Statins During Radiotherapy for High-Risk Prostate Cancer Improve Outcomes – Renal and Urology News

Statins During Radiotherapy for High-Risk Prostate Cancer Improve Outcomes

via Statins During Radiotherapy for High-Risk Prostate Cancer Improve Outcomes – Renal and Urology News.

Statins are medicines that are taken to lower cholesterol.  Many studies have shown they are beneficial in preventing heart disease and many diseases.  Some experts believe that these medicines help prevent prostate  cancer and this study shows that patients with HIGH risk prostate cancer receiving radiation therapy had a better result when they were on statins.

 

The Prognostic Impact of Seminal Vesicle Involvement Found at Prostatectomy and the Effects of Adjuvant Radiation

Source: Urotoday

Patients with seminal vesicle positive disease who received adjuvant radiation compared to observation realized an improvement in 10-year biochemical failure-free survival from 12% to 36% (p = 0.001), in 10-year overall survival from 51% to 71% (p = 0.08) and in metastasis-free survival from 47% to 66% (p = 0.09), respectively.

Although seminal vesicle involvement is a negative prognostic factor, long-term control is possible especially if patients are given adjuvant radiation therapy. This therapy appears to be effective in patients with seminal vesicle involvement.


This one study showed an advantage of giving patients radiation if they had cancer in the seminal vesicles at the time of radical prostatectomy. Many factors need to be addressed in determining if radiation is necessary after surgery.

MedWire News – Prostate Cancer – Endocrine and radiotherapy ‘standard care’ for locally advanced prostate cancer

Source Medwire News

Adding local radiotherapy to endocrine treatment halves the 10-year prostate cancer-specific mortality in patients with locally advanced or high-risk local prostate cancer compared with endocrine treatment alone, researchers report.
“In the light of these data, endocrine treatment plus radiotherapy should be the new standard,” Anders Widmark (Umeå University, Sweden) and team write in The Lancet.

This study looked at 875 patients with locally advanced prostate cancer (T3; 78%; PSA<70; N0; M0) without evidence of distant spread. These men were from multiple centers in Norway, Sweden, and Denmark. In this set of patients, adding radiation helped men live longer compared to hormonal therapy alone.

The only difference in my practice, and in many centers in the US is that we sometimes perform surgery for these patients as well. The other difference is that these patients were given continuous endocrine treatment using flutamide, which is not as effective as other hormonal therapy regimens that we usually use (gonadotropin-releasing hormone (GnRH) agonists).

Medical News: ASTRO: Proton Radiation Fails to Impress in Prostate Cancer Study – in Meeting Coverage, ASTRO

Source: Med page today

Proton radiation for early prostate cancer had an acceptable tolerability profile but produced little evidence of a “gee whiz” impact to support its cost, according to preliminary results from a phase I/II clinical trial.
Two-thirds of patients had acute genitourinary or gastrointestinal toxicity, and a third had late GU/GI toxicity, Anthony Zietman, M.D., of Harvard and Massachusetts General Hospital, reported at the American Society for Therapeutic Radiology and Oncology meeting.
Although most of the toxicity was grade 2 in severity, the overall profile provided little reason for enthusiasm.
“The bottom line is that the treatment was safe, it was reasonably well tolerated, but probably no better tolerated than any other form of radiation that we give,” Dr. Zietman said.

According to this study, the less available and much more expensive proton radiation therapy for prostate cancer is not much different than traditional radiation.

Prostate Cancer-Specific Survival Following Salvage Radiotherapy vs Observation in Men With Biochemical Recurrence After Radical Prostatectomy: Abstract

Source: JAMA
Prostate Cancer-Specific Survival Following Salvage Radiotherapy vs Observation in Men With Biochemical Recurrence After Radical Prostatectomy
Bruce J. Trock, PhD; Misop Han, MD; Stephen J. Freedland, MD; Elizabeth B. Humphreys, MS; Theodore L. DeWeese, MD; Alan W. Partin, MD, PhD; Patrick C. Walsh, MD
JAMA. 2008;299(23):2760-2769.

