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Academic Journal
Main Category: Prostate / Prostate Cancer
Article Date: 27 Jan 2012 – 10:00 PST

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According to a study from radiation oncologists at the Kimmel Cancer Center at Jefferson, high-risk prostate cancer patients who receive brachytherapy, alone or together with external beam radiation therapy (EBRT) had considerably lower mortality rates. The study is published online January 23 in the International Journal of Radiation Oncology*Biology*Physics.

Brachytherapy is a form of radiotherapy where a radiation source is placed directly at the site of a tumor. The treatment is generally used to treat men with low and intermediate risk prostate cancers.

The procedure is less common and controversial in men with high-risk prostate cancer, partly due to results from prior studies suggesting that the treatment is associated with lower cure rates than EBRT.

According to many experts, these earlier studies were limited by poor brachytherapy technique, and they believe that high-quality contemporary brachytherapy could be an effective tool to treat individuals with high-risk prostate cancer.

Co-author Timothy Showalter, M.D., assistant professor in the Department of Radiation Oncology at Thomas Jefferson University Hospital, and associate research member of Jefferson’s Kimmel Cancer Center, explains:

“The study contradicts traditional policies of using brachytherapy in just low and intermediate risk patients by suggesting there may instead be an improvement in prostate cancer survival for high-risk patients. Although studies like this cannot prove an advantage of brachytherapy, our report does suggest that brachytherapy is no less effective than EBRT and should be considered for some men with high-risk prostate cancer.”

The team identified 12,745 men diagnosed with high-grade prostate cancer of poorly differentiated grade from 1988 to 2002, using the Surveillance, Epidemiology, and End Results database:

• 7.1% of the patients received brachytherapy
• 73.5% received EBRT alone
• 19.1% received brachyherapy in combination with EBRT

The researchers used multivariate models to analyze patient and tumor characteristics connected with the chances of treatment with each radiation modality, in addition to the effect of radiation modality on prostate cancer-specific mortality.

The researchers found that treatment with brachytherapy, alone or in combination with EBRT, was linked to considerable reduction in prostate-related mortality rates than EBRT alone.

Significant predictors of use of brachytherapy, alone or in combination with EBRT were later year of diagnosis, urban resistance, earlier T-stage, and younger age.

Lead research Xinglei Shen, M.D., a resident in the Jefferson’s Department of Radiation Oncology and a part-time master’s degree student in the Jefferson School of Population health, and colleagues explained that the findings supply enough evidence to continue investigation brachytherapy as part of an effective treatment strategy for patients with high-risk prostate cancer.

Dr. Shen explained:

“Today, for the most part, brachytherapy is not being used for these high-risk patients or even recommended. But if you look at the biology and theory behind it, it makes sense: you can really give a lot more dose with brachytherapy than with EBRT alone to the prostate. And this presents an opportunity for high-risk patients.”

Written by Grace Rattue

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International Journal of Radiation Oncology*Biology*Physics

Source: Thomas Jefferson University

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Source: http://www.medicalnewstoday.com/articles/240880.php

Editor’s Choice
Academic Journal
Main Category: Prostate / Prostate Cancer
Article Date: 26 Jan 2012 – 6:00 PST

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According to Beth Israel Deaconess Medical Center and prostate expert Marc B. Garnick, MD, physicians who advise PSA tests for men being screened for prostate cancer must base their decision more on available evidence when recommending screening, biopsies and treatments, instead of holding on to long held beliefs that PSA-based testing benefits all.

Garnick wrote in the February issue of Scientific American, stating that the current system of relying on prostate-specific antigens levels in the blood is “deeply flawed,” and physicians must consider that “the PSA test does not tell you if a man has cancer, just that he might have it.”

According to the latest US Preventative Services Task Force’s evaluation of studies published in 2009, PSA testing demonstrates more harm than good in terms of results. Furthermore, the report shows that in light of the evidence, a more cautious, individualized approach should be taken towards patient treatment, instead of aggressive early treatment for all. The approach is currently underway at BIDMC.

Garnick, who is also an editor-in-chief of Harvard Medical School’s Annual Report on Prostate Diseases and related website, states:

“Most people outside the medical community do not realize how flimsy evidence has been in favor of the PSA screening data. In a perfect world, a screening test would identify only cancers that would prove lethal if untreated. Then, men who had small, curable cancers would be treated, and their lives would be saved. Ideally, the treatments would not only be effective, they would have no serious side effects. Such a scenario would justify massive screening and treatment of everyone with a positive test.”

