Timing of Radiotherapy (RT) After Radical Prostatectomy (RP): Long-term outcomes in the RADICALS-RT trial [NCT00541047]

BACKGROUND

The optimal timing of radiotherapy (RT) after radical prostatectomy for prostate cancer has been uncertain. RADICALS-RT compared efficacy and safety of adjuvant RT versus an observation policy with salvage RT for PSA failure.

METHODS

RADICALS-RT was a randomised controlled trial enrolling patients with ≥1 risk factor (pT3/4, Gleason 7-10, positive margins, pre-op PSA≥10ng/ml) for recurrence after radical prostatectomy. Patients were randomised 1:1 to adjuvant RT ("Adjuvant-RT") or an observation policy with salvage RT for PSA failure ("Salvage-RT") defined as PSA≥0.1ng/ml or 3 consecutive rises. Stratification factors were Gleason score, margin status, planned RT schedule (52.5Gy/20 fractions or 66Gy/33 fractions) and treatment centre. The primary outcome measure was freedom-from-distant metastasis, designed with 80% power to detect an improvement from 90% with Salvage-RT (control) to 95% at 10yr with Adjuvant-RT. Secondary outcome measures were bPFS, freedom-from-non-protocol hormone therapy, safety and patient-reported outcomes. Standard survival analysis methods were used; HR<1 favours Adjuvant-RT.

FINDINGS

Between Oct-2007 and Dec-2016, 1396 participants from UK, Denmark, Canada and Ireland were randomised: 699 Salvage-RT, 697 Adjuvant-RT. Allocated groups were balanced with median age 65yr. 93% (649/697) Adjuvant-RT reported RT within 6m after randomisation; 39% (270/699) Salvage-RT reported RT during follow-up. Median follow-up was 7.8 years. With 80 distant metastasis events, 10yr FFDM was 93% for Adjuvant-RT and 90% for Salvage-RT: HR=0.68 (95%CI 0·43-1·07, p=0·095). Of 109 deaths, 17 were due to prostate cancer. Overall survival was not improved (HR=0.980, 95%CI 0.667-1.440, p=0.917). Adjuvant-RT reported worse urinary and faecal incontinence one year after randomisation (p=0.001); faecal incontinence remained significant after ten years (p=0.017).

INTERPRETATION

Long-term results from RADICALS-RT confirm adjuvant RT after radical prostatectomy increases the risk of urinary and bowel morbidity, but does not meaningfully improve disease control. An observation policy with salvage RT for PSA failure should be the current standard after radical prostatectomy.

A150 MODERATE AGREEMENT IN ENDOSCOPIC DISEASE SCORING OF PEDIATRIC EOSINOPHILIC ESOPHAGITIS AMONG PEDIATRIC GASTROENTEROLOGISTS IN CANADA

Background

Endoscopy is an important tool in assessing the severity of gastrointestinal diseases including Eosinophilic Esophagitis (EoE). Agreement regarding endoscopy outcomes is important when using tools such as the Endoscopic Reference Score for EoE (EREFS).

Purpose

Our goal was to determine interrater and intrarater agreement of EREFS among Canadian pediatric gastroenterologists.

Method

Survey-based study of interrater and intrarater reliability amongst pediatric gastroenterologists with interest in pediatric EoE. Participants were sourced from the Canadian Pediatric EoE Network. Participants were asked how many years of training they’ve had with endoscopy for pediatric EoE and their comfort in disease scoring for pediatric EoE. Pediatric EoE cases were identified from the pediatric EoE registry at the Stollery Children’s Hospital with an endoscopic video associated with each case. Participants were asked to score each video using the EREFS questionnaire for the proximal, middle and distal segments of the esophagus. 15 endoscopic videos were evaluated, with 3 cases provided each week over a period of 5 weeks. Additional data included ratings of the video quality and endoscopy quality. Of 15 cases, 12 were unique cases, distributed evenly in severity between no active disease to severe disease. 3 cases were repeated to assess intrarater reliability. The maximum grade of the proximal, middle and distal segments of the esophagus for each component endoscopic finding (edema, rings, exudates, furrows, strictures) were used for reliability calculations. Fleiss Kappa was calculated for all EREFS items and for each component endoscopic finding. Cohen’s Kappa was calculated to assess intrarater reliability.

Result(s)

Fifteen participants were recruited for the study. The participants had a median of 12 years (IQR: 7, 19) of clinical experience in endoscopy for pediatric EoE. The majority of participants were “comfortable” (i.e., 4 on 5-point scale) with EREFS scoring for pediatric EoE. Fleiss Kappa for all EREFS items was 0.481. For each component endoscopic finding (edema, rings, exudates, furrows, strictures), Fleiss Kappa was 0.365, 0.293, 0.548, 0.263, 0.445 respectively. Cohen’s Kappa had a median of 0.620 (IQR: 0.593, 0.704). The majority of raters rated video quality and endoscopy quality as “good” (i.e., 4 on 5-point scale).

