostate Cancer.

The U.S. Food and Drug Administration approved enzalutamide for the treatment of patients with chemotherapy-naïve metastatic castration-resistant prostate cancer (mCRPC). At the prespecified interim analysis, a statistically significant improvement in overall survival was demonstrated for patients

Source: U.S. Food and Drug Administration Approval Summary: Enzalutamide for the Treatment of Patients With Chemotherapy-Naïve Metastatic Castration-Resistant Prostate Cancer.

I have been using enzalutamide in my patients who have metastatic disease proven by imaging or pathology and have progressed where hormonal therapy isn’t enough to keep the PSA near 0.

Sexual Intercourse May Clear Distal Ureteral Stones

Having sex 3-4 times a week was associated with a significantly greater stone passage rate than tamsulosin or standard medical therapy.

Source: Sexual Intercourse May Clear Distal Ureteral Stones

This was an interesting study that compared men that had stones that they were trying to pass.  Some of the men were treated with flomax, which is commonly prescribed to help pass stones by allowing the ureter (kidney drainage tube) to relax and allow the stone more room to pass.  Other men were not given anything and some of the men had regular sexual intercourse.

The men that had regular sexual relations had the highest rate of passing stones.

I will start advising my patients to increase sexual activity when trying to pass stones based on this study.

Renal cell carcinoma growing into the renal pelvis and mimicking transitional cell carcinoma: A case report and literature review – Abstract

27 Jun 2015 Miscellaneous 5

Renal cell carcinoma growing into the renal pelvis and mimicking transitional cell carcinoma: A case report and literature review – Abstract.

My partner and I had a similar patient that presented with a large kidney tumor that was growing into the renal pelvis and ureter. We performed a ureteroscopy and the tumor appeared as a large bulge growing down the ureter that reminded me of renal cancer growing into the renal vein. A biopsy came back as benign urothelium.

On these rare cases, I have developed a protocol to perform a robotic radical nephrectomy and transect the ureter by stapling it. I obtain pathological analysis at the time of surgery, and if the diagnosis is transitional cell cancer, I proceed to remove the rest of the ureter and a bladder cuff with robotic surgery at the same time.

Study: MRI Missed 1 in 6 High-Grade Prostate Cancers

Study: MRI Missed 1 in 6 High-Grade Prostate Cancers.

The much ballyhooed multiparametric (mp) MRI does not appear to be suited as stand-alone test for diagnosing prostate cancer after an elevated PSA, according to new research.

The expensive and powerful technology failed to identify 16% of men with high-grade cancer (Gleason score ≥7) in a prospective study of 1044 men with an elevated PSA.

This study looked at patients who had negative MRI searching for prostate cancer. It found that the MRI missed almost half of all prostate cancers, but more importantly, missed 1 in 6 moderately aggressive cancers which are the ones that most need treatment.

I have been using MRI as a tool to help stratify the risk of prostate cancer, but I do not rely solely on the MRI results.

Mist worrisome to me is that at some place, radiologists are the only specialists trying to diagnose prostate cancer.

In my opinion, MRIs are useful, as our are radiology colleagues in helping to read the MRIs, but this should be done with the leadership of a urologist.

3D vs 2D laparoscopic radical prostatectomy in organ-confined prostate cancer: Comparison of operative data and pentafecta rates: A single cohort study – Abstract

3D vs 2D laparoscopic radical prostatectomy in organ-confined prostate cancer: Comparison of operative data and pentafecta rates: A single cohort study – Abstract.

This study shows one surgeons experience performing laparoscopic prostatectomy with 3d vision. There are headsets that doctors can wear to overcome the 2d limitation of conventional surgery. The 3d vision improved outcomes. This is an expected results since surgeons that can see better can perform more accurate surgery. Robotic surgery has the advantage of 3d vision, as well as allowing the surgeon to make more precise movements based on the dexterity of the waisted instruments.

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