Der ältere Prostatakrebspatient

Introduction

Some data exist on information and decision-making preferences of elderly prostate cancer patients but little is known about whether communication needs are being met in urological practice. Therefore, it was the aim of this study to examine the information and shared decision-making experiences of prostate cancer patients over 75 years old.

Materials and methods

The HAROW (hormonal therapy, active surveillance, radiation, operation and watchful waiting) study is a prospective, observational study designed to collect clinical data and patient reported outcome of different treatment options for patients newly diagnosed with localized prostate cancer under real conditions. At 6-month intervals general clinical data, PROs (e.g. quality of life, quality of physician-patient interaction) and individual costs are documented. Data from 2,482 patients at 4 time points from T0 (initial diagnosis) to T3 (24 months follow-up) were analyzed.

Results

T-tests and χ²-tests revealed no significant differences in terms of shared decision-making and information to different treatment options between patients aged over 75 years old and the rest of the sample. Regarding information on self-help groups, rehabilitation options and a second medical opinion, there were significant differences between prostate cancer patient age groups: patients aged over 75 years old received less information on these aspects at all points in time.

Conclusion

Patients at all ages feel activated by urologists and are informed about different treatment options. However, there is room for improvement in terms of informing especially elderly prostate cancer patients about rehabilitation, second medical opinions and self-help groups. Special information tools and decision aids for prostate cancer patients aged over 75years old should be developed and implemented to meet the specific information needs.     

The clinical impact of pathological review on selection the treatment modality for localized prostate cancer in candidates for brachytherapy monotherapy

Aim

To evaluate the impact of pathological review by pathologist with genitourinary expertise (PGU) on treatment modality of localized prostate cancer, we analyzed Gleason grade (GG) migration and the final treatment decision in a cohort of patients designated for permanent prostate brachytherapy (PPB).

Methods

From February 2005 to July 2010, a total of 247 patients with localized prostate cancer diagnosed by local community hospitals were referred to our hospital for PPB monotheray. All pathologic slides of prostate biopsies were reviewed by a single PGU. Patients ultimately selected their treatment modality from our recommendations based on the review. Indication for PPB monotherapy was the NCCN classification of patients as good or intermediate risk. In addition, patient with Primary GG 4 was regarded as unadapted case.

Results

Six cases were reinterpreted as no cancer (2.4%). GG change occurred in 94 cases (38.1%) of which 77 (81.9%) were upgraded and 17 (18.1%) downgraded. Of the total 247 patients, 86 (34.8%) changed therapies and 30 (12.1%) did so based on the pathologic slide review.

Conclusions

Pathological review of biopsy specimens is mandatory for the determination of treatment modality especially in candidates for monotherapy of permanent prostate brachytherapy.     

Is sampling transitional zone in patients who had prior negative prostate biopsy necessary?

Objective

To assess the necessity of transitional zone sampling of the prostate during repeat prostate biopsy procedures.

Methods

Patients treated for lower urinary tract symptoms with transurethral resection of the prostate (TURP) from April 2004 to July 2009 whom had at least 1 negative prostate biopsy prior to this treatment were chosen as the study group. A histopathological analysis of surgical specimens was employed to determine cancer detection rates.

Results

A total of 72 patients with the mean age of 66.1, mean prostate-specific antigen (PSA) of 10.4?ng/mL and mean prostate volume of 63.2?cc were included. Of the patients, 50 had 1 biopsy set, 17 had 2 sets, 4 had 3 sets and 1 patient had 4 sets of consecutive biopsies. All biopsy results were negative for prostate cancer. After the analysis of surgical specimens obtained during TURP, cancer was detected in 3 patients (4.2%). Transitional zone sampling during prostate biopsies did not significantly improve the cancer detection rate. Transitional zone sampling was performed in 29 biopsies taken from 20 patients, one of whom (5%) had prostate cancer. The remaining 71 biopsies were taken from 52 patients without transitional zone sampling, and cancer was detected in 2 (3.8%) of them.

