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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.
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.
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.
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.
Continue reading "Salvage radiation after prostate cancer surgery" »
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
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.
Continue reading "Hormonal therapy with radiation for prostate cancer" »
Prostatectomy Effective for SV-Negative Locally Advanced Prostate Cancer
At a mean follow-up of 37.2 months (median, 21.2 months), the pT3 (pT3a plus pT3b) patients' overall and disease-specific 10-year survival rates were 77% and 92%, respectively, and at 15 years, 52% and 75%. These results are similar to those of previous studies for overall survival of patients with advanced prostate cancer who undergo radical prostatectomy.
However, in the present study, Dr. Suttmann said, "The main issue is that you have 10-year disease-specific survival for those with pT3a of 92%, which is probably as much as those with pT2 tumors, while disease-specific survival is much worse for those who have pT3b disease, and so have seminal vesicle involvement."
Although Dr. Suttmann indicated that they had not included any specific analysis for prognostic factors, he said, "We would still conclude that radical prostatectomy [with or without hormonal therapy] is a pretty good therapeutic option for those with pT3 disease.
Continue reading "Prostate Cancer: Surgery for locally advanced prostate cancer" »
Dr. Koop - Biopsy Underestimates Prostate Cancer in Overweight Men:
Researchers compared the biopsy grade to the cancer grade following radical prostatectomy, which is the removal of the prostate. In 1,113 men who underwent radical prostatectomy between 1996 and 2005 within the Shared Equal Access Regional Cancer Hospital database, 299 men, or 27 percent, had more severe cancer than suggested by biopsy. In 123 patients, or 11 percent, cancer diagnosis was actually less severe.
This was an interesting study that concluded that obesity is one of the risk factors for upgrading at the time of pathological analysis.
The last time I reviewed my database I found that 30% of my gleason 6 cancers were upgraded to 7. I have not done an analysis to see which patients are more at risk yet.
This is one of the most common questions that patients ask me, especially if the cancer is confined to one area on biopsy.
With robotic surgery I am able to remove part of a prostate if I want to, and I often do that for BPH operations.
For prostate cancer it is not the correct thing to do. The prostate is made up of an inner part that usually grows and causes BPH and the outer, peripheral part that is usually where the cancer starts. Once you have cancer in one area, it is likely to be in several areas. All prostate glands are at risk for developing into new cancers. I recently presented an abstract at the prostate cancer symposium in Orlando entitled:
Extent of prostate cancer in patients presenting with presumed minimal tumor burden.
This was a study I did by looking at my robotic prostatectomy database. I found patients that only had 1 area of gleason 6 cancer and a PSA of less than 10. The results and conclusions were as follows:
On radical prostatectomy, all cancers were organ confined and 34 of 35 cancers showed negative margins. Despite having been selected for presumed minimal tumor burden, the majority of the cases were found to be multifocal (24 cases or 69%). The pathological stage based on final pathology was most commonly T2c reflecting bilateral disease (26 cases or 74%), while the remaining 9 cases (26%) were at T2a. Lymph nodes were not assessed on these patients. The Gleason's score was upgraded to 7 in 4 patients and to 8 in 1 patient. Tumor volume was > 2 cc in 14 patients and > 5 cc in 2 patients.
Conclusions: Although prostate cancer is often diagnosed early, physicians should understand that it is difficult to predict solitary lesions based on needle core biopsy and PSA value. Our results suggest that prostate cancers are frequently multifocal and bilateral, and should be managed as such. Focused therapy that targets only a portion of the prostate gland may not be adequate for long term cancer control.
My main reason for doing the study was to show that I did not think treating part of the prostate by freezing or ultrasound was a good therapy from a cancer control standpoint.
The operation that I do currently is the same as what I did when I did open the open radical prostatectomy: I remove the prostate in its entirety, seminal vesicles, part of the vas deferens, and the pelvic lymph nodes for staging.
The main log term side effects are sexual, which I have discussed previously.
The other side effects are urinary leakage which usually gets back to normal with a better flow.
UroToday - Surgery, Radiation Treatment Double Life Expectancy of Patients with Aggressive Prostate Cancer
Thursday, 15 March 2007
BERKELEY, CA (Newswise) - After being diagnosed with aggressive prostate cancer, many men are told that their disease is untreatable and that less aggressive treatment is best. Often this means patients are told to watch and wait -- that is, to do nothing at all. A new study by physician-scientists at NewYork-Presbyterian Hospital/Weill Cornell Medical Center turns conventional wisdom on its head, finding either surgical removal of the prostate (prostatectomy) or radiation treatment more than doubles the life expectancy for these patients when compared with those receiving the conservative approach.
Patients with the most aggressive non-metastatic prostate cancers (Gleason scores 8–10), if treated with prostatectomy or radiation, can expect to live more than 14 years; those treated conservatively will live, on average, less than 7 years. The study appears in the March Journal of Urology.
I've been aggressive at treating high grade prostate cancers with surgery. These patients tend to have more side effects after surgery (I am sure with radiation as well) than lower grade cancer patients. I will look forward to reading the actual study. A study like this is prone to selection bias.
