Opioid Use after Nephrectomy for Kidney Cancer in Ontario: A Population-Based Study

OBJECTIVE

To compare the odds of early and prolonged post-operative opioid use in patients undergoing minimally invasive surgery (MIS) versus open surgery for nephrectomy.

METHODS

For opioid-naïve patients in Ontario who underwent nephrectomy for kidney cancer (1994-2017, n=7900), post-discharge opioid use was determined by prescriptions in the Ontario Drug Benefit database (age ≥65 years) and the Narcotics Monitoring System (all patients from 2012). Early opioid use was defined as ≥ 1 prescription 1-90 days after surgery. Two separate definitions of prolonged opioid use were examined: (1) prescription(s) for ≥ 60 days during post-operative days 90-365; (2) ≥ 1 prescriptions between both of: 1-90 days AND 91-180 days after surgery. Predictors of opioid use were assessed using multivariable generalized estimating equation logistic regression, accounting for surgeon clustering.

RESULTS

Overall, 67.4% of patients received early opioid prescriptions; however, prolonged use was low, ranging from 1.6 to 4.4% of patients depending on the definition. In multivariable analysis, open nephrectomy was associated with higher odds of early opioid use compared to MIS nephrectomy (Odds Ratio [OR] 1.36, 95% Confidence Interval [CI] 1.19-1.55). Surgery type was not significantly associated with prolonged opioid use for either definition (OR 1.22, CI 0.79 1.89 and OR 1.06, CI 0.83, 1.35).

CONCLUSIONS

In this population-level study of patients undergoing nephrectomy for kidney cancer, patients who received open surgery were at increased odds of receiving early post-operative opioids compared to MIS. Prolonged opioid use was low overall and was not significantly with associated with type of surgery.

The role of lifestyle characteristics on prostate cancer progression in two active surveillance cohorts

BACKGROUND

Although much research has examined the relationship between lifestyle and prostate cancer (PCa) risk, few studies focus on the relationship between lifestyle and PCa progression. The present study examines this relationship among men initially diagnosed with low- to intermediate-risk PCa and managed with active surveillance (AS).

METHODS

Men enrolled in two separate AS programs were recruited for this study. Data regarding clinical, demographic and lifestyle characteristics were collected. Results were then compared between men whose disease remained low- to intermediate-risk and men whose disease progressed.

RESULTS

Demographic, clinical and physical characteristics were similar between comparative groups and cohorts, with the exception that age at the time of diagnosis and questionnaire was increased among men whose disease progressed. Lifestyle scores among men who remained low- to intermediate-risk were higher than those whose risk progressed; however, scores were only significant in one cohort on univariable analysis. On multivariable analysis, the only predictor of progression was age at diagnosis. Physical activity was consistently higher in both low risk groups, although this difference was insignificant. Consistent differences in other lifestyle variables were not observed.

CONCLUSIONS

Age remains an important predictor of PCa progression. Improving lifestyle characteristics among men initially managed with AS might help to reduce the risk of progression. Given the limitations of this study, more rigorous investigation is required to confirm whether lifestyle characteristics influence the progression of low- to intermediate-risk PCa.

Should follow-up biopsies for men on active surveillance for prostate cancer be restricted to limited templates?

OBJECTIVE

To investigate if prostate biopsy templates with fewer cores can be used during active surveillance (AS) for prostate cancer.

METHODS

At present, we use an AS protocol template (ASPT) consisting of 13-17 cores. We hypothesize in the setting of known cancer, sextant (6 cores) or standard extended (10-12 cores) templates, could be used with similar effect. We identified patients in our referral institution database (1997-2009) with entry prostate-specific antigen <10 ng/mL, stage ≤cT2, Gleason sum ≤6, ≤3 cores positive for cancer, <50% of single core involved, and age ≤75 years (N = 272). Patients fulfilling standard criteria for pathologic reclassification (N = 94) at any follow-up biopsy were selected for evaluation. By mapping tumor location on the pathologic reclassification determining biopsy, hypothetical scenarios of sextant or standard extended templates (SET) were compared with our ASPT and examined for frequency of cancer detection and pathologic reclassification.

RESULTS

For the 94 patients analyzed, the median number of cores taken was 9.7 (6-22) at baseline and 15 (14-17) for the reclassification biopsy. The median time between baseline and the pathologic reclassification determining biopsy was 15.4 months. Analysis of subgroupings showed that sextant template would identify 84% of cancers and 47.9% of the reclassification events, whereas SET detected 99% of cancers and 81.9% of patients who pathologically reclassified. When only considering Gleason sum ≥7 related progression events, SET found 16.2% less (n = 57) compared with ASPT (n = 68).

CONCLUSION

When monitoring patients on AS, a 13-17 core template detects more pathologic reclassification than standard sextant (18.1%) or extended (52.1%) biopsy templates.

Prevention strategies in prostate cancer

Prostate cancer (PCa) prevention has been an exciting and controversial topic since the results of the Prostate Cancer Prevention Trial (PCPT) were published. With the recently published results of the reduce (Reduction by Dutasteride of Prostate Cancer Events) trial, interest in this topic is at a peak. Primary pca prevention will be unlikely to affect mortality significantly, but the reduction in overtreatment and the effect on quality of life from the avoidance of a cancer diagnosis are important factors to consider.This review provides a comparative update on the REDUCE and PCPT trials and some clinical recommendations. Other potential primary preventive strategies with statins, selective estrogen response modulators, and nutraceutical compounds-including current evidence for these agents and their roles in clinical practice-are discussed. Many substances that have been examined in the primary prevention of pca and for which clinical data are either negative or particularly weak are not covered.The future of PCa prevention continues to expand, with several ongoing clinical trials and much interest in tertiary prostate cancer prevention.