Conclusion(s)

There is moderate interrater reliability in EREFS scoring for pediatric EoE. Interrater reliability was between fair to moderate for each component endoscopic finding. Intrarater reliability was good. This study shows there is room for improvement in disease scoring for pediatric EoE. This could be in the form of additional training, expert-defined conventions, or centralized reading which have reduced variability in endoscopic reporting for adult GI disease in past studies and could be used in a follow-up study to attempt to improve agreement. Additionally, incorporating EREFS into routine clinical practice may increase agreement amongst endoscopists.

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None

Disclosure of Interest

None Declared

A143 PEDIATRIC EOSINOPHILIC ESOPHAGITIS IN CANADA: A MULTI-CENTER COHORT WITH FOCUS ON THE STRICTURING PHENOTYPE

Background

Eosinophilic esophagitis (EoE) is a chronic eosinophil-predominant esophageal inflammatory condition, and is now recognized as one of the most common organic causes of dysphagia in pediatrics. While fibrostenotic esophageal strictures are a common complication of adult EoE, characterization of the stricturing phenotype in pediatric EoE remains at an early stage.

Purpose

Describe the Canadian pediatric EoE experience, with focus on the stricturing phenotype.

Method

New pediatric EoE diagnoses from 2015-2018 were retrospectively identified in Vancouver (BC), Northern Alberta (AB), Hamilton (ON) and Nova Scotia (NS). Incidence rates were calculated using 2016 Federal census data. Clinical, endoscopic and histologic data were gathered for each patient’s initial clinical encounter and for any esophagogastroduodenoscopies (EGD) until the end of the follow-up period (fall 2019).

Result(s)

332 new EoE cases were identified during the study period across all 4 sites. The incidence of EoE in patients less than 15 years old was 9.1 (AB), 6.5 (NS), 3.1 (BC) and 5.4 (combined) per 100,000 person-years. Incidence was not calculated for Hamilton due to risk of ascertainment bias given their catchment area overlaps with multiple other centers. Of identified cases, 40 (12.0%) had endoscopically-identified esophageal strictures at diagnosis or during the follow-up period, with a subset of 11 (3.3%) of these patients undergoing mechanical esophageal dilation. Another 11 (3.3%) patients had more subtle signs of esophageal narrowing (ex. mucosal rents), while the majority had no evidence of esophageal narrowing (281, 84.6%). The median age at diagnosis was higher in the cohort with strictures (12.4 years, IQR 8.9-14.1) than those without (10.3 years, IQR 6.1-13.6) but with wide IQR's. A similar trend was seen for the median duration of symptoms at diagnosis (1.5 years, IQR 0.5-3 versus 1.0 years, IQR 0.6-2.8). Patient reported food bolus impaction (OR 9.8, 95% CI 3.9-19.9) and dysphagia (OR 3.3, 95% CI 1.3-7.8) were associated with stricturing disease, with other symptoms less clearly linked. Trachealization was the endoscopic finding most closely associated with esophageal strictures (OR 5.7, 95% CI 2.8-11.5). Esophageal stricture(s) were noted on 72 EGDs, including 27 endoscopic esophageal dilations, but excluding 10 esophageal dilations by interventional radiology. Of the 65 EGDs done in follow-up of a known esophageal stricture (see Table), 4 of 31 had resolution of this finding post mechanical dilation, and 19 of 39 had resolution of the stricture after initiation of new medical or dietary treatments (without dilation).

Conclusion(s)

EoE is common in Canadian children, with esophageal strictures within a few years of diagnosis in 12% of cases. Interestingly, a large portion of strictures resolved without mechanical dilation, which seems to point away from fibrosis as the primary driver of esophageal strictures in this patient population.

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CAG, Other

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Women and Children's Health Research Institute

Disclosure of Interest

None Declared

A14 WIDE VARIATION IN CLINICAL MANAGEMENT OF PAEDIATRIC EOSINOPHILIC ESOPHAGITIS: A CANADIAN EXPERIENCE

Background

Eosinophilic esophagitis (EoE) is a chronic disorder treated by food elimination diet (FED), topical steroids and/or proton-pump inhibitors (PPI). Serial endoscopies and biopsies assess response to therapy. EoE management has evolved as guidelines are updated.

Aims

To identify practice variation among Canadian paediatric gastroenterologists (PG) who care for children with EoE.

Methods

An online survey using REDCap about decision-making in children with EoE was distributed to PG in Canada in November 2020.

Results

62 PG completed the survey (response rate 69%, 62/94). The majority work in academic centres (92%). 3 centers indicated an accrual of &gt;50 new patients per year; 9/16 centres have &gt;100 patients in follow-up. An EoE Clinic is present in 5 centres.

Diagnosis: Familiarity with the 2018 AGREE and 2020 AGA EoE guidelines was found to be 57% and 67% respectively. Criteria required to diagnose EoE according to current guidelines were correctly indicated by 42% of PG. (Figure 1).