Conclusions

Since no significant difference was observed between patient groups (those with and those without transitional zone biopsies) in the detection of prostate cancer in the transitional zone, strategies for increasing the number of cores taken from transitional zone during repeat biopsies should be reconsidered.     

Laparoscopic radical cystectomy for bladder cancer with prostatic and neurovascular sparing: initial experience

Purpose

This study presents our initial experience with laparoscopic radical cystectomy with preservation of the neurovascular bundles and partial prostate for the treatment of bladder cancer.

Methods

Thirty-seven patients with bladder cancer were selected for the study between June 2007 and December 2009. The criteria for patient selection included prostate-specific antigen level below 4.0?ng/mL; negative involvement of the trigone and/or prostatic urethra; and no self-reported erectile dysfunction. The surgical procedure included laparoscopic prostate- and neurovascular bundles-sparing cystectomy with an ileal neobladder construction. Mean follow-up was 18?months.

Results

All patients underwent laparoscopic resection without requiring a traditional open procedure. The mean operation time was 215?min with a mean volume of intraoperative hemorrhage of 190?mL. After removal of the urinary catheter, all patients had a daytime urinary continence; six had a short period of nighttime urinary incontinence. Most patients reported a strong desire for sexual activity and were able to complete sexual intercourse without auxiliary measures at 3?months postoperatively. Grade-3 complications developed in 2 patients graded by the classification of Clavien system. One patient was diagnosed with pelvic recurrence 16?months postoperatively.

Conclusion

The laparoscopic radical cystectomy with a partial prostate preservation offers the advantages of a high continence, minimal impairment of erectile function, and low recurrence rate.     

The presence of a pituitary tumor in patients with prostate cancer is not a contraindication for leuprolide therapy

Purpose

Gonadotropin analogs like leuprolide play an important role in the management of prostate cancer. Pituitary apoplexy has been reported after leuprolide therapy. This report examines whether the presence of a pituitary tumor is a contraindication for leuprolide therapy in patients with prostate cancer.

Materials and methods

Two patients with prostate cancer and pituitary tumors were treated with leuprolide and radiation therapy. The first patient with a previously unknown pituitary adenoma had a leuprolide injection for prostate gland downsizing prior to brachytherapy. The second patient with a known pituitary microadenoma had a biochemical recurrence and was treated with leuprolide and radiation therapy.

Results

The first patient developed symptoms of apoplexy a few hours after the leuprolide injection. He underwent a transsphenoidal resection of the sellar mass with complete neurologic recovery. The second patient did not have any adverse events after leuprolide with follow-up MRI scans showing no growth of the microadenomas.

Conclusion

The presence of a pituitary tumor is not a contraindication for leuprolide therapy. While patients with a macroadenoma should have surgery first, those with a microadenoma may be considered for leuprolide therapy after careful evaluation by a multidisciplinary team.     

Robot-assisted laparoscopic radical prostatectomy after previous open transvesical adenomectomy

Introduction

Robot-assisted laparoscopic radical prostatectomy (RALRP) is one of the best treatment for patients with localized prostate cancer. RALRP is currently performed in patients without previous surgical treatment for benign prostatic hyperplasia. This paper presents a successfully performed RALRP after previous open transvesical adenomectomy (TVA).

Case report

A 68-year-old patient underwent nerve-sparing RALRP for prostate cancer revealed by transrectal ultrasound guided prostate biopsy, 7 years after TVA.

Results

Postoperatively, a regular diet was allowed on day 1. The Foley catheter was removed on day 7. At 3 months’ follow-up, the patient complained of moderate stress incontinence but erectile function was responsive to Tadalafil^®. Serum prostate-specific antigen was undetectable. Quality of life was satisfactory.

Conclusions

A history of previous prostatic surgery does not appear to compromise the outcome of RALRP. Nerve sparing is still indicated. Long-term follow-up is necessary to define RALRP as a gold standard also in patients with previous TVA.     