Dr.Kattlove's Cancer Blog:
| If you have prostate cancer, that isn’t a bad idea.
Recently surgeons from Detroit’s Henry Ford Hospitals reported their
outcomes using the da Vinci robotic system in over 2500 men (European
Urology 2007;51:648-58). With the da Vinci, which has been in use in the
U.S. for prostate cancer surgery since 2000, the surgeon doesn’t actually
do any cutting – he or she just turns dials. The instrument, which has
telescopic lenses for super vision and lots of little arms for cutting and
suturing, actually does the surgery. Also, instead of an incision,
everything is done through 6 tiny holes. The instruments and telescopes
are passed through the holes to do their work. |
Dr. Kattlove is a little off with some of his takes on robotics, but it is nice to see an experienced medical oncologist start blogging. I look forward to reading his blog. Welcome.
There is a decent website from a pharmaceutical company: prostateinfo.com.
It does a decent job of going over the basics involved in screening and explaining the treatment options.
My one big criticism is that is out of date when it comes to robotic surgery and how accepted it is, making up about 30-35% of all radical prostatectomies currently.
I would add HIFU as an experimental therapy and make laparoscopic and robotic procedures an accepted form. I know that there are more robotic prostatectomies done than perineal ones, and pretty sure there are more laparoscopic prostatectomies done in the US than perineal.
Straightfromthedoc: JAMA Study Confirms Prostate Cancer Treatment is Preferable over "Watchful Waiting"
According to Endocare President, Chairman and CEO Craig T. Davenport:
"This study offers further scientific evidence that 'watchful waiting' may not be the best option for many patients, particularly when there are effective, minimally invasive treatments like cryoablation available. Based on the results of the study, 'watchful waiting' patients should consider some kind of treatment.
We believe cryoablation is an excellent option for many patients given its proven, long-term cancer control rate, low morbidity, and typically fast recovery time. Additionally, we believe cryoablation is a particularly good option for 'watchful waiting' patients who are not able to tolerate surgery or radiation, or for men with very small amounts of cancer in their prostate."
Straight from the doc reported on a press release from endocare, a company that is a leader in cryosurgery.
I am a supporter of cryosurgery and discuss it as an option for all prostate cancer patients, but I thought that some of the conclusions were not supported by the paper.
The JAMA article that I have previously discussed only looked at surgery and radiation, bot cryosurgery. The press release did not state this.
Elderly men with very small tumors are candidates for watchful waiting and cryosurgery is not without side effects.
The ultimate deadline Chicago Tribune: "The ultimate deadline
Faced with conflicting medical advice, newsman Robert Jordan took the road less traveled to treat his prostate cancer
By Robert Jordan
Special to the Tribune
Published June 18, 2006"
This story was given to me by a patient. Mr. Jordan has done excellent research and has hit on the important points that are overlooked by many patients and not stressed by all physicians.
1- Second opinions are a good thing. There are many opinions in choosing the best form of treatment for prostate cancer and a second opinion can help get multiple views.
2- In his decision making about choosing radiation, he writes: "Doctors there use tomotherapy, which targets radiation on the cancerous area. Patients can continue a nearly normal lifestyle during the course of the therapy, which is painless and non-invasive. It leaves most patients continent and potent, but subsequent scarring from the radiation, sometimes two to three years later, can cause problems in both those areas."
You are trading in short term side effects for long term effects with radiation.
3- He understands the importance of cautery free surgery: "I read up on the da Vinci procedure in medical journals and discovered papers discussing the advantages of not using cautery-a technique that stops blood vessels from bleeding with an electrical arc, which immediately coagulates the blood. Zapping a blood vessel so near a nerve couldn't be good for the nerve, I thought, so I looked for da Vinci surgeons who did not cauterize."
Even bipolar devices that do not spread electricity, will spread heat and I try to limit any cautery near the nerves including the prostate pedicles.
I think this article hits on most of the important points in choosing therapy for prostate cancer and is a must read for newly diagnosed patients.
UroToday - Control of Prostate Cancer by Transrectal HIFU in 227 Patients
HIFU, or high intensity focused ultrasound, works by creating ultrasound waves that are concentrated on the prostate to destroy the tumor cells.
I did research on HIFU for the destruction of kidney tissue when I was a resident at Indiana University. Our institution was doing a clinical research project on using HIFU to treat localized prostate cancer in newly diagnosed men.
This study from France has a much larger series then what we had, and shows some interesting results.
I concentrate on the 14% of patients that still had cancer on biopsy. These biopsies were done after 3 months and is only a small sampling of total prostate tissue, but still shows a high number of cancers.
They also lumped in hormone treatment which can lower PSA values, but cause many side effects and are not curative.
An incontinent rate of 9% is still high as well.
I will await further HIFU studies, but have not seen anything that yet that is an improvement over available therapies.
HIFU is still not FDA approved in our country, but there are centers in Europe and Canada that offer it.
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