Bone health practices in men on androgen deprivation therapy (ADT): A population-based analysis of 25,802 patients

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Background: ADT is used in up to 1 in 2 men with prostate cancer. Osteoporosis and fragility fractures are important side effects of ADT. Guidelines recommend 2 important bone health practices for men on ADT - measurement of bone mineral density with dual x-ray absorptiometry (DEXA) and use of bisphosphonates in men at risk of osteoporosis. The implementation of these guidelines in practice is not well known. Methods: Using linked administrative databases, we identified 25,802 men (mean age 75.9 y, range 66–100 y) with prostate cancer who were treated with at least 6 months of ADT or who underwent bilateral orchiectomy in Ontario, Canada between 1995 and 2005. Performance of DEXA and prescription of bisphosphonates were captured using specific procedure codes and drug identification numbers, respectively. Prior use of DEXA and bisphosphonates, as well as prior diagnoses of osteoporosis and fragility fracture, were captured with specific diagnostic codes and a 3 y look-back period. Annual rates per 100 person-years were determined for both outcomes. Results: Among 25,802 men, 3.09% had a DEXA more than one year prior to starting ADT, and 3.14% had a prior diagnosis of osteoporosis. Within 2 years of starting ADT, the rate of undergoing DEXA rose from 0.50 per 100 person-years in 1995 to 19.47 in 2005. Rates of DEXA testing were higher among those with a prior diagnosis of osteoporosis, prior DEXA test, or prior fragility fracture but did not reach rates above 50 per 100 person-years in any of these groups. Bisphosphonate use increased from 0.27 per 100 person-years in 1995 to 3.18 in 2005 among prior non-users. More men on ADT were started on a bisphosphonate in the third year after starting ADT as compared to the second year, and rates were higher in year 2 than year 1. Less than one-third of men starting a bisphosphonate underwent any DEXA testing within 12 months of bisphosphonate initiation. Conclusions: Rates of DEXA testing and bisphosphonate use have increased over time among older men starting ADT, but significant gaps and delays remain in the quality of bone health care in this population.

No significant financial relationships to disclose.

Prostate Cancers Scored as Gleason 6 on Prostate Biopsy are Frequently Gleason 7 Tumors at Radical Prostatectomy: Implication on Outcome

PURPOSE

Differentiation between Gleason score 6 and 7 in prostate biopsy is important for treatment decision making. Nevertheless, under grading errors compared with the actual pathological grade at radical prostatectomy are common. We compared the characteristics and outcomes of tumors that were scored 6 on prostate biopsy but were 7 on subsequent radical prostatectomy pathological evaluation to those in tumors with a consistent rating of Gleason score 6 or 7 at biopsy and surgery.

MATERIALS AND METHODS

We performed a retrospective database analysis from our referral center (1989 to 2004). We compared pre-prostatectomy characteristics, radical prostatectomy pathological features and the post-radical prostatectomy prostate specific antigen failure rate, defined as any 2 consecutive detectable prostate specific antigen measurements, in 3 subgroups of patients, including 156 with matched Gleason score 6 in the prostate biopsy and radical prostatectomy, 205 with upgraded Gleason score 6/7, that is prostate biopsy Gleason score 6 and radical prostatectomy Gleason score 7, and 412 with matched Gleason score 7 in the prostate biopsy and radical prostatectomy.

RESULTS

Radical prostatectomy Gleason score matched the prostate biopsy score in 38.2% of biopsy Gleason score 6 and 81.4% of biopsy Gleason score 7 cases. Higher prostate specific antigen was associated and an increased percent of cancer in the prostate biopsy was predictive of discordance between the prostate biopsy and radical prostatectomy Gleason scores (p <0.001). Margin (p = 0.0075) or seminal vesicle involvement (p = 0.0002), cancer volume (p <0.001) and the prostate specific antigen failures rate (p = 0.014) were significantly higher in under graded Gleason score 7 cancer compared to those in matched Gleason score 6 cases. However, they were comparable to those with a matched Gleason score 7 tumor grade (p = 0.66).

CONCLUSIONS

Almost half of tumors graded Gleason score 6 at biopsy are Gleason score 7 at surgery. Upgraded Gleason score 6 to 7 tumors have outcomes similar to those of genuine Gleason score 7 cancer. For prostate biopsy Gleason score 6 tumors clinicians should consider the overall likelihood of tumor upgrading as well as specific patient characteristics, such as prostate specific antigen and the percent of tumor in the prostate biopsy, when contemplating treatments that are optimized for low grade tumors, including watchful waiting or brachytherapy.

Is physical function affected by androgen deprivation therapy (ADT) in men with non-metastatic prostate cancer?