At present, however, there is no reliable approach for doctors to determine which of these small cancers identified by biopsy are potentially dangerous and which remain harmless throughout life. Additionally, all treatments currently available pose substantial risks and long-term side effects.

Garnick says that the number of men who would need to receive treatment, and potentially suffer the consequences of the treatment to successfully prevent just one single prostate cancer death, has prompted the Task Force to recommend against wide spread PSA testing for all those without symptoms of prostate cancer.

Two 2009 studies, one in Europe and one in the US, randomly divided healthy men in their 50s and 60s into two groups. One group was periodically screened for prostate cancer using PSA testing, adigital rectal exam or both, whilst the other group received standard medical care as required without being offered routine testing.

The European study revealed that only those tested and treated for prostate cancer had a mortality risk of 20%, although such a decrease was not observed in the U.S. study. Neither study demonstrated whether those who were tested and treated had a longer life expectancy, compared with those not offered routine testing.

The researchers in the European study established that about 1,400 men would have to be screened to prevent one single person from dying of prostate cancer, and result in 48 others needing to undergo treatment, whilst the other 47 men would be likely to suffer serious side effects, like incontinence and impotence, due to the radiation or surgery.

Garnick explains:

“The overall death rate from all causes was not statistically different in both the screened and unscreened groups. Unfortunately, the mortality data collected over the past 25 years shows that the natural history of prostate cancer is not as straightforward as my colleagues and I once believed. Many cancers will never cause problems during the patient’s lifetime, and hence do not need to be treated, at least immediately.”

According to findings from a long-term Canadian study, the prostate cancer mortality rate for those men who chose active surveillance or delayed treatment following PSA testing resulted in a cancer diagnosis of 1% over 10 years in comparison to a 0.5% mortality risk due to post prostate cancer surgery complications within one month after surgery.

Garnick declares:

“The point is that the initial decision to forgo treatment is not necessarily the final one. Surgery, radiation and other therapies are still available later on, and most current data indicate that the outcome will not be negatively affected by the delay. Such an approach is improving our ability to tailor treatments for individuals rather than always treating everyone the same.”

The results of this decision suggests that doctors, as well as patients both need a precise scientific understanding about these issues, in particular during a doctor-patient discussion. Garnick comments: “We need to have the courage to act on the evidence and not just our beliefs.”

Written by Petra Rattue

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Source: http://www.medicalnewstoday.com/articles/240803.php

Editor’s Choice
Academic Journal
Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology
Article Date: 25 Jan 2012 – 6:00 PST

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A study published Online First in The Lancet has found that a common medication (dutasteride) used to treat enlargement of the prostate, may also reduce the need for treatments that pose risks of incontinence and impotence and delay growth of early-stage prostate cancer.

Neil Fleshner, lead researcher of the investigation from Princess Margaret Hospital, Toronto, Canada, said:

“Our trial is the first study to show the benefits of use of a 5α-reductase inhibitor to reduce the need for aggressive treatment in men undergoing active surveillance for low-risk prostate cancer…delaying their time to pathological progression and initiation of primary therapy.”

In the United States about 20% of males will be diagnosed with the disease, although the majority will have low-risk (low-grade, low-volume) prostate cancer. For them, it can be appropriate to stay under conservatively managed active surveillance, meaning they do not have to undergo immediate therapy in favor of regular assessment and biopsies to monitor the disease.

Dutasteride is a 5α-reductase inhibitor that works by preventing testosterone from converting to dihydrotestosterone (the male sex hormone involved in the development of prostate cancer). The drug has been approved for treating benign prostatic hyperplasia, a non-cancerous enlargement of the prostate, and has shown to decrease the volume of some prostate cancers.

302 men aged between 48 to 82 years old undergoing active surveillance for low-risk localized prostate cancer were enrolled to participate in the Reduction by Dutasteride of Clinical Progression Events in Expectant Management (REDEEM). The researchers randomly assigned the participants to two groups; one group received 0.5 mg dutasteride once daily for 3 years, while the other group received placebo for the same duration.

In order to measure time to disease progression, participants received biopsies at 18 months and 3 years. In addition, the researchers gave participants a questionnaire in order to examine anxiety associated to the disease.

