Results of a large cryosurgery trial

UroToday – Outcomes of Cryotherapy for Prostate Cancer

beige_quote.bmpThe mean follow-up was 20 months. A total of 4% of patients who were continent pre-procedure were incontinent after therapy. A total of 39% of patients reported being potent pre-treatment and all men were impotent immediately after cryotherapy. The probability for a man potent prior to treatment to regain his ability to have intercourse with or without PDE-5 inhibitor assistance at 1, 2, and 4 years was 29%, 49%, and 51%, respectively. Nearly 80% of men achieved a PSA nadir of less than 0.4ng/mlwith a 4-year biochemical freedom from disease rate of 80%. In those experiencing disease failures, the mean time to failure was 4.2 months. Of 168 patients who underwent a prostate biopsy, 10% had CaP at a mean of 10 months after treatment.

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Prostate cancer options now on google documents.

My prostate cancer counseling sheet.  This is meant to give an idea of
the major forms of prostate cancer therapy and are the main one I focus on at a
consultation for newly diagnosed prostate cancer.  This should only be used
under the supervision of a urologist.
A printable form can be
found online
.

This was my first venture into google documents and my original experience was extremely positive. My counselling sheet changes periodically based on new treatments or side effects that I want to add. This will be extremely easy to edit without the need for an editor on the computer and can be done anywhere. I will likely place most of my instruction sheets on google documents. It also makes an easy to print out document for patients and has an internal PDF creator built into the online google editor.

Age

Gleason

Amount of cancer

Size of Prostate (urinary
symptoms)

PSA

Bone Scan

CT Scan:

Overview: Reviewed options of
watchful waiting, radiation (brachytherapy, external beam, combination
brachytherapy and external beam), cryotherapy, hormonal therapy and
surgery.

Watchful waiting.
Usually inadvisable in an otherwise healthy man with a greater than 10
year life expectancy. Prostate cancer that is found early and has a low
Gleason (2-6) may grow slowly and may be monitored rather than treated.

Advantages- No
side effects from therapy.

Disadvantages-
Cancer eventually may spread and be incurable.

Hormonal therapy.
Prostate cells need testosterone to maintain themselves. Removing a man’s
testosterone may slow down the growth of prostate cancer cells. Usually
inappropriate for long term therapy of localized disease. There is
evidence that the cancer can spread even during long term hormonal
therapy. Hormonal therapy is not curative. Hormonal therapy may be
given prior to radiation.

Disadvantages-
Hot flashes, osteoporosis, etc.

Radiation: High energy
x-rays are used to kill cancer cells.

Brachytherapy.

Procedure: Performed as
outpatient, under anesthesia. Places radioactive seeds into the prostate
to burnout the cancer from within.

Concerns: Seeds may migrate
during placement leading to over or under treatment of certain areas of
the prostate (and cancer). Therefore, as a sole modality, may be less
effective than external beam or combination radiation therapy.

Side effects: Radiation
cystitis and proctitis (probably will be worse than other forms of
radiation); erectile dysfunction (may be less so than external beam or
combination radiation therapy).

Advantages:
Short duration of therapy. Few side effects up front if the prostate is
small.

Disadvantages:
Least effective treatment,. Side effects can occur even years after
therapy and may be underappreciated by some radiation oncologists.
Bladder outlet obstruction can occur and be difficult to treat,
especially if the prostate is enlarges.

MAY NEED OTHER
FORMS OF THERAPY TO SHRINK THE PROSTATE.

External Beam:

Procedure: Cast is made of
the body. Radiation is applied to the prostate through many ports,
5d/week for 7-8 weeks. Each session lasts about 20 minutes.

Side effects: Radiation
cystitis, proctitis, and erectile dysfunction.

Advantages-
Cure rates similar to surgery at 10-15 years with hormones added

Disadvantages-
Daily therapy for 2 months causes a systemic effect. Side effects can
happen later. Radiation effect in long term is unknown- new study shows
a 70% higher rate of rectal cancer after XRT.


Combination External
Beam and Brachytherapy

Combination of above, but
external beam will only last about 5 weeks. Same Side effect profile and
cure rate as external beam alone.