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Background: Although prolonged use ofADT is hypothesized to adversely affect physical function, only a few small studies have examined this relationship and it remains unclear if self-reported weakness represents a decline in actual physical performance or is related to fatigue. Loss of physical function may be particularly important to older men who already have limited functional reserves. Methods: Men age 50 or older with non-metastatic prostate cancer who were starting continuous ADT were enrolled in this prospective longitudinal study. Physical function was tested using a Jamar dynamometer (grip strength), the Timed Up and Go (TUG) test, and the six-minute walk test (6MWT), representing upper extremity strength, lower extremity strength, and endurance, respectively. Assessments were done at baseline (prior to ADT), 3 months, 6 months, and 12 months. Results: 42 patients on ADT have been enrolled to date (mean age 74.8 y). There was a gradual but steady decline in grip strength from baseline (39.2 kg) to 3 months (38.1 kg), 6 months (37.9 kg), and 12 months (35.3 kg) (p < 0.05 for all comparisons). On average, patients took 7.3 seconds to complete the TUG and walked 1507 feet during the 6MWT at baseline. TUG and 6MWT scores did not worsen over time (p > 0.05). Conclusions: Preliminary data suggest that 3–12 months of ADT is associated with worsening upper extremity strength but lower extremity strength and endurance are relatively unaffected. A larger sample size is needed to determine if all aspects of physical function or only upper extremity strength deteriorate with ADT use. Additionally, most patients in our study reported excellent health and functional status at baseline and our results may not adequately reflect the impact of ADT in more frail older men.

No significant financial relationships to disclose.

Qualitative assessment of patient experiences related to extended pelvic resection for rectal cancer

BACKGROUND

Patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) represent a complex management challenge. While there is potential for cure in a subset of patients, the cost in terms of morbidity can be high. Few descriptions of the physical, psychological, social, and emotional experiences of these patients exist.

METHODS

Face-to-face interviews were completed with ten LARC and LRRC patients treated with multimodal therapy that included surgery. Patient opinions and experiences were explored in depth until information redundancy and common themes were delineated using qualitative research methods. Clinical information was obtained from the database.

RESULTS

Nine of the ten patients were male, seven had LARC, and the median age was 71. Six themes were identified from the patient interviews. Themes reflected patients' highly focused desire to seek wellness and cure, but also revealed misunderstanding of their disease biology, probability of cure, therapeutic options, and treatment morbidity.

CONCLUSIONS

Patient experiences confirm that this is challenging treatment to complete, and that patient understanding of pre-operative information is incomplete. Our findings underscore the need for a multidisciplinary approach when managing this patient population, with emphasis on both supportive care needs and the technically skilled delivery of surgery, chemotherapy, and radiotherapy.

Novel antiproliferative flavonoids induce cell cycle arrest in human prostate cancer cell lines

Epidemiologic studies have demonstrated an inverse association between flavonoid intake and prostate cancer (PCa) risk. The East Asian diet is very high in flavonoids and, correspondingly, men in China and Japan have the lowest incidence of PCa worldwide. There are thousands of different naturally occurring and synthetic flavonoids. However, only a few have been studied in PCa. Our aim was to identify novel flavonoids with antiproliferative effect in PCa cell lines, as well as determine their effects on cell cycle. We have screened a representative subgroup of 26 flavonoids for antiproliferative effect on the human PCa (LNCaP and PC3), breast cancer (MCF-7), and normal prostate stromal cell lines (PrSC). Using a fluorescence-based cell proliferation assay (Cyquant), we have identified five flavonoids, including the novel compounds 2,2'-dihydroxychalcone and fisetin, with antiproliferative and cell cycle arresting properties in human PCa in vitro. Most of the flavonoids tested exerted antiproliferative effect at lower doses in the PCa cell lines compared to the non-PCa cells. Flow cytometry was used as a means to determine the effects on cell cycle. PC3 cells were arrested in G2/M phase by flavonoids. LNCaP cells demonstrated different cell cycle profiles. Further studies are warranted to determine the molecular mechanism of action of 2,2'-DHC and fisetin in PCa, and to establish their effectiveness in vivo.

Synergistic effect of vitamin E and selenium in human prostate cancer cell lines

Vitamin E and selenium are the two most popular dietary supplements used to prevent prostate cancer. The hypothesis that these antioxidants reduce prostate risk is being tested in the selenium and vitamin E chemoprevention trial (SELECT). We hypothesize that selenium potentiates vitamin E-induced inhibition of prostate cancer cell growth in vitro. Prostate cancer cell populations growing asynchronously were treated with a combination of vitamin E and selenium and processed for flow cytometric analysis. Prostate cancer cells treated with a combination of the antioxidants revealed that selenium potentiates vitamin E-induced inhibition of LNCaP cells in vitro. This was demonstrated by a reduction in the percentage of cells in the S phase. This crucial finding confirms our previous observations that antioxidant molecules act via distinct mechanistic pathways. These independent biological effects can be exploited in order to augment the anticancer properties of individual agents. These data also validate the two factorial design of the SELECT trial, permitting pairwise comparisons between agents in combination and alone.

High level perinuclear antineutrophil cytoplasmic antibody (pANCA) in ulcerative colitis patients before colectomy predicts the development of chronic pouchitis after ileal pouch-anal anastomosis

BACKGROUND

The reported cumulative risk of developing pouchitis in ulcerative colitis (UC) patients undergoing ileal pouch-anal anastomosis (IPAA) approaches 50% after 10 years. To date, no preoperative serological predictor of pouchitis has been found.

AIMS

To assess whether preoperative perinuclear antineutrophil cytoplasmic antibody (pANCA) expression was associated with acute and/or chronic pouchitis after IPAA.

METHODS

Patients were prospectively assessed for the development of clinically and endoscopically proved pouchitis. Serum obtained at the time of colectomy in 95 UC patients undergoing IPAA was analysed for pANCA by ELISA and indirect immunofluorescence. pANCA+ patients were stratified into high level (>100 ELISA units (EU)/ml) (n=9), moderate level (40-100 EU/ml) (n=32), and low level (<40 EU/ml) (n=19) subgroups.