The researchers found that dutasteride considerably delayed disease progression in comparison with placebo – 48% of men given placebo experienced disease progression compared with 38% of participants receiving dutasteride.

Furthermore, cancer was less likely to be detected at final biopsy for participants in the dutasteride group (36% [50 men]) compared with 23% (31) men in the placebo group. Throughout the duration of the study, those who received dutasteride also reported considerably lower cancer-related anxiety compared with men in the placebo group.

Similar side effects were observed between both groups. Drug-related adverse effects, consisting mainly of adverse sexual events or breast enlargement or tenderness, were experienced by more participants in the dutasteride group (24%) than those given placebo (15%). There were no cases of disease spread or deaths related to prostate cancer during the duration of the study.

In an associated comment, Chris Parker from the Royal Marsden National Health Service Foundation Trust, Sutton, UK warns:

“These data are consistent with the hypothesis that dutasteride reduces the volume of low-grade prostate cancers but has no effect, or even an adverse effect, on the progression of high-grade disease. Thus, although reducing overall prostate cancer detection, dutasteride could plausibly have no effect (or possibly a deleterious one) on prostate cancer mortality.”

The researchers conclude:

“The benefit of dutasteride is to reduce the amount of low-grade cancer, not to reduce the risk of being diagnosed with higher-grade cancer. This reduction leads to fewer men with biopsy-detectable prostate cancer, and therefore fewer treatment interventions. Dutasteride…provides a treatment option for men with low-risk, localized disease.”

Written by Grace Rattue

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Source: http://www.medicalnewstoday.com/articles/240752.php

Main Category: Prostate / Prostate Cancer
Also Included In: MRI / PET / Ultrasound;  Neurology / Neuroscience
Article Date: 25 Jan 2012 – 1:00 PST

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Preoperative MRI helps surgeons make more informed decisions about nerve-sparing procedures in men with prostate cancer, according to a new study published online in the journal Radiology.

Excluding skin cancer, prostate cancer is the most common cancer diagnosed in American men, according to the Centers for Disease Control and Prevention. Open radical prostatectomy, or removal of the prostate, is a common treatment for the disease, but it carries substantial risks, including incontinence and impotence.

“I think preoperative MRI will be useful for surgeons who are uncertain whether to spare or resect the nerves,” said Daniel J. A. Margolis, M.D., assistant professor of radiology at the David Geffen School of Medicine at the University of California Los Angeles. “Our surgeons feel that, compared with clinical information alone, MRI is worthwhile for all patients, because it identifies important information leading to a change in the surgical plan in almost a third of patients.”

Robotic-assisted laparoscopic prostatectomy (RALP) is a newer treatment performed with the assistance of a surgical robot. RALP uses smaller incisions than those of open radical prostatectomy and offers improved cosmetic results, less blood loss and briefer postoperative convalescence. However, surgeons performing RALP lack tactile feedback, which may compromise their ability to evaluate neurovascular bundles – the collections of blood vessels and nerves that course alongside prostate. An aggressive surgical approach could unnecessarily damage the bundles and leave patients with loss of function, while an approach that is not aggressive enough may leave some cancer behind. There are no conventional preoperative urological techniques that provide information to take the place of tactile feedback.

Dr. Margolis and colleagues investigated endorectal coil MR imaging as a way to improve preoperative assessment of prostate cancer and the involvement of the neurovascular bundles. They prospectively evaluated 104 prostate cancer patients who underwent preoperative endorectal coil MRI of the prostate and subsequent RALP. The researchers determined the differences in the surgical plan before and after review of the MRI report and compared them with the actual surgical and pathologic results.

Preoperative prostate MRI data changed the decision to use a nerve-sparing technique during RALP in 28 (27 percent) of the 104 patients. The surgical plan was changed to the nerve-sparing technique in 17 (61 percent) of the 28 patients and to a non-nerve-sparing technique in 11 patients (39 percent). The decision to opt for nerve-sparing surgery did not compromise oncologic outcome.

Dr. Margolis cautioned that the study group represented a population of men with low to medium grade cancer and that the findings might not apply to all patients.

“There is a learning curve for prostate MRI,” Dr. Margolis said. “What we and others have found is that one has to select patients where there is likely to be a benefit from the imaging.”

For the approach to become more commonplace, Dr. Margolis said that two things were needed: a better way to stratify which patients would benefit from preoperative MRI, and a more standardized means of acquiring and interpreting prostate MRI results.