Potential cost-effectiveness for using patient decision aids to guide osteoporosis treatment

Summary

We use a model to predict whether using a patient decision aid in patients considering bisphosphonate therapy would be a good use of health resources. We found that if the decision aid improved adherence, and only marginally increased time physicians needed with their patients, then the decision-aid would be cost-effective.

Introduction

Oral bisphosphonates have been shown to reduce the risk of osteoporotic fracture. Adherence is crucial but suboptimal. A recent study suggests that a patient decision aid, which facilitates shared decision-making, could be effective in increasing adherence to bisphosphonates. But decision aids come at a cost in terms of additional time spent with physicians. This study considers the emerging evidence on the role of patient decision aids in improving adherence to bisphosphonates and their potential costs to inform future decision-making and research priorities.

Methods

We estimate the hypothetical cost-effectiveness of a patient decision aid detailing the benefits and risks of bisphosphonates for osteoporotic patients, from a Canadian healthcare perspective. A previously developed and validated Markov microsimulation model was adapted to include use of a patient decision aid to support the decision of whether to initiate bisphosphonate therapy, and subsequent influence on adherence and future fractures. We considered 2014 costs and benefits in terms of quality-adjusted life-years (QALYs).

Results

A patient decision aid that could improve treatment initiation rates or persistence (adherence) by 20 %, or a linear combination of the two, in osteoporotic women aged 70+ over a 3-year treatment period was found to have an incremental cost-effectiveness ratio below $50,000/QALY.

Conclusions

Patient decision aids have the potential to be cost-effective in osteoporosis so long as they increase adherence under certain conditions. Funding further research on the long-term effectiveness and costs of a patient decision aid which outlines all treatment options for osteoporosis patients is justified.

     

Patient preferences and urologist recommendations among local-stage prostate cancer patients who present for initial consultation and second opinions

Objectives

This study describes urologist recommendations for treatment among local-stage prostate cancer patients presenting for initial management consultations versus second opinions. We hypothesized that urologists present a wider range of management recommendations and are less likely to consider the patient preference during the initial consultation.

Methods

Newly diagnosed local-stage prostate cancer patients and their urologists participated in a survey at urology practices in three states. The urologist??s survey included questions about the patient??s clinical status, treatments discussed and recommended, and factors that influenced the urologist??s recommendations.

Results

Of the 238 eligible patients, 95 men presented for an initial consultation, and 143 men presented for a second opinion. In multivariate analysis, urologists recommended 0.52 more treatments (standard error 0.19, P?Conclusions In second opinion settings urologists discussed fewer treatment options and recommended surgery more often. These findings also applied to men with low-risk prostate cancer.     

Fokale Therapie des Prostatakarzinoms

Introduction

Patients with low-risk prostate cancer (PCa) face the difficult decision between a potential overtreatment by one of the standard therapies and active surveillance (AS) with the potential insecurity regarding cancer control. A focal therapy (FT) implies a treatment of the tumor within the prostate only.

Methods

This review evaluates the current literature and expert opinion of different therapies suited for FT as well as concepts for prostate imaging, biopsy and histopathological evaluation.

Results

Currently there is a lack of multicenter, randomized, prospective data on the effectiveness of FT. Nonetheless, the published data indicate a sufficient tumor control with a favorable side effect profile. There are still flaws in the diagnostics with regard to tumor detection and histological evaluation. Multicenter studies are currently recruiting worldwide which will provide new data with a higher level of evidence.

Conclusion

At present, the effectiveness of FT should not be compared directly to standard radical therapies and FT should only be performed within studies. In cases of cancer progression after FT a salvage treatment should still be possible.     

Biopsy-proven brain metastases from prostate cancer: a series of four cases with review of the literature

Aims

Prostate cancer is very common and is the second most common cause of cancer death in males in Australia; however, brain metastases are exceedingly rare.

Materials and methods

We review four cases of biopsy-proven brain metastases from prostate cancer and review the relevant literature.