RESULTS

Sixty of the 95 patients (63%) expressed pANCA. After a median follow up of 32 months (range 1-89), 32 patients (34%) developed either acute (n=14) or chronic (n=18) pouchitis. Pouchitis was seen in 42% of pANCA+ patients compared with 20% of pANCA- patients (p=0.09). There was no significant difference in the incidence of acute pouchitis between the three pANCA+ patient subgroups. The cumulative risk of developing chronic pouchitis among patients with high level pANCA (56%) before colectomy was significantly higher than in patients with medium level (22%), low level (16%), and those who were pANCA- (20%) (p=0.005). Multivariate analysis revealed that the sole parameter significantly associated with the development of chronic pouchitis after IPAA was the presence of high level pANCA before colectomy (p=0.005).

CONCLUSION

High level pANCA before colectomy is significantly associated with the development of chronic pouchitis after IPAA.

Early experience in intermediate-risk penile cancer with sentinel node identification using the gamma probe

OBJECTIVES

To report the initial experience with sentinel node identification using the gamma probe in patients with intermediate-risk penile cancer (T2NXM0, or T1 with intermediate or high-grade disease) and impalpable groin nodes.

METHODS

Technetium-99m-labeled sulfur colloid was injected at the site of primary penile carcinoma 1 hour before surgery. The sentinel lymph nodes were located using the gamma probe and excised through a 3-cm inguinal incision. A full groin dissection was performed only in cases in which frozen section of the node demonstrated metastasis.

RESULTS

Nine sentinel nodes were identified by the gamma probe and excised in 5 men. In 3 patients, the sentinel nodes were negative bilaterally. In 2 patients, the sentinel node, although grossly normal, showed a single focus of metastasis by frozen section analysis. In both of these patients, a full groin dissection was carried out and revealed no other nodal metastases. All 5 remained free of recurrence (median follow-up 18 months, range 16 to 23).

CONCLUSIONS

In patients with microscopic involvement of a single lymph node only (confirmed by full groin dissection), gamma probe identification was 100% accurate. None of the patients with negative sentinel nodes had a recurrence. Biopsy of the sentinel nodes using the gamma probe can predict the presence or absence of inguinal node metastasis in patients with intermediate-risk penile cancer, sparing many patients the long-term morbidity of a full groin dissection. These initial results suggest further study is warranted.

Antioxidant dietary supplements: Rationale and current status as chemopreventive agents for prostate cancer

Epidemiologic data suggest that the environment is responsible for most prostate cancers (PCA). One major mechanism by which the environment can influence carcinogenesis is oxidative damage. This refers to the generation of reactive oxygen species (ROS) that then damage important biomolecules, including DNA, protein, and lipids. Experimental observations suggest that oxidative damage is associated with PCA. These include: a) the association of PCA and dietary fat consumption (a major substrate for oxidative stress), b) oxidative biomarker data (suggesting increased oxidative stress among patients with PCA), c) ubiquitous defects in the glutathione-s-transferase pi pathway (a major endogenous antioxidant mechanism), and d) evidence that androgens (an important promoter of PCA growth) work in part via generation of ROS. Perhaps the best indirect evidence for oxidative stress comes from randomized double-blind prevention trials of antioxidants. Vitamin E and selenium have both been shown to reduce prostate cancer incidence. Although PCA prevention was not the primary endpoint of these studies, the statistical likelihood that both would prove beneficial by chance alone is 1 in 400. These data suggest that antioxidants may be beneficial in preventing PCA. Further research including randomized trials is warranted.

Trends in hormonal management of prostate cancer: a population-based study in Ontario

OBJECTIVE

To provide a population-based description of current practice in the use of hormonal management of prostate cancer. DESIGN,SETTING & PARTICIPANTS: All men in Ontario, Canada, age 65 and older, with confirmed prostate cancer starting maintained hormonal therapy, from July 1992 through December 1998 (11,435 patients). Data sources included the provincial drug benefit plan, hospital services data, and Ontario Cancer Registry.

OUTCOME MEASURES

Rates and trends in the use of: surgical or medical castration; total androgen blockade (TAB); and monotherapies based on steroidal or nonsteroidal antiandrogens.

RESULTS

In 5.5 years, use of 'standard' therapy based on surgical or medical castration alone dropped from 36% to 26% of patients, while the use of TAB doubled from 22% to 41%. Approximately 15% of patients received nonsteroidal antiandrogens without evidence of therapy aimed at central androgen blockade. Marked regional differences were observed and not explained by patient age or practitioner specialty.

CONCLUSIONS

New hormonal therapies for prostate cancer have implications in terms of disease control, patient survival, side effects, and costs. Rapid growth in prescribing of antiandrogens may represent an unnecessary expense for public or private payers, and observed regional differences likely reflect lack of consensus on the relative merit of TAB. Patients and practitioners must have current information on the advantages and disadvantages of different therapeutic options, and quality-of life, particularly with respect to emerging drug therapies.

Diet, androgens, oxidative stress and prostate cancer susceptibility

Prostate cancer is the most common human malignancy and the second leading cause of cancer deaths among men in Western nations. Descriptive epidemiologic data suggest that androgens and/or environmental exposures, such as diet (in particular, dietary fat), play an important role in prostatic carcinogenesis. One plausible link between diet and prostate cancer is oxidative stress. This process refers to the generation of reactive oxygen species, which can then trigger a host of pro-carcinogenic processes. Recent studies also indicate that androgens increase oxidative stress within human prostate cancer cell lines. Recent data from our institution indicate that oxidative stress is higher within the benign epithelium of prostate cancer patients than men without the disease. This confirms our hypothesis and suggests that antioxidants such as lycopene, vitamin E, and selenium may play an important role in preventing disease progression. Large-scale clinical trials with some of these agents are currently in the design phase.

