Rectal Complications After Prostate Brachytherapy

PURPOSE Prostate brachytherapy is gaining wide popularity as an alternative to resection for the treatment of locally advanced prostate cancer. Rectal-urethral fistula after prostate brachytherapy is a rare but serious complication, and its incidence, presentation, risk factors, and clinical management have not been well described.METHODS From January 1997 to October 2002, seven patients with rectal-urethral fistulas were referred to two institutions (Brigham and Womens Hospital and West Roxbury Veterans Administration Hospital) of a major teaching referral center. Clinical presentation, risk factors, prostate staging, and clinical management were examined in a retrospective fashion.RESULTS Seven rectal-urethral fistulas developed from roughly 700 (1 percent) patients treated with prostate brachytherapy for prostate cancer. The average patient age was 67.7 years, preimplant prostate-specific antigen was 7.1, and Gleason score was 3+3. Symptoms occurred at a mean of 27.3 months after prostate brachytherapy was started and included anorectal pain (57 percent), clear mucous discharge (57 percent), diarrhea (43 percent), and rectal ulceration (43 percent). Coronary artery disease was a common comorbidity (71 percent). Previous transurethral resection of prostate (28 percent) and pelvic irradiation or external beam radiation therapy (14 percent) were not associated with increased risk of rectal-urethral fistula. All patients underwent a diverting colostomy (86 percent) or ileostomy (14 percent), and four patients went on to have definitive therapy. Definitive resection was performed between 5 and 43 months after diverting ostomy and was chosen on the basis of comorbid disease, quality of life, and degree of operation. Two patients required a second diversion after definitive resection because of anorectal pain and a colocutaneous fistula. Postoperative complications included myocardial infarction (14 percent), blood transfusion (14 percent), and bowel perforation (14 percent). Patients became symptom-free nine months after surgery. Six patients are alive and well today; one died from an unrelated cause.CONCLUSIONS Rectal-urethral fistula after prostate brachytherapy is a rare but devastating complication. Patients should be followed for at least three years after prostate brachytherapy because symptoms can develop late in the course. Although diversion of fecal stream does not heal the fistula, all patients diagnosed with rectal-urethral fistula should first undergo diverting ostomy to alleviate symptoms. Then, one should consider definitive resection and ostomy closure.Read at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.     

Prostate Cancer Testing following a Negative Prostate Biopsy: Over Testing the Elderly

Background Screening elderly men for prostate cancer is not recommended because definitive treatments are unlikely to extend life expectancy. Objective Describe clinical outcomes after a negative prostate biopsy in a population-based cohort of men ages 65 and older. Design Retrospective cohort study. Participants 9,410 Medicare-eligible men who underwent a prostate biopsy in Los Angeles or New Mexico in 1992. Measurements We used Medicare and SEER databases to identify a cohort with an initial negative biopsy (n = 7,119) and to ascertain survival, subsequent PSA testing, prostate biopsies, and prostate cancer detection and treatment through 1997. Results The overall 5-year survival was 79.4% (95% CI 78.4–80.3), but only 74.6% (72.4–76.7) for men ages 75–79 at the time of the initial negative biopsy and 55.0% (51.9–57.9) for men ages 80+. During a median 4.5 years follow-up, a cumulative 75.0% (73.9–76.1) of the cohort underwent PSA testing. Among men ages 75–79 and 80+, the cumulative proportions that underwent PSA testing were 75.4% (73.0–77.8) and 74.3% (71.1-77.5), respectively. Additionally, 29.1% (26.7–31.6) of men ages 75–79 and 20.1% (17.6–23.1) of men ages 80+ underwent repeat prostate biopsy, and 10.9% (9.4–12.7) and 8.3% (6.6–10.4), respectively, were diagnosed with cancer. Among men ages 75+ with localized cancers, approximately 34% received definitive treatment. Conclusions High proportions of men ages 75+ underwent PSA testing and repeat prostate biopsies after an initial negative prostate biopsy. Given the known harms and uncertain benefits for finding and treating localized cancer in elderly men, most continued PSA testing after a negative biopsy is potentially inappropriate. This work was presented in part at the Annual National Meeting of the Society for General Internal Medicine. Los Angeles, California, May 2006.     

Personalized surgical management of colorectal cancer in elderly population

Colorectal cancer(CRC)in the elderly is extremely common but only a few clinicians are familiar with the complexity of issues which present in the geriatric population.In this phase of the life cycle,treatment is frequently suboptimal.Despite the fact that,nowadays,older people tend to be healthier than in previous generations,surgical undertreatment is frequently encountered.On the other hand,surgical overtreatment in the vulnerable or frail patient can lead to unacceptable postoperative outcomes with high mortality or persistent disability.Unfortunately,due to the geriatric patient being traditionally excluded from randomized controlled trials for a variety of factors(heterogeneity,frailty,etc.),there is a dearth of evidence-based clinical guidelines for the management of these patients.The objective of this review was to summarize the most relevant clinical studies available in order to assist clinicians in the management of CRC in the elderly.More than in any other patient group,both surgical and non-surgical management strategies should be carefully individualized in the elderly population affected by CRC.Although cure and sphincter preservation are the primary goals,many other variables need to be taken into account,such as maintenance of cognitive status,independence,life expectancy and quality of life.     