Results

Three of four patients had acinar adenocarcinoma of prostate with one patient having ductal adenocarcinoma variant on histopathology. Three patients had the brain as the only site of metastatic disease. All patients underwent surgery, and three of four patients underwent adjuvant palliative radiotherapy to the brain.

Conclusion

Brain metastases from prostate cancer are rare, but brain metastases without other sites of metastatic disease are exceedingly rare and may be more common with ductal adenocarcinoma variant.     

Casodex treatment induces hypoxia-related gene expression in the LNCaP prostate cancer progression model

Background

The changes in gene expression profile as prostate cancer progresses from an androgen-dependent disease to an androgen-independent disease are still largely unknown.

Methods

We examined the gene expression profile in the LNCaP prostate cancer progression model during chronic treatment with Casodex using cDNA microarrays consisting of 2305 randomly chosen genes.

Results

Our studies revealed a representative collection of genes whose expression was differentially regulated in LNCaP cells upon treatment with Casodex. A set of 15 genes were shown to be highly expressed in Casodex-treated LNCaP cells compared to the reference sample. This set of highly expressed genes represents a signature collection unique to prostate cancer since their expression was significantly greater than that of the collective pool of ten cancer cell lines of the reference sample. The highly expressed signature collection included the hypoxia-related genes membrane metallo-endopeptidase (MME), cyclin G2, and Bcl2/adenovirus E1B 19 kDa (BNIP3). Given the roles of these genes in angiogenesis, cell cycle regulation, and apoptosis, we further analyzed their expression and concluded that these genes may be involved in the molecular changes that lead to androgen-independence in prostate cancer.

Conclusion

Our data indicate that one of the mechanisms of Casodex action in prostate cancer cells is induction of hypoxic gene expression.     

Specialist visits and initiation of cancer-directed treatment among a large cohort of men diagnosed with prostate cancer

Background

The urologist generally manages the treatment of men immediately following the diagnosis of prostate cancer (PCa). The role of other physician specialists in this setting is less clear. We investigated whether involvement of other physician specialty types immediately following diagnosis affects initiation of cancer-directed treatment.

Ratio Between Positive Lymph Nodes and Total Excised Axillary Lymph Nodes as an Independent Prognostic Factor for Overall Survival in Patients with Nonmetastatic Lymph Node-Positive Breast Cancer

Background

The status of the axillary lymph nodes in nonmetastatic lymph node-positive breast cancer (BC) patients remains the single most important determinant of overall survival (OS). Although the absolute number of nodes involved with cancer is important for prognosis, the role of the total number of excised nodes has received less emphasis. Thus, several studies have focused on the utility of the axillary lymph node ratio (ALNR) as an independent prognostic indicator of OS. However, most studies suffered from shortcomings, such as including patients who received neoadjuvant therapy or failing to consider the use of adjuvant therapy and tumor receptor status in their analysis.

Methods

We conducted a single-center retrospective review of 669 patients with nonmetastatic lymph node-positive BC. Data collected included patient demographics; breast cancer risk factors; tumor size, histopathological, receptor, and lymph node status; and treatment modalities used. Patients were subdivided into four groups according to ALNR value (<.25, .25–.49, .50–.74, .75–1.00). Study parameters were compared at the univariate and multivariate levels for their effect on OS.

Results

On univariate analysis, both the absolute number of positive lymph nodes and the ALNR were significant predictors of OS. On multivariate analysis, only the ALNR remained an independent predictor of OS, with a 2.5-fold increased risk of dying at an ALNR of ≥.25.

Conclusions

Our study demonstrates that ALNR is a stronger factor in predicting OS than the absolute number of positive axillary lymph nodes.     

Importance of prostate volume in the European Randomised Study of Screening for Prostate Cancer (ERSPC) risk calculators: results from the prostate biopsy collaborative group

Objectives

To compare the predictive performance and potential clinical usefulness of risk calculators of the European Randomized Study of Screening for Prostate Cancer (ERSPC RC) with and without information on prostate volume.