Clinical significance of small (less than 0.2 cm3) hypoechoic lesions in men with normal digital rectal examinations and prostate-specific antigen levels less than 10 ng/mL

OBJECTIVES

Most men diagnosed with prostate cancer in 1998 presented with a normal digital rectal examination (DRE) and minimal elevations in serum prostate-specific antigen (PSA) (less than 10 ng/mL). Considerable attention is often given toward identifying small hypoechoic (less than 0.2 cm3) lesions at the time of transrectal ultrasound-guided prostate biopsy. We sought to determine the significance of these lesions and whether an additional biopsy of this area is clinically useful.

METHODS

A prospective data base containing detailed information on 614 biopsies performed by a single urologist was examined. All patients with a hypoechoic lesion underwent sextant prostate biopsy plus a separately labeled core directed through the hypoechoic area. Eighty-one patients who fit the following criteria were assessed: PSA less than 10 ng/mL, normal DRE, and hypoechoic lesion volume less than 0.2 cm3.

RESULTS

The mean age of this group was 63.5 years, and the mean PSA was 7.1 ng/mL. Of the 81 patients with small hypoechoic lesions, 20 (24.7%) were positive for cancer in at least one prostatic core. Of the 81 hypoechoic area biopsies (HABs), 14 (17.3%) were positive for cancer; 1 (1.2%) demonstrated high-grade prostatic intraepithelial neoplasia, and 66 (81 .5%) were negative. In 11 of the patients (78.6%) with positive HABs, at least one additional core was positive for cancer. In 3 of the patients (21.4%) with positive HABs, no additional cores were positive for cancer (P<0.05).

CONCLUSIONS

A significant proportion of small hypoechoic lesions in patients with early T1c prostate cancer are positive for malignancy. Although the overall yield of separate hypoechoic area biopsy is low (3.7%), approximately 15% of cancers would be missed if directed HABs were not performed (P<0.05). Identification and biopsy of small hypoechoic lesions are indicated in this group of patients.

Repeat transrectal ultrasound-guided prostate biopsy: a strategy to improve the reliability of needle biopsy grading in patients with well-differentiated prostate cancer

OBJECTIVES

Gleason grade from prostate needle biopsy (PNB) specimens is important in guiding therapeutic decision making in patients with localized prostate cancer. Recent data from our institution suggest a significant discordance between Gleason grading from PNB versus the actual pathologic grade at radical prostatectomy (RRP). Of most concern is that a substantial proportion of patients with Gleason score of 6 or less from PNB actually have Gleason score of 7 or more at RRP. Under classic measurement theory, one useful way to improve the reliability of an inherently unreliable test is to repeat it. We investigated this strategy in an effort to reduce undergrading errors.

METHODS

The control group of patients (n = 51) from our neoadjuvant androgen deprivation protocol was used as the test (two-biopsy) group in this study. These patients underwent two separate PNBs before RRP. We used the highest Gleason score from the two biopsies in these patients and compared the error rates with a concurrent group of patients treated at our institution (n = 226) who had only one set (single-biopsy group) of prostate biopsies. All pathologic slides were reviewed at our institution. Any PNB grade of 6 or less that was scored as 7 or more on final pathology was considered significant.

RESULTS

Mean age, prostate-specific antigen levels, and stage distribution were not significantly different between these two groups. In the single-biopsy group, 165 patients had PNB Gleason score of 6 or less. Of these patients, 63 (38%) had final pathologic grade of 7 or more. In the two-biopsy group, 37 patients had PNB Gleason score of 6 or less. Of these patients, only 7 (19%) had final pathologic grade of 7 or more (P = 0.04).

CONCLUSIONS

Prostate rebiopsy minimizes the inherent unreliability of PNB derived grade and should be considered for patients in whom watchful waiting or nomogram-based therapy has been selected.

Dose escalation with three-dimensional conformal radiation therapy affects the outcome in prostate cancer

PURPOSE

Three-dimensional conformal radiation therapy (3D-CRT) is a technique designed to deliver prescribed radiation doses to localized tumors with high precision, while effectively excluding the surrounding normal tissues. It facilitates tumor dose escalation which should overcome the relative resistance of tumor clonogens to conventional radiation dose levels. The present study was undertaken to test this hypothesis in patients with clinically localized prostate cancer.

METHODS AND MATERIALS

A total of 743 patients with clinically localized prostate cancer were treated with 3D-CRT. As part of a phase I study, the tumor target dose was increased from 64.8 to 81 Gy in increments of 5.4 Gy. Tumor response was evaluated by post-treatment decrease of serum prostate-specific antigen (PSA) to levels of < or = 1.0 ng/ml and by sextant prostate biopsies performed > or = 2.5 years after completion of 3D-CRT. PSA relapse-free survival was used to evaluate long-term outcome. The median follow-up was 3 years (range: 1-7.6 years).

