Targeted-cryosurgical ablation of the prostate with androgen deprivation therapy： quality of life in high-risk prostate cancer patients

Aim:To present preliminary results on health-related quality of life(QoL),prostate-associated symptoms and thera-peutic effects of targeted-cryosurgical ablation of the prostate(TCSAP)with androgen deprivation therapy(ADT)inhigh-risk prostate cancer(PCa)patients.Methods:Thirty-four men with high-risk PCa features underwent TCSAP,and ADT was added to improve the treatment outcomes.High-risk parameters were defined as either prostate-specific antigen(PSA)≥10ng/mL,or Gleason score≥8,or both.The Genito-Urinary Group of the European Orga-nization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30(EORTC QLQ-C30)withprostate-cancer-specific module(QLQ-PR25)was used for evaluating morbidities and PSA levels were recordedevery 3 months.PSA failure was defined as the inability to reach a nadir of 0.4 ng/mL or less.Results:Although itwas not statistically significant,the global health status scores increased after TCSAP with ADT.The scores for fivefunctional scales also became higher after treatment.The most prominent symptom after treatment was sexualdysfunction,followed by treatment-related and irritative voiding symptoms.Conclusion:TCSAP with ADT appearsto be minimally invasive with high QoL except for sexual dysfunction.Long-term follow-up of PSA data and survivalis necessary before any conclusions can be made on the efficacy of this promising new therapeutic modality in thetreatment of PCa.(Asian J Androl 2006 Sep;8:629-636)     

Assessment of men’s risk thresholds to proceed with prostate biopsy for the early detection of prostate cancer

Purpose

To delineate the range of “risk thresholds” for prostate biopsy to determine how improved prostate cancer (CaP) risk prediction tools may impact shared decision-making (SDM).

Methods

We conducted a cross-sectional survey study involving men 45–75 years old attending a multispecialty urology clinic. Data included demographics, personal and family prostate cancer history, and prostate biopsy history. Respondents were presented with a summary of the details, risks, and benefits of prostate biopsy, then asked to indicate the specific risk threshold (% chance) of high-grade CaP at which they would proceed with prostate biopsy.

Results

Of a total of 103 respondents, 18 men (17%) had a personal history of CaP, and 31 (30%) had undergone prostate biopsy. The median risk threshold to proceed with prostate biopsy was 25% (interquartile range 10–50%). Risk thresholds did not vary by race, education, or employment. Personal history of CaP or prostate biopsy was significantly associated with lower mean risk thresholds (19% vs. 32% [P?=?0.02] and 23% vs. 33% [P?=?0.04], respectively). In the lowest versus highest risk threshold quartiles, there were significantly higher rates of CaP (36% vs. 1%, P?=?0.01) and prior prostate biopsy (46% vs. 17%, P?<?0.01).

Conclusions

Men have a wide range of risk thresholds for high-grade CaP to proceed with prostate biopsy. Men with a prior history of CaP or biopsy reported lower risk thresholds, which may reflect their greater concern for this disease. The extent to which refined risk prediction tools will improve SDM warrants further study.

     

Does cigarette smoking influence the survival of patients with prostate cancer?

In the last few years, prostate cancer has become one of the most common causes of mortality worldwide. It is therefore important to detect possible risk factors for this malignant disease. Besides risk factors which increase incidence, attention should be paid to factors which have a possible influence on the course of the disease. In our analysis, we demonstrate a worse course for the disease in patients with prostate cancer who smoked cigarettes at the time of first diagnosis. In spite of comparable staging, grading and PSA values at the time of primary diagnosis, individuals who smoked had a threefold higher risk of dying from prostate cancer. This effect is probably caused by metabolic changes which are activated by cigarette smoking and promote tumor growth and the development of metastases.     

Analysis of monotherapy prostate brachytherapy in patients with prostate cancer. Initial PSA and Gleason are important for recurrence?

Purpose

To evaluate the clinical outcome of a cohort of localized prostate cancer patients treate with 125-I permanent brachytherapy at the São José Hospital – CHLC, Lisbon.

Materials and Methods

A retrospective analysis was carried out on 429 patients with low and intermediate-risk of prostate adenocarcinoma, according to the recommendations of the EORTC, who underwent 125I brachytherapies in intraoperative dosimetry “real-time” system between September 2003 and September 2013.

Results

The mean follow-up was 71.98 months. Biochemical relapse of disease by rising PSA (Phoenix criterion) was observed in 18 patients (4.2%). Through the application of Kaplan-Meier survival curves in this sample, the rate of survival at 6 years without biochemical relapse was higher than 95%. By Iog rank test comparing biochemical relapse with initial PSA (15-10 and <10) and Gleason values (7 and <7), there was no statistical difference (P=0.830) of the initial PSA in the probability of developing biochemical relapse. In relation to Gleason score, it was noted a statistical difference (P<0.05), demonstrating that patients with Gleason 7 are more likely to develop biochemical relapse.