Prediction of Postoperative Mortality in Elderly Patients With Colorectal Cancer

Purpose This study was designed to develop a model for predicting postoperative mortality in elderly patients undergoing surgery for colorectal cancer. Methods This multicenter study was conducted by using routinely collected clinical data, assessing patients older than aged 80 years, with 30-day operative mortality as the primary end point. Data were collected from The Association of Coloproctology of Great Britain and Ireland database, encompassing 8,077 newly diagnosed colorectal cancer patients undergoing resectional surgery in 79 hospitals between April 2000 to March 2002, The Association of Coloproctology Malignant Bowel Obstruction Study, encompassing 1,046 patients with malignant bowel obstruction in 148 hospitals, between April 1998 to March 1999, and The Wales-Trent audit, encompassing 3,522 newly diagnosed colorectal cancer patients, between July 1992 to June 1993. A multilevel logistic regression model was developed to adjust for case-mix and to accommodate the variability of outcomes between the three study populations. The model was internally validated using a Bayesian resampling technique and tested using measures of discrimination, calibration, and subgroup analysis. Results A total of 2,533 patients satisfied the inclusion criteria, with a 30-day mortality of 15.6 percent. Multivariate analysis identified the following independent risk factors: age (odds ratio for 85–90, 90–95, >95 vs. 80–85 = 1.1, 1.8, 2.9), American Society of Anesthesiology grade (odds ratio for Grade III, IV vs. I–II = 2.7, 6.1), operative urgency (odds ratio for emergency vs. elective = 1.9), no cancer excision vs. resection (odds ratio = 1.2), and metastatic disease (odds ratio for metastases vs. no metastases = 1.9). The model offered adequate discrimination (area under receiver operator curve = 0.732) and excellent agreement between observed and predicted outcomes during eight colorectal procedures (P = 0.885). Conclusions The elderly colorectal cancer model can accurately estimate 30-day mortality in patients older than aged 80 years undergoing surgery for colorectal cancer. Because the mortality can be considerable, this may have important implications when determining management for this group of patients. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004, and the meeting of The Association of Coloproctology of Great Britain and Ireland, Birmingham, United Kingdom, June 28 to July 1, 2004.     

The Impact of Surgery for Colorectal Cancer on Quality of Life and Functional Status in the Elderly

Purpose Colorectal cancer is a common diagnosis in the elderly. Frequently concerns arise about outcomes after surgery, and little is known about postoperative quality of life in this older group after major bowel surgery. The objective of this study was to compare quality of life and functional status of elderly patients (older than aged 80 years) who have undergone surgery for colorectal cancer with a younger (younger than aged 70 years), procedure-matched control group. Methods Patients in the case (older than aged 80 years) and control groups (younger than aged 70 years) were identified from the colorectal cancer database at Mount Sinai Hospital, Toronto, Canada. All had treatment for colorectal cancer within the last five years. Patients were surveyed by mail using the European Organization for Research and Treatment of Cancer quality of life scales specific to cancer and colorectal cancer (EORTC-C30 and EORTC-CR38) and the Short Form-36. Student’s t-test was used to test differences. Results There were 29 patients in each of the groups. The current average ages were 83.2 (standard deviation = 2.79) years, and 67.7 (standard deviation = 5.1) years, respectively. The two groups scored similarly on the European Organization for Research and Treatment of Cancer quality of life scales in all domains except physical functioning, functional role, micturition, and stoma-related problems. Similarly, the mean scores of the Short Form-36 were similar with the exception of the vitality domain. Most patients did not require special assistance or alternate living arrangements after discharge from the hospital, and most patients seemed to be able to return to their preoperative level of functioning. However, stoma care was a greater concern to the elderly. Conclusions Elderly patients older than aged 80 years who are selected for surgery have a quality of life comparable to younger patients in most respects. Therefore, colorectal cancer surgery may be offered to the highly functioning elderly with the expectation of a good quality of life postoperatively. Reprints are not available.     

Molecular Diagnostics in Prostate Cancer

Since there are no effective therapeutic options for advanced prostate cancer, early detection of this tumour is pivotal and can increase the curative success rate. Although the routine use of serum PSA testing has undoubtedly increased prostate cancer detection, one of its main drawbacks has been the lack of specificity that results in a high negative biopsy rate. Since prostate cancer is a heterogeneous disease, it has become clear that a defined set of markers will provide significantly more diagnostic information than any one biomarker. The list of potential prostate cancer biomarkers will continue to grow. Only when research groups use the proposed guidelines for biomarker development, then systematic evaluation and clinical investigation of these biomarkers will gain more insight into their true diagnostic potential.