RESULTS

Induction of an initial clinical response was dose-dependent, with 90% of patients receiving 75.6 or 81.0 Gy achieving a PSA nadir < or = 1.0 ng compared with 76% and 56% for those treated with 70.2 Gy and 64.8 Gy, respectively (p < 0.001). The 5-year actuarial PSA relapse-free survival for patients with favorable prognostic indicators (stage T1-2, pretreatment PSA < or = 10.0 ng/ml and Gleason score < or = 6) was 85%, compared to 65% for those with intermediate prognosis (one of the prognostic indicators with a higher value) and 35% for the group with unfavorable prognosis (two or more indicators with higher values) (p < 0.001). PSA relapse-free survival was significantly improved in patients with intermediate and unfavorable prognosis receiving > or = 75.6 Gy (p < 0.05). A positive biopsy at > or = 2.5 years after 3D-CRT was observed in only 1/15 (7%) of patients receiving 81.0 Gy, compared with 12/25 (48%) after 75.6 Gy, 19/42 (45%) after 70.2 Gy, and 13/23 (57%) after 64.8 Gy (p < 0.05).

CONCLUSIONS

The data provide evidence for a significant effect of dose escalation on the response of human prostate cancer to irradiation and defines new standards for curative radiotherapy in this disease.

Cancer of the prostate: a nutritional disease?

In summary, epidemiologic and laboratory evidence increasingly demonstrate that nutritional factors, especially reduced fat intake, soy proteins, vitamin E derivatives, and selenium, may have a protective effect against prostate cancer. The experimental observation that low-fat diets and soy protein extracts may influence the progression of established tumors, rather than inhibiting etiologic factors, is particularly intriguing because it may serve to help explain the paradox whereby the incidence of clinical prostate cancer shows wide geographic variation, yet the evidence persists that the incidence of microfocal tumors is essentially the same worldwide. These observations, plus the likelihood that nutrition trials are likely to have little in the way of toxicity that would preclude their completion, argue that such trials should be performed. It is estimated that 30% to 50% of human malignancies may be related to dietary factors, and although the feasibility of trials involving low-fat diets has been proved in ongoing trials for colon and breast cancer, no similar study exists for prostate malignancy. Critics of epidemiologic research argue that data derived from case-control studies are subject to recall bias and are thus artifactual. Indeed, many researchers now believe that the breast cancer-dietary fat hypothesis has been discredited. The major difference between the prostate cancer and breast cancer literature is the remarkable consistency of the cohort studies. In these studies, exposure is determined prospectively and is therefore free from recall bias. In this sense they more closely resemble a clinical trial. The majority of cohort studies involving dietary fat and breast cancer have been negative. We believe that these data justify large-scale trials in the area of prevention of prostate cancer. One such proposed study already submitted for National Institutes of Health funding from a consortium of centers is the Prostate Interventional Nutrition Study (PINS), modeled after the Women's Interventional Nutrition Study, which investigates the effect of low-fat diets in women receiving therapy for node-positive breast cancer. The PINS study will be limited to men who have detectable serum PSA levels but no other clinical evidence of disease after radical prostatectomy. All subjects will receive nutritional guidance, with randomization between a control arm receiving the currently recommended 30% fat diet and an interventional arm in which a 15% fat diet is supplemented with soy protein, vitamin E, and selenium. The end points for evaluation will be compared with progression based on changes in PSA and the time of onset of clinical, as opposed to biochemical, disease. Single-institution trials involving groups thought to be at high risk of developing clinical cancer--including men with persistently elevated PSA levels, two negative prostate biopsies, high-grade prostatic intraepithelial neoplasia on biopsy, and a strong family history of prostate cancer--are being initiated at MSKCC and other institutions.

CONCLUSIONS

We have reviewed the evidence that nutritional factors play a role in the progression rate of prostate cancer and may help to explain the geographic variation in the incidence observed. However, without well-controlled prospective trials, the attractive hypothesis that nutrition plays a role in tumor progression remains simply an attractive hypothesis. To date, no definite proof of a preventive effect has been shown in a study that will withstand rigid scientific scrutiny. The opportunity exists, however, for the urologic community, working together with experts in the area of nutrition, not only to advance our understanding of prostate tumorigenesis, but to rebut those critics of modern medical technology who claim that we have ignored the total or holistic approach to healing. (ABSTRACT TRUNCATED)

Prevalence and predictors of a positive repeat transrectal ultrasound guided needle biopsy of the prostate

PURPOSE

We determined the prevalence of and risk factors for carcinoma in patients with 1 previously negative prostate biopsy.

MATERIALS AND METHODS

Transrectal ultrasound guided prostate needle biopsies were repeated in 130 men. Risk factors analyzed included age, pathological result of initial biopsy, inter-biopsy interval, prostate specific antigen (PSA), PSA density, PSA velocity, digital rectal examination, abnormal transrectal ultrasound and family history of prostate cancer.

RESULTS

A total of 39 patients (30%) had positive biopsies for cancer. Univariate analysis revealed that PSA more than 20 ng./ml. and abnormal transrectal ultrasound were more frequent in men with positive second biopsies. Using multivariate logistic regression analysis only PSA more than 20 ng./ml. was a significant risk factor (adjusted odds ratio 4.48, 95% confidence interval 1.02 to 20.1). We determined the incidence of carcinoma in patients who represent the lowest risk group as defined by PSA less than 10 ng./ml., PSA density less than 0.15 mg./ml./cm.3, PSA velocity less than 0.75, ng./ml. per year, no prostatic intraepithelial neoplasia plus negative transrectal ultrasound, digital rectal examination and family history. Of 21 patients who fit this cohort 5 (23.8%) had carcinoma on repeat biopsy.

CONCLUSIONS

A significant false-negative rate for initial transrectal ultrasound guided prostate biopsies exists. Baseline risk in lowest risk patients is sufficiently high such that one cannot define a subset of patients for whom repeat biopsy is unnecessary. We recommend repeat biopsy in all patients who meet the criteria for a transrectal ultrasound guided biopsy and in whom the initial biopsy is negative.