Context Biochemical disease recurrence after radical prostatectomy often prompts salvage radiotherapy, but no studies to date have had sufficient numbers of patients or follow-up to determine whether radiotherapy improves survival, and if so, the subgroup of men most likely to benefit.
Objectives To quantify the relative improvement in prostate cancer-specific survival of salvage radiotherapy vs no therapy after biochemical recurrence following prostatectomy, and to identify subgroups for whom salvage treatment is most beneficial.
Design, Setting, and Patients Retrospective analysis of a cohort of 635 US men undergoing prostatectomy from 1982-2004, followed up through December 28, 2007, who experienced biochemical and/or local recurrence and received no salvage treatment (n = 397), salvage radiotherapy alone (n = 160), or salvage radiotherapy combined with hormonal therapy (n = 78).
Main Outcome Measure Prostate cancer-specific survival defined from time of recurrence until death from disease.
Results With a median follow-up of 6 years after recurrence and 9 years after prostatectomy, 116 men (18%) died from prostate cancer, including 89 (22%) who received no salvage treatment, 18 (11%) who received salvage radiotherapy alone, and 9 (12%) who received salvage radiotherapy and hormonal therapy. Salvage radiotherapy alone was associated with a significant 3-fold increase in prostate cancer-specific survival relative to those who received no salvage treatment (hazard ratio [HR], 0.32 [95% confidence interval {CI}, 0.19-0.54]; P<.001). Addition of hormonal therapy to salvage radiotherapy was not associated with any additional increase in prostate cancer-specific survival (HR, 0.34 [95% CI, 0.17-0.69]; P = .003). The increase in prostate cancer-specific survival associated with salvage radiotherapy was limited to men with a prostate-specific antigen doubling time of less than 6 months and remained after adjustment for pathological stage and other established prognostic factors. Salvage radiotherapy initiated more than 2 years after recurrence provided no significant increase in prostate cancer-specific survival. Men whose prostate-specific antigen level never became undetectable after salvage radiotherapy did not experience a significant increase in prostate cancer-specific survival. Salvage radiotherapy also was associated with a significant increase in overall survival.
Conclusions Salvage radiotherapy administered within 2 years of biochemical recurrence was associated with a significant increase in prostate cancer-specific survival among men with a prostate-specific antigen doubling time of less than 6 months, independent of other prognostic features such as pathological stage or Gleason score. These preliminary findings should be validated in other settings, and ultimately, in a randomized controlled trial.

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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.

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.”

Salvage radiation after prostate cancer surgery

UroToday – Predicting the Outcome of Salvage Radiation Therapy for Recurrent Prostate Cancer after Radical Prostatectomy

This retrospective study with a large cohort of patients treated with salvage radiotherapy after prostatectomy suggests that up to 50% of patients may remain free of disease 6 years after treatment if it is instituted before their serum PSA rises above 0.5 ng/ml. The nomogram proposed predicts with reasonable accuracy which patients are more likely to exhibit a favorable response to salvage radiotherapy and may aid in clinical decision-making.

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Hormonal therapy with radiation for prostate cancer

UroToday – Phase II Study of Neoadjuvant Androgen Deprivation Followed by External-Beam Radiotherapy With 9 Months of Androgen Deprivation for Intermediate- to High-Risk Localized Prostate Cancer

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Testosterone returned to normal in 69% of patients with a median time to recovery of 9 months. Testosterone returned to it baseline level after ADT in 37% with a median recovery time of 11 months. Patients who recovered testosterone to normal levels after ADT were not more likely to fail BDFS or CDFS at 5 years. Due to the small numbers of deaths, cause of death analysis was limited but there was no difference in cause of death between those who did and did not recover testosterone to normal levels. The majority of patients lost potency during treatment, but up to 65% recovered some potency 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.

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