“The former is something we are investigating now,” Dr. Margolis said. “The latter is something that a number of leading experts in prostate MRI are working toward. However, most centers already have this technology, so this may become widespread relatively soon.”

“Use of MR Imaging to Determine Management of the Neurovascular Bundles at Robotic-Assisted Laparoscopic Prostatectomy.” Collaborating with Dr. Margolis were Timothy D. McClure, M.D., Robert E. Reiter, M.D., James W. Sayre, Ph.D., Albert Thomas, Ph.D., Rajakumar Nagarajan, Ph.D., Mittul Gulati, M.D., and Steven S. Raman, M.D.
Radiological Society

of North America

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Source: http://www.medicalnewstoday.com/releases/240719.php

Main Category: Prostate / Prostate Cancer
Also Included In: MRI / PET / Ultrasound;  Neurology / Neuroscience
Article Date: 25 Jan 2012 – 1:00 PST

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Preoperative MRI helps surgeons make more informed decisions about nerve-sparing procedures in men with prostate cancer, according to a new study published online in the journal Radiology.

Excluding skin cancer, prostate cancer is the most common cancer diagnosed in American men, according to the Centers for Disease Control and Prevention. Open radical prostatectomy, or removal of the prostate, is a common treatment for the disease, but it carries substantial risks, including incontinence and impotence.

“I think preoperative MRI will be useful for surgeons who are uncertain whether to spare or resect the nerves,” said Daniel J. A. Margolis, M.D., assistant professor of radiology at the David Geffen School of Medicine at the University of California Los Angeles. “Our surgeons feel that, compared with clinical information alone, MRI is worthwhile for all patients, because it identifies important information leading to a change in the surgical plan in almost a third of patients.”

Robotic-assisted laparoscopic prostatectomy (RALP) is a newer treatment performed with the assistance of a surgical robot. RALP uses smaller incisions than those of open radical prostatectomy and offers improved cosmetic results, less blood loss and briefer postoperative convalescence. However, surgeons performing RALP lack tactile feedback, which may compromise their ability to evaluate neurovascular bundles – the collections of blood vessels and nerves that course alongside prostate. An aggressive surgical approach could unnecessarily damage the bundles and leave patients with loss of function, while an approach that is not aggressive enough may leave some cancer behind. There are no conventional preoperative urological techniques that provide information to take the place of tactile feedback.

Dr. Margolis and colleagues investigated endorectal coil MR imaging as a way to improve preoperative assessment of prostate cancer and the involvement of the neurovascular bundles. They prospectively evaluated 104 prostate cancer patients who underwent preoperative endorectal coil MRI of the prostate and subsequent RALP. The researchers determined the differences in the surgical plan before and after review of the MRI report and compared them with the actual surgical and pathologic results.

Preoperative prostate MRI data changed the decision to use a nerve-sparing technique during RALP in 28 (27 percent) of the 104 patients. The surgical plan was changed to the nerve-sparing technique in 17 (61 percent) of the 28 patients and to a non-nerve-sparing technique in 11 patients (39 percent). The decision to opt for nerve-sparing surgery did not compromise oncologic outcome.

Dr. Margolis cautioned that the study group represented a population of men with low to medium grade cancer and that the findings might not apply to all patients.

“There is a learning curve for prostate MRI,” Dr. Margolis said. “What we and others have found is that one has to select patients where there is likely to be a benefit from the imaging.”

For the approach to become more commonplace, Dr. Margolis said that two things were needed: a better way to stratify which patients would benefit from preoperative MRI, and a more standardized means of acquiring and interpreting prostate MRI results.

“The former is something we are investigating now,” Dr. Margolis said. “The latter is something that a number of leading experts in prostate MRI are working toward. However, most centers already have this technology, so this may become widespread relatively soon.”

“Use of MR Imaging to Determine Management of the Neurovascular Bundles at Robotic-Assisted Laparoscopic Prostatectomy.” Collaborating with Dr. Margolis were Timothy D. McClure, M.D., Robert E. Reiter, M.D., James W. Sayre, Ph.D., Albert Thomas, Ph.D., Rajakumar Nagarajan, Ph.D., Mittul Gulati, M.D., and Steven S. Raman, M.D.
Radiological Society

of North America

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MediLexicon International Ltd
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Source: http://www.medicalnewstoday.com/releases/240719.php