– 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.

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.

Upgrading after radical prostatectomy

UroToday – Prostate Cancer Volume at Biopsy Predicts Clinically Significant Upgrading – Abstract

Preoperative prostate specific antigen greater than 5.0 ng/ml (p = 0.036), prostate weight 60 gm or less (p = 0.004) and more cancer volume at biopsy, defined by cancer involving greater than 5% of the biopsy tissue (p = 0.002), greater than 1 biopsy core (p < 0.001) or greater than 10% of any core (p = 0.014), were associated with pathological upgrading. Upgraded patients were more likely to have extraprostatic extension and positive surgical margins at radical prostatectomy (p < 0.001 and 0.001, respectively).

This study gives some preoperative parameters that may be suggestive of a hogher gleason score after surgery. When prostates are removed, they are analyzed in more detail and a more accurate gleason score is obtained. In my series about 1/3 of gleason 6 prostate cancers are upgraded. I have noticed that tumor volume is related to upgrading similar to these authors.

IMRT external beam radiation review

UroToday – Current Status of Intensity-Modulated Radiation Therapy (IMRT)

In the International Journal of Clinical Oncology, Dr. Hatano and colleagues from Chiba, Japan provide an excellent overview of intensity-modulated radiation therapy (IMRT). Problems with conventional, four field radiotherapy have been ineffective dose distribution and overdoses to organs at risk (OARs), such as the bladder and rectum. The use of dose escalation from 64Gy to 81Gy improves tumor response but increases toxicity. Three-dimensional conformal radiotherapy (3D-CRT) is a technique to increase dose while conforming the beam to the target organ but still has toxicity limitations. IMRT has been introduced for dose escalation with the goal of minimizing toxicity to the bladder and rectum. In fact, IMRT is an advanced form of 3D-CRT where there is enhanced control over the 3D-CRT dose distribution through the superposition of a large number of independent segmented fields either from a number of fixed directions or from directions distributed on one or multiple arcs. IMRT therefore, requires dose specifications for both the target and the surrounding normal structures.

An explanation of image guided radiation and some of its side effects. There is a new quality marker made by the government that suggests that image guided therapy is preferred over conventional radiation.

Sex After Robotic Prostatectomy: Penile Rehabilitation

I have previously written about sexual function and how it changes after prostate cancer surgery.

As men are being diagnosed with prostate cancer at a younger age and at an earlier stage, the preservation of erectile function and the ability to maintain satisfactory erections has become more important. My partners and I offer a variety of options to assist in the recovery of erections including having a vacuum device specialist come in to the office once a month, teaching patients how to give penile injections and intra-urethral suppositories, and prescribing viagra, levitra, and cialis on a maintenance, preventative basis.

One of the most frustrating things is insurance companies not paying for maintenance medicines even though most urologists feel these medicines help erections return sooner and possibly more fully. There was an excellent review of the literature by Dr. McCullough of NYU that I read this weekend. He is one of the world’s authorities on erectile dysfunction.

This is a great source of information for urologists who can receive 1.5 CME credits.
I will start giving this link out to patients with a letter to see if it helps get them at least partial payment from insurance companies.
I hope patients report any positive experiences with insurance companies paying for their PDE5 inhibitors after surgery.

I have been personally prescribing 1/2 of a pill of the maximum strength to be taken on Mon, Wed, and Friday evenings.

Excellent review of HIFU in contemporary urology

HIFU for prostate cancer – For more than a decade, HIFU has been investigated as a less invasive alternative to surgical treatment in men with localized prostate cancer. A growing and maturing body of research suggests that HIFU is a safe and efficacious option for several subgroups of patients. – Contemporary Urology

HIFU for prostate cancer
For more than a decade, HIFU has been investigated as a less invasive alternative to surgical treatment in men with localized prostate cancer. A growing and maturing body of research suggests that HIFU is a safe and efficacious option for several subgroups of patients.

I am still skeptical of long term cancer cures of HIFU for prostate cancer, but I expect it to be in the USA in the next 2-3 years. Reading the article shows that there have been advances since I was involved with HIFU research 6 years ago at Indiana University.
This was a good review of the current technology and side effects and early outcomes.
Important negatives that the article point out are the difficulty in treating large prostates. They recommend treating the prostate before HIFU hormones (which have side effects of hot flashes, mood swings, etc.), a TURP (which can be very bloody in large prostates, or treatment with 2 rounds of HIFU. This last option is most attractive in my opinion if you have a large prostate and elect to have HIFU.
The other negative is the use of a foley catheter (2-7 days) which is similar to my catheter length after dvP. Patients also need a suprapubic catheter which is not needed with dvP.
My last issue is the suggestion that a negative biopsy is similar to a cure. A biopsy will only sample a small part of the prostate and longer followup will be needed to see how many cancer cells will not be destroyed and lead to clinical failures.

Swiss study shows survival advantage for surgery over radiation therapy for prostate cancer

Prostate Cancer: Surgery Best Option?

Men who choose surgery for early prostate cancer are more likely to be alive 10 years later than men who opt for other treatments, a Swiss study shows.
“If you look not only at this study but at the studies we brought out in the last three or four years, in terms of survival for 10 or even 15 years, there is a distinct advantage in patients who underwent surgery for localized prostate cancer,” Tewari tells WebMD. “This has implications for patients comparing different treatment options.”

HIFU study for prostate cancer

UroToday – High Intensity Focused Ultrasound Therapy for Clinically Localized Prostate Cancer: Efficacy and Morbidity of the Minimally Invasive Procedure
I am not personally that impressed with HIFU from what I have been reading and from my research at Indiana.
This series shows a relatively high failure rate of almost 30% and over 30% of patients having trouble with erections even though 23% of patients needed re-treatment.
My other main concern is how patients will fo after failing and needing surgery, which will be more complicated and have more side effects than primary surgery.

1 2 3 4