Prognostic significance of prostate-specific antigen in stage T1c prostate cancer treated by radical prostatectomy

OBJECTIVES

Increasingly, nonpalpable prostate-specific antigen (PSA)-detected (Stage T1c) tumors are being treated with curative intent. Presently, only limited information is available regarding pathologic findings correlated with preoperative PSA levels. Herein, we report the characteristics of Stage T1c tumors in a contemporary surgical series.

METHODS

Clinical and pathologic results in 107 patients with Stage T1c tumors treated with radical prostatectomy were compared with those in 300 patients with palpable (Stage T2) tumors. Multivariate analysis was performed to determine which clinical variables independently predicted pathologic staging.

RESULTS

Stage T1c tumors were equivalent to Stage T2 tumors with respect to organ-confined and margin-positive rates. PSA level was the strongest independent predictor of extracapsular and margin-positive rates (P = 0.003). The absence of palpability was not a significant predictor of pathologic outcome. Significantly higher rates of organ- and specimen-confined disease were seen in patients with PSA levels less than 10.0 ng/mL, particularly less than 7.0 ng/mL. Patients with serum PSA levels greater than 20 ng/mL were at high risk for positive margins (relative risk 5.42, P < 0.001).

CONCLUSIONS

Stage T1c tumors represent a heterogeneous group of cancers. These tumors are pathologically similar to Stage T2 tumors, and patients should be offered similar treatment options. PSA level was the strongest predictor of pathologic stage, irrespective of tumor palpability. These results suggest that efforts directed toward identifying cancers, including nonpalpable tumors, in patients with early PSA elevations may result in improved rates of organ-confined disease. The impact of treatment on Stage T1c tumors remains to be defined.

Indications for transition zone biopsy in the detection of prostatic carcinoma

PURPOSE

We determined the indications for transition zone biopsy in the detection of prostatic carcinoma.

MATERIALS AND METHODS

A total of 185 men underwent 204 transition zone prostate biopsies due to elevated prostate specific antigen (PSA) alone in 19 (group 1), with hypoechoic transition zone lesions in 10 (group 2) and with a previous negative transrectal ultrasound guided biopsy in 156 (group 3). In addition, 13 men underwent 19 repeat transition zone biopsies.

RESULTS

Of the patients 58 (31.4%) had positive biopsies, with 8 (4.3%) having cancer in the transition zone biopsies only. In 3 men with positive peripheral and transition zone biopsies the cancer was upgraded based on the transition zone specimens. No patient with elevated PSA and no previous biopsy (group 1) or sonographic transition zone abnormalities (group 2) had a positive transition zone biopsy only. None of the analyzed risk factors (age, PSA, prostate volume, PSA density or PSA velocity) was significantly greater in men with isolated transition zone tumors.

CONCLUSIONS

Routine transition zone biopsies should be reserved for patients with previously negative transrectal ultrasound guided biopsies. In some patients disease upgrading based on transition zone biopsies may influence treatment decisions.

Correlation between Gleason score of needle biopsy and radical prostatectomy specimen: accuracy and clinical implications

PURPOSE

Despite the reliability of Gleason grading with respect to the same specimen, the correlation between the biopsy and prostatectomy specimen is less well defined. We compared the accuracy of Gleason grading of biopsies in predicting histological grading of radical retropublic prostatectomy specimens.

MATERIAL AND METHODS

Gleason scores of 18 gauge needle biopsies were compared to those of radical retropublic prostatectomy specimens in 226 consecutive patients. In addition to comparing numeric discrepancies, differences between biopsy and specimen Gleason scores of 2 or more and a change in group from Gleason scores 2 to 4, 5 to 7 or 8 to 10 were evaluated by kappa testing, as well as any change in group from Gleason scores 2 to 4, 5 and 6, 7 and 8 to 10.

RESULTS

The biopsy score was identical to the specimen score in 31% of cases, while 26% were discrepant by 2 or more Gleason scores. Overall, 54% of biopsies were under graded, while 15% were over graded. If only cases in which discrepancies of 2 or more Gleason scores and a change in group were considered, there was good overall agreement (kappa 0.468, accuracy 80%). Among the cases with any change in group, the accuracy was only 46% with poor agreement (kappa 0.153).

CONCLUSIONS

Overall, the reliability of Gleason grading of needle biopsies in predicting final pathology was good. However, the limitations of Gleason grading based on biopsy should be considered when discussing treatment options and comparing results based on biopsy data.

Anti-androgenic effects of combination finasteride plus flutamide in patients with prostatic carcinoma

OBJECTIVES

To determine the anti-androgenic effects and safety of the combination of finasteride and flutamide in men with prostate cancer.

PATIENTS AND METHODS

Seventeen men with various stages of prostate cancer, all of whom were candidates for androgen deprivation therapy, were treated with finasteride plus flutamide and were followed for a mean of 13.6 months using measurements of serum prostate specific antigen (PSA), and an assessment of regression and side-effects.

RESULTS

The initial median PSA level was 19.8 ng/mL: at 3, 6 and 12 months the median PSA had fallen to 1.2, 0.85 and 0.8 ng/mL, respectively. In four patients followed for 2 years, the anti-neoplastic effects were sustained. Patients with initially palpable disease had regression, as assessed by a digital rectal examination. Side-effects included gynaecomastia (five patients), mildly elevated hepatic transaminases (two) and diarrhoea (one). Most men maintained their previous sexual function.