Endoscopy: The majority of PG (95%) adhere to guidelines in terms of required number and location of biopsies for the initial diagnosis. Ideal timing of repeat endoscopy after change in therapy in patients who are not in histological remission was 8–12 weeks by 67% of PG, timing in stable patients on maintenance therapy varied (33% only if patient is symptomatic). 25% used the EREFS Score in reporting endoscopic findings.

Therapy: Improvement of symptoms was the highest ranked goal (64%), followed by remission of histologic findings (30%). A treatment algorithm was in place in 4 centers. The majority routinely assess adherence to therapy (73%) and consult a dietitian for FED (77%). Most (87%) do not consult an allergist for initial management. Preferred choices of 1st-line therapy varied among PG (Figure 2). When FED was selected, 32% of PG started with 1 food, 32% started with 2 foods, most frequently excluding dairy, followed by wheat. 14 (26%) start with ≥6 FED. Prescription of budesonide slurry was consistent among PG with doses of 1 and 2 mg/day in children &lt;10 and &gt;10 years, respectively.

Conclusions

The is the first Canadian study to assess the variation in management of children with EoE by PG. Overall, PG demonstrated good adherence to the guidelines in terms of initial diagnosis, but differences in maintenance therapy choice and timing of endoscopies. The results highlight a need for standardized management algorithms to deliver uniform care to this growing group. Grounding these guidelines in evidence will warrant a significant investment in further paediatric EoE research.

Funding Agencies

None

A196 INCIDENCE OF PEDIATRIC EOSINOPHILIC ESOPHAGITIS IN EDMONTON ZONE AND RISK OF STRICTURING AT DIAGNOSIS

Background

Eosinophilic esophagitis (EoE) is a common cause of esophageal dysfunction in children. A subset of children have a more severe phenotype of EoE, complicated by esophageal stricturing. Limited work has been done to characterize this phenotype.

Aims

To determine the incidence of EoE, and the frequency of esophageal stricturing in pediatric EoE.

Methods

We retrospectively identified all new cases of EoE at the Stollery Children’s Hospital from 2015–2018 using esophageal biopsy reports for the province of Alberta (CoPath database), EoE clinic lists and an OR database for esophageal dilatation at the Stollery. Electronic medical records (EMR) were reviewed to confirm EoE diagnosis. For each confirmed case, clinical data was captured from the outpatient EMR and gastroscopy/pathology reports. A review of peri-endoscopy OR/nursing charts was performed on a subset of patients (n=75) to capture scope adverse event. Statistics Canada 2016 census data was used to calculate incidence rates.

Results

185 new cases of EoE were diagnosed at our center during the study period (see table). For patients &lt; 15 years old living in Edmonton zone (n=73), the incidence over the 4 years was 11.1 cases per 100,000 person years {8.7 (0–4 year-old), 7.6 (5–9 year old), and 18.1 (10–14 year old)}. There was limited variation in incidence in the 4 years (9.1–12.1 per 100,000 person years). 8 of 185 (4%) patients had endoscopically confirmed esophageal strictures, 4 of which required mechanical dilation (mean 3.75 dilations per patient, range 1–6). 11/185 (5.9%) patients had more subtle signs of esophageal narrowing, but no strictures. No perforations or episodes of significant bleeding were reported in peri-endoscopy charts reviewed for 239 gastroscopes, including 16 dilations. Pain was reported after 15% of all scopes, including 50% of the 28 scopes with strictures and 63% of the 16 scopes involving dilations.

Conclusions

Edmonton zone has one of the highest incidences of EoE reported in children. In this cohort, 4% had esophageal stricture (half required dilatation) and 5.9% had more subtle narrowing. Patients with strictures were older, had more frequent food impaction and longer duration of symptoms (Table). This data will be included in an ongoing multicenter case-control study across Canada.

Funding Agencies

CAGWomen and Children’s Health Research Institute (Univ. Alberta)

A multicentre assessment of prostate MRI quality and compliance with UK and international standards

AIM

To assess prostate magnetic resonance imaging (MRI) image quality and compliance with technical standards between centres in the South West region of the UK.

MATERIALS AND METHODS

Fifteen imaging sites in the region submitted seven consecutive anonymised MRI studies. These were assessed by two experienced radiologists in consensus. Overall, subjective image quality for T2-weighted imaging (T2W), diffusion weighted imaging (DWI), and dynamic contrast enhancement (DCE) was scored on a five-point Likert scale. Five additional quality parameters were also assessed visually, including image noise, motion, artefact, and distortion. The degree of compliance by each site with 21 published technical standards was also assessed.

RESULTS

Ninety-four MRI examinations were reviewed from across all sites (mean 6.3 scans per site, range 5-7). Mean compliance with technical standards was 63% (range 38-86%). Forty-seven percent of sites did not perform DCE. One site used a 3 T