Methods

We studied 6 cohorts (5 European and 1 US) with a total of 15,300 men, all biopsied and with pre-biopsy TRUS measurements of prostate volume. Volume was categorized into 3 categories (25, 40, and 60?cc), to reflect use of digital rectal examination (DRE) for volume assessment. Risks of prostate cancer were calculated according to a ERSPC DRE-based RC (including PSA, DRE, prior biopsy, and prostate volume) and a PSA?+?DRE model (including PSA, DRE, and prior biopsy). Missing data on prostate volume were completed by single imputation. Risk predictions were evaluated with respect to calibration (graphically), discrimination (AUC curve), and clinical usefulness (net benefit, graphically assessed in decision curves).

Results

The AUCs of the ERSPC DRE-based RC ranged from 0.61 to 0.77 and were substantially larger than the AUCs of a model based on only PSA?+?DRE (ranging from 0.56 to 0.72) in each of the 6 cohorts. The ERSPC DRE-based RC provided net benefit over performing a prostate biopsy on the basis of PSA and DRE outcome in five of the six cohorts.

Conclusions

Identifying men at increased risk for having a biopsy detectable prostate cancer should consider multiple factors, including an estimate of prostate volume.     

Prostate cancer risk after anti-androgen treatment for priapism

Background

Patients with recurrent ischemic priapism have historically been treated with anti-androgen therapy due to the limited available evidence for more targeted therapies to treat the underlying pathophysiologic mechanisms of this condition. We report a case in which anti-androgen therapy caused significant adverse side effects and likely masked this patient’s elevated prostate-specific antigen (PSA) levels, which adversely impacted the timely diagnosis and treatment of his prostate cancer.

Case report

A 69-year-old man treated with anti-androgens for priapism initially developed unwanted anti-androgenic side effects such as gynecomastia, erectile dysfunction, and decreased libido. After decreasing his anti-androgen dosage and starting a specified regimen of phosphodiesterase type 5 inhibitor therapy, his serum PSA levels were found to be elevated. He was subsequently diagnosed with adenocarcinoma of the prostate and underwent a radical prostatectomy with the pathologic finding of high-grade, locally progressive disease.

Conclusion

Anti-androgen therapy carries significant complication risks, including the potential to alter the diagnosis and treatment of prostate cancer. Clinicians administering this therapy for priapism management should be aware of these possible risks.     

Avoiding Axillary Treatment in Sentinel Lymph Node Micrometastases of Breast Cancer: A Prospective Analysis of Axillary or Distant Recurrence

Background

The need for axillary lymph node dissection (ALND) in breast cancer patients with sentinel lymph node (SLN) micrometastases remains controversial. The aims of the study were to evaluate the locoregional failure and outcome of breast cancer patients with sentinel node micrometastases who did not undergo completion ALND.

Methods

Between November 2000 and December 2006, SLN biopsy was successfully performed in 1178 patients with invasive breast carcinoma. Only patients with macrometastasis (>2 mm) underwent ALND, while patients with negative SLN or micrometastases did not undergo further treatment of the axilla, by either surgery or radiotherapy. Regarding adjuvant therapy decision, patients with SLN-micrometastases (pN1_mi) were considered as node-positive patients.

Results

Of 1,178 patients, 59 (5%) had micrometastases. Of those with micrometastases, 14 (24%) underwent ALND because the intraoperative study of the SLN yielded a positive result. With a median follow-up of 60 (range, 8–94) months, none of the patients with SLN micrometastases in whom ALND was omitted developed an axillary recurrence, while one patient in whom ALND was performed developed infraclavicular lymph node recurrence. One patient, who declined postoperative breast irradiation, developed breast recurrence and distant metastasis.

Conclusions

Breast cancer patients with SLN micrometastases in whom ALND was omitted had a very low locoregional failure rate. This study supports the theory that ALND might be avoided in these patients, providing that adjuvant systemic treatment equal to treatment provided to treat node-positive disease is administered. However, longer follow-up and results of additional prospective studies are needed.     

Urological cancer care pathways: development and use in the context of systematic reviews and clinical practice guidelines

Background

Making healthcare treatment decisions is a complex process involving a broad stakeholder base including patients, their families, health professionals, clinical practice guideline developers and funders of healthcare.

Methods

This paper presents a review of a methodology for the development of urological cancer care pathways (UCAN care pathways), which reflects an appreciation of this broad stakeholder base. The methods section includes an overview of the steps in the development of the UCAN care pathways and engagement with clinical content experts and patient groups.

Results

The development process is outlined, the uses of the urological cancer care pathways discussed and the implications for clinical practice highlighted. The full set of UCAN care pathways is published in this paper. These include care pathways on localised prostate cancer, locally advanced prostate cancer, metastatic prostate cancer, hormone-resistant prostate cancer, localised renal cell cancer, advanced renal cell cancer, testicular cancer, penile cancer, muscle invasive and metastatic bladder cancer and non-muscle invasive bladder cancer.

Conclusion

The process provides a useful framework for improving urological cancer care through evidence synthesis, research prioritisation, stakeholder involvement and international collaboration. Although the focus of this work is urological cancers, the methodology can be applied to all aspects of urology and is transferable to other clinical specialties.     

Treatment outcomes and resource use of patients with neurogenic detrusor overactivity receiving botulinum toxin A (BOTOX®) therapy in Germany

Purpose

To evaluate treatment outcomes and resource consumption of patients with neurogenic detrusor overactivity (NDO) before and after botulinum toxin A (Botox ^® ) therapy in Germany.

Methods

In a multi-center, cross-sectional, retrospective cohort study, data of patients with NDO 12 months before and after the first Botox ^® therapy were analyzed.

Results

214 patients (mean age 38 ± 14.8 years, 145 male, 69 female) with NDO due to spinal cord injury (81%); myelomeningocele (14%), or Multiple Sclerosis (5%) from seven hospitals were included. Mean interval between treatments was 8 months. Following treatment, mean maximum detrusor pressure, maximum cystometric capacity and detrusor compliance improved significantly. Prior to Botox ^® therapy, 68% reported urinary tract infections (UTI), 63% had incontinence episodes, and 58% used incontinence aids. These numbers decreased significantly (p < 0.05) after treatment to 28, 33, and 28%, respectively. In patients using incontinence aids, mean costs per patient decreased from €2 to €1 per day, whereas the mean cost of drugs to treat UTIs per patient decreased from €163 to €80 per year, respectively.

Conclusion

This is the first study demonstrating the clinical usefulness of Botox ^® therapy in clinical practice. Successful treatment resulted in lower costs for NDO associated morbidity due to less need for incontinence aids and UTI medication.     

Radikale Prostatektomie in einem zertifizierten Prostatakarzinom-Zentrum

Introduction

Open radical prostatectomy (RPE) is a standardized surgical technique with good oncologic/functional results. Nevertheless, the postoperative quality of life can be affected significantly by urinary incontinence and erectile dysfunction. Consequently, data of postoperative health-related quality of life come increasingly into public interest.

Materials and methods

This paper aims to evaluate the quality of care after radical RPE at a certified prostate cancer center. The oncological outcome, rate of complications, reintervention and transfusions as well as the rate of continence and potency of a total collective of nearly 400 patients was obtained in a standardized manner between January 2008 and June 2012 using the clinic’s internal tumor documentation system and commonly used, validated questionnaires. Due to consistent methodology, partial results can finally be compared with data prior to establishment of the prostate cancer center.

Results

This study is the first German report demonstrating an improvement of treatment results in a certified prostate cancer center. The rate of complications, reintervention, transfusions, and R1 status were significantly lower than in the precenter era. The evaluation of potency is sobering compared to current published literature, whereas satisfactory results were obtained for continency.

Discussion

Evaluation of the data contributes to the quality of treatment and outcome of certified prostate cancer centers and allows reliable decision-making and honest patient education in the future.