CONCLUSIONS

Early results suggest that the combination of finasteride and flutamide provides significant anti-androgenic therapy and maintains sexual function in most men. A further investigation with more patients and a longer follow-up is warranted.

The National Cancer Data Base report on bladder carcinoma. The American College of Surgeons Commission on Cancer and the American Cancer Society

BACKGROUND

Previous Commission on Cancer Data from the National Cancer Data Base (NCDB) have examined time trends in stage of disease, treatment patterns, and survival for selected cancers. The most current (1993) data relating to patients with bladder carcinoma are described here.

METHODS

Five calls for data have yielded a total of 3,700,000 cases for the years 1985 through 1993, including 447,679 cases for 1988 and 608,593 cases for 1993, from hospital cancer registries across the U.S. Data were received on 18,053 bladder carcinoma cases in 1988 and 22,606 cases in 1993.

RESULTS

Interesting trends are 1) younger patients (49 years of age and younger) present with earlier stages of disease than do older patients; 2) women are slightly more likely to be diagnosed with later stages (II, III, and IV) of bladder carcinoma than men; 3) African Americans are less likely to be diagnosed with Stage 0 or Stage I disease than either Hispanic or non-Hispanic whites; and 4) National Cancer Institute designated centers treat more patients with advanced disease than do other types of hospitals.

CONCLUSIONS

The NCDB data are important for analyzing what cancer treatments and outcomes are used and occurring in the country. The data suggest that African Americans are diagnosed at later stages of disease progression. The relative survival rates among African Americans are lower than among Hispanics or non-Hispanic whites. Also, the decreasing utility of adjuvant chemotherapy is being recognized.

Combination finasteride and flutamide in advanced carcinoma of the prostate: effective therapy with minimal side effects

PURPOSE

The efficacy of the combination of finasteride and flutamide in select patients with advanced prostatic cancer is determined.

MATERIALS AND METHODS

A total of 22 sexually active patients with stages C and D1 carcinoma of the prostate was treated with finasteride plus flutamide. Mean followup was 22 months.

RESULTS

Initial mean prostate specific antigen level was 42.9 ng./ml. At 3 and 6 months, the mean prostate specific antigen level was 3.6 ng./ml. and 2.9 ng./ml., respectively. The results appear durable at 24 months. Side effects were minimal, with 86% of the men maintaining sexual function.

CONCLUSIONS

Finasteride plus flutamide should be considered in sexually active patients with minimal volume advanced prostate cancer.

Treatment of advanced prostate cancer with the combination of finasteride plus flutamide: early results

In an attempt to maximize the quality of life of advanced prostate cancer patients on prolonged total androgen ablation and to minimize side effects, we have devised a strategy of 'sequential androgen blockade'. Animal studies have demonstrated that the combination of the 5 alpha-reductase inhibitor finasteride and the antiandrogen flutamide was as effective as a luteinizing hormone-releasing hormone analog and flutamide in inhibiting the growth of the prostate. In a pilot trial, 10 potent patients with clinical stage C and D1 prostate cancer were given the combination of finasteride (5 mg b.i.d.) and flutamide (125-250 mg t.i.d.). Eight of ten men remained potent. At 3 months the mean prostate-specific antigen level of all patients was 3.8 ng/ml (34 ng/ml prior to therapy). In all patients serum testosterone increased and those with the highest increase demonstrated gynecomastia. The combination was easily tolerable and side effects were few. This treatment regime appears to offer the benefits of total androgen blockade, is less expensive and has fewer side effects. Further trials are warranted.

Sequential androgen blockade: a biological study in the inhibition of prostatic growth

We attempted to determine the effects of the combination of a 5-alpha reductase inhibitor and an antiandrogen on rat ventral prostate and seminal vesicle weight. We also attempted to determine whether the prostatic cell death gene TRPM-2 would be expressed using this combination of drugs. Adult male Sprague-Dawley rats were randomly assigned to 7 groups of 15 animals. Four groups served as controls: an intact group sacrificed at the initiation of the trial (group 1), a castrate control group (group 2), an intact control group (group 3), and a group treated with the combination of an LHRH agonist plus antiandrogen (group 7). Three other groups were treated with daily subcutaneous injections of 5 alpha reductase inhibitor (group 5), a nonsteroidal pure antiandrogen (group 4) or both (group 6). After 5 days of treatment 5 animals in each group were sacrificed and prostatic tissue was assayed for the androgen repressed prostatic cell death gene TRPM-2. At 30 days (35 days for group 7) the remaining animals were sacrificed and their ventral prostates, seminal vesicles, and testes (except group 3) were weighed. The combination group (group 6) had a significantly lower prostate weight than either of the monotherapy groups (4, 5), or intact control groups, was equivalent to group 7 but was significantly heavier than the castrate group 2. The seminal vesicle weights of the combination group 6 were significantly lower than the monotherapy groups (4, 5), intact control group, castrate group (3) and was equivalent to group 7. Only castration was able to induce expression of the cell death gene TRPM-2. In this model, the combination of 5 alpha reductase inhibitor and an antiandrogen is as effective a mode of androgen ablation as combination therapy of LHRH agonist plus antiandrogen. Clinically, this combination may translate into adequate androgen blockade without impotence or other side effects of testosterone deprivation. Clinical trials appear warranted to assess this hypothesis.

Repair of an autotransplant renal artery aneurysm: case report and literature review

We report the successful repair of a renal artery aneurysm involving the autotransplanted kidney of a 25-year-old hypertensive woman. The risk factors for renal artery aneurysm rupture, and the relationships between hypertension and renal artery aneurysms are presented.