Conclusions

Brachytherapy as monotherapy is at present an effective choice in the treatment of localized prostate adenocarcinoma. Biochemical relapses are minimal. The initial PSA showed no statistically difference in the rate of relapses, unlike the value Gleason, where it was demonstrated that patients with Gleason 7 have a higher probability of biochemical relapse. Cases with PSA bounce should be controlled before starting a salvage treatment.     

Optimal management of prostate cancer with lethal biology – state-of-the-art local therapy

Defining prostate cancer with lethal biology based upon clinical criteria is challenging. Locally advanced/High-Grade prostate cancer can be downstaged or even downgraded with cure in up to 60% of patients with primary therapy.1,2,3,4,5 However, what is known is that high-grade prostate cancers have a greater potential for recurrence and progression to metastatic disease, which can ultimately result in a patient''s death. Patients with clinical features of “high-risk” prostate cancer (cT2c, PSA >20, ≥ Gl 8 on biopsy) are more likely to harbor more aggressive pathologic findings. The optimal management of high-risk prostate cancer is not known as there are not prospective studies comparing surgery to radiation therapy (RT). Retrospective and population-based studies are subject to many biases and attempts to compare surgery and radiation have demonstrated mixed results. Some show equivalent survival outcomes6 while others showing an advantage of surgery over RT.7,8,9,10,11 Local therapy for high-risk disease does appear to be beneficial. Improved outcomes realized with local therapy have been clearly demonstrated by several prospective studies evaluating androgen deprivation therapy (ADT) alone versus ADT plus RT. The combination of local with systemic treatment showed improved disease-specific and overall survival outcomes.12,13,14 Unfortunately, primary ADT for N0M0 prostate cancer is still inappropriately applied in general practice.11 While the surgical literature is largely retrospective, it too demonstrates that surgery in the setting of high-risk prostate cancer is effective in providing durable disease-specific and overall survivals.2,3,15Whether both treatment modalities provide equivalent results is yet to be determined. In fact, many patients may benefit from a multimodality approach potentially including surgical excision, followed by postoperative radiation with or without ADT. However; when initiating therapeutic strategies, there may be certain clinical scenarios where relevant clinical findings or patient history could direct a clinician toward an optimal therapy. These decisions are typically based on inherent risks, theoretical concerns or the preponderance of evidence surrounding a single aspect of the particular clinical scenario. The following are clinical scenarios where RT or surgery may be considered as the best initial treatment for primary therapy in cTxN0M0 prostate adenocarcinoma. While this is by no means meant to be a strict guide for application of therapy, it does call to attention considerations as to appropriate clinical decision-making.     

Which patients with prostate cancer are actually candidates for hormone therapy?

In this article, we will try to address the following aspects: which factors are responsible of the introduction of new candidates for hormone therapy in prostate cancer, who are actually candidates for hormone therapy, classifying them on the basis of the stage of the disease, and which treatment modalities can be proposed for each candidate. Since the introduction of hormone therapy for the treatment of prostate cancer, there has been a debate about the optimal timing of hormone therapy. A modification in the timing of hormone therapy produced new candidates for hormone manipulation. In particular, the use of hormone treatment for younger patients, longer periods and early prostate cancer, absolutely requires a whole re-evaluation of which therapy is indicated and it may produce new problems such as higher risk of over-treatment, need of a better evaluation of quality of life in younger patients and the research for better tolerated therapies. Therapies that resist for longer periods without the production of a hormone-refractory disease are also required.     

Does educational printed material manage to change compliance with prostate cancer screening?

BACKGROUND/AIM: The effects of printed educational material on cancer screening in women (Pap test and mammography) are well documented and confirmed by several studies. The aim of our study was to evaluate the impact of similar printed educational material on prostate cancer screening by PSA and DRE. MATERIAL AND METHODS: Thousand five hundred men aged between 50 and 86 years of age, who attended our institutions for various medical conditions except prostate-related conditions, were randomly assigned to two study groups. Men in the informed group, received an educational leaflet with simple, general information on prostate cancer screening methods given by their physician along with treatment and other regular recommendations, while men in the non-informed group, were only informed by their physician in the examination room during an interview. RESULTS: After 24 months, there was no statistically significant difference between the two groups in terms of DRE screening. The percentages of men who were actually screened by DRE were 4 and 5% in the informed and non-informed groups, respectively, while the difference in the percentages of PSA screening was of statistical significance, with 31% of men screened in the non-informed group as compared to 93% of men screened in the informational leaflet group. CONCLUSIONS: A single, one-shift distribution of printed educational material on prostate cancer screening, changed their attitude regarding prostate cancer screening only in favour of PSA testing, while did not manage to change the DRE acceptance behavior. However, since the combination of the two tests is more sensitive for diagnosis than either one alone, there is a need of introducing intervention strategies, in the efforts of ameliorating the prostate cancer screening behavior.