UroToday – Percent Tumor Involvement and Risk of Biochemical Progression After Radical Prostatectomy

From UroToday:

We examined the association between percent tumor involvement in the radical prostatectomy specimen and the outcome measures of pathological stage and biochemical progression using multivariate logistic regression and Cox proportional hazards analysis, respectively, in 2,220 patients from the Duke Prostate Center radical prostatectomy database.

This was a study that showed that if you had more cancer in the prostate, you had a higher risk of the cancer coming back after surgery. Although this is obvious, it is important to show these type of things with studies.

Would I would like to see is if patients with the same gleason score and stage (meaning the extent of cancer spread) have different rates of recurrences.

For example, 2 men with organ confined prostate cancer that both have gleason 6 cancers. If 1 man has 1% of tumor volume in his prostate and the other 30%, I would imagine the man with 30% would be more likely to have a recurrence. I am not aware of any studies that have looked at this.

Determinants of Long-Term Retention of Prostate Cancer Patients in Active Surveillance Management Programs

From Urotoday and the AUA

Of the 2134 PCa cases, 169 (7.9%) had AS as their initial management. Of the 169 AS cases, 89 (53%) remained untreated throughout follow-up (mean 7.1 years) and the remaining 47% received treatment an average of 3.1 years post-diagnosis. Significant predictors of eventual active treatment in multivariate models included younger age at diagnosis (60-69 vs. 70+ years), higher Gleason score (>6 vs. <6), and higher prostate cancer aggressiveness/risk. The researchers observed similar rates for development of clinical metastases and PCa death in both AS and immediate treatment groups, respectively (metastases: N=8 and N=92, 6.5 vs. 6.7 events per 1,000 person-years, p=1.0; PCa death: N=4 and N=51, 2.4 vs. 2.7 deaths per 1,000 person-yrs, p=1.0).

This one study shows that men that did active surveillance, needed therapy about half of the time. The results seemed similar for both groups. My main concern is that we do not know the cancer characteristics of the patients. It is possible that the active surveillance patients had less cancer than the treated patients and should have done better.
I also think that waiting 3 years to treat someone may later the treatment approach and possibly lead to more side effects after therapy.

Vitamin D doesn’t cut prostate cancer risk

Source Reuters

U.S. National Cancer Institute researchers set out to see if vitamin D might protect against prostate cancer, the second most frequently diagnosed cancer in men worldwide. They tracked vitamin D concentrations in the blood of 749 men diagnosed with prostate cancer and 781 men who did not have the disease.
They found no association between higher levels of the vitamin and a reduced prostate cancer risk. The findings hinted at a possible increased risk for aggressive prostate cancer in men with higher blood concentration of vitamin D, but this link was not statistically significant, the researchers said.

This one study did not reveal any benefit from Vitamin D. There have been others that do show a benefit. This is why it is important to continue to do studies and use scientific method to assess things.

I ask patients to take a multivitamin a day, but not extra Vitamin D.

Surgical experience affects prostate cancer control ‘regardless of risk’

From MedWire News – Oncology –

Prostate cancer control after radical prostatectomy improves with increasing surgeon experience, regardless of patients’ risk, say US scientists who suggest that the primary reason for recurrence in low-risk patients is inadequate surgical technique.
The team, led by Eric Klein from the Cleveland Clinic in Ohio, previously discovered that open radical prostatectomy has a learning curve, and other studies have indicated that patients treated by higher-volume surgeons have shorter hospital stays, fewer peri-operative complications, and better urinary continence than those treated by lower-volume surgeons.

This study was done for open radical prostatectomy patients.
My guess is that we will have similar results for robotic surgeons, but I think novice robotic surgeons that have vast experience with laparoscopic or open prostate cancer surgery will have better results than those who do not.

Median Lobe in Robot-Assisted Radical Prostatectomy: Evaluation and Management

UroToday –

The surgical margins were similar between the two groups. No significant difference was found in the postoperative urinary bother score or the interval to social or perfect continence between the two groups.

The results of this study have shown that the presence of a median lobe does not alter the outcomes in patients who undergo robot-assisted prostatectomy.

The median lobe can be a scary finding for the novice robotic surgeon. My team at NBI has developed several techniques to handle median lobes while preserving as much bladder as possible. Below is a video showing one of our techniques:

I have changed by preoperative management to include a cystoscopy about 1 year ago on all patients to assess for prostate shape. I can now predict these in all patients.

I am a little surprised that these patients did not have differences except more needed bladder neck repairs. I think these patients are more likely to have bladder symptoms since most have obstruction and over active bladders to start with. In my series, they usually get their catheters out in 5 days instead of 3, and I warn them of expecting more urinary problems in the short term than others.

– Oncology – High saturated fat diet linked to postop biochemical failure

From MedWire News

Among prostatectomy patients, those with diets high in high saturated fat (HSF) are almost twice as likely to experience biochemical failure as those who consume a low saturated fat (LSF) diet, say US scientists.
Several studies have indicated that obesity is associated with an increased risk of biochemical failure after treatment with radical prostatectomy or external beam radiation for localized prostate cancer.

Patients at risk of prostate cancer and thosewith prostate cancer should reduce their fat intake.

Active Surveillance for Prostate Cancer Patients

From Medscape

May 12, 2008 — The urine test for the PCA3 gene, already marketed for use in diagnosing prostate cancer, could also be useful in prognostication. It might have clinical application in selecting men with low-grade and low-volume tumors who would be suitable candidates for active surveillance, say researchers writing in the May issue of the Journal of Urology.
The PCA3 urine test, marketed in Europe by Gen-Probe, has been shown in previous studies to be more accurate in diagnosing early prostate cancer than serum levels of prostate-specific antigen (PSA).

I usually use the PCA 3 test for men who have had a negative biopsy and we are considering performing a second one. I usualy use it for men with high grade PIN after one biopsy. If the PCA 3 is positive, I usually perform a second biopsy. I have not looked at my data to see if the above correlation exists, but that would be interesting.
I also am not sure if you can use PCA 3 tests that are taken a few months apart to mean anything. For example, would a rise in PCA 3 be expected if a man develops cancer or the cancer is growing?

Newer Prostate Cancer Treatment Similar to Traditional Surgery

From Washington Post.com

“This reaffirms what many other manuscripts have shown, if you go to an individual who has experience, who does this on a consistent basis, your outcomes will be better,” said Dr. Ihor S. Sawczuk, chief of urologic oncology for the Cancer Center at Hackensack University Medical Center, in New Jersey. “If you go to someone who does 20 to 50 procedures a year, that’s better than somebody who only does two to three a year.

I agree with Dr. Sawczuk, a friend and colleague, that more experienced surgeons are more likely to have better results. The surgeon is important, probably more so than the technique. I think the best way to analyze this would have been to set up a study looking at high volume robotic vs. lap vs. open surgeons and having a 3rd party analyze the results. I do not think this is something that would ever be done.

My feeling after performing many open prostate cancer surgeries, a few laparoscopic ones, and over 400 robotic ones is that robotics gives me the ability to perform more accurate surgery, and the difference is more pronounced with more difficult cases.
Being able to remove the catheter within 3 days routinely without needing X-Rays would be difficult for me to achieve with open or laparoscopic surgery.

Biomarker predicts malignancy potential of prostate lesions –

From Urology Times

Spanish researchers have found a means of distinguishing between high-grade prostatic intraepithelial neoplasia (HGPIN) lesions destined to become cancerous and those that will remain benign, which may spare patients the discomfort and inconvenience of unnecessary needle biopsies, according to a study in Clinical Cancer Research (2008; 14:2617-22).

This is the first studay that I am familiar with that has a genetic marker for patients with diagnosis of high grade PIN. High grade PIN was once thought to be higly associated with prostate cancer (about 50%) and warranted a repeat biopsy. This was when urologists performed 6 biopsies routinely.

Now that we are performing at least 10, the finding is not as ominous as before. About 20% of pateints will develop cancer.

A Step Backward: The ACPM Recommendations on Prostate Cancer Screening

Medscape article summarizing PSA recommendations:
The most aggressive screening protocol is from the NCCN.

NCCN guidelines start from the premise that the patient has made a decision to seek early prostate cancer detection. They recommend beginning screening at age 40. The baseline PSA level, race, and family history are then used to determine the subsequent screening intervals. They recommend considering a biopsy for men with a total PSA level > 2.5 ng/mL, after further consideration of the PSA velocity, PSA density, and percent free PSA. They explain how these parameters can be used to lessen the possibility of confounding from benign prostatic hyperplasia. Furthermore, they describe how repeating PSA determinations with or without a trial of antibiotic therapy, as well as consideration of variability between different PSA assays, can reduce the likelihood of confounding from prostatitis or differences in PSA assay standardization. Moreover, they provide advice about whether or not repeat biopsies are needed and how to deal with the findings of high-grade prostatic intraepithelial neoplasia or atypical glands suspicious for carcinoma on an initial biopsy.

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