Surgery:

Procedure involves removal of
the entire prostate and seminal vesicles. The goal of this procedure is
to completely remove the cancer while it is contained within the
prostate. Surgery is typically about 3 hours long, and is considered
major surgery. Average blood loss is 2 units, but may be higher.
Patients are usually asked to bank blood for themselves prior to surgery
(“autologous blood”). Average hospital stay is about 3 days. A catheter
remains in the bladder for about 1-2 weeks. Back to work is usually no
sooner than 1 month after surgery.

Small risks of injury to
rectum or ureters, blood vessels, nerves.

Side effects: Incontinence,
usually lasting a few months. Erectile dysfunction.

Advantages: We
can more accurately predict your prognosis. Best long term cure rates.
Least amount of bladder outlet obstruction.

Disadvantages:
Major surgery with blood loss and recovery.

Robotic Prostatectomy:

The Robotic Radical
Prostatectomy represents a quantum leap forward in prostate cancer
surgery. The da Vinci Surgical System enables urologic surgeons to
perform a radical prostatectomy with similar, or improved technique when
compared to the standard open
procedure, while maintaining all the advantages of minimally invasive
surgery.

The robot controls tiny
jointed instruments, which can move at the tip like the human hand.
Unlike conventional laparoscopy and its two dimensional image, the da
Vinci camera has two lenses that combine to provide the surgeon a true
3-D image with 10x magnification. Also, any position or movement of the
surgeon’s hands is enhanced with scaling and tremor reduction and is
mirrored in real time.

Advantages of the
minimally invasive procedure may include reduced pain, scarring, risk of
infection, and less operative blood loss. Additionally, these
benefits have translated into shorter hospital stays, faster
recovery times
, and a quicker return to employment and recreational
activities.

The robotic radical
prostatectomy can be performed with minimal blood loss and patients are
no longer advised to donate blood for their operation. Patients
typically go home after one night and can return to work within one to
two weeks. The urinary catheter remains in place for approximately six
days and continence is achieved more quickly and completely than with
the other surgical techniques. Erectile function is regained more
quickly and with greater frequency.

Advantages:
Best therapy available with least amount of side effects overall in
experienced hands.

Disadvantages:
Blood loss is still possible, as are other side effects of surgery.
Surgery can be longer than open for inexperienced surgeons.

Requires a
general anesthetic.

Learning curve
is longer than open surgery.

Cryosurgery: Involves
the use of liquid nitrogen to freeze and destroy cancer cells. Its main
use currently is for the control of local disease if primary therapy is
unsuccessful. Long term results using current technology are still not
known.

HIFU:

Similar to cryosurgery except
we are heating up the prostate with a focused ultrasound probe instead of
icing the prostate.

Advantages:
Probably least amount of side effects overall.

Disadvantages: It
is currently experimental in the US and available in Canada and Europe.

The worst cure
rates at the current time.

Cryosurgery better than watchful waiting for elderly?

Straightfromthedoc: JAMA Study Confirms Prostate Cancer Treatment is Preferable over “Watchful Waiting”
According to Endocare President, Chairman and CEO Craig T. Davenport:
“This study offers further scientific evidence that ‘watchful waiting’ may not be the best option for many patients, particularly when there are effective, minimally invasive treatments like cryoablation available. Based on the results of the study, ‘watchful waiting’ patients should consider some kind of treatment.
We believe cryoablation is an excellent option for many patients given its proven, long-term cancer control rate, low morbidity, and typically fast recovery time. Additionally, we believe cryoablation is a particularly good option for ‘watchful waiting’ patients who are not able to tolerate surgery or radiation, or for men with very small amounts of cancer in their prostate.”
Straight from the doc reported on a press release from endocare, a company that is a leader in cryosurgery.
I am a supporter of cryosurgery and discuss it as an option for all prostate cancer patients, but I thought that some of the conclusions were not supported by the paper.
The JAMA article that I have previously discussed only looked at surgery and radiation, bot cryosurgery. The press release did not state this.
Elderly men with very small tumors are candidates for watchful waiting and cryosurgery is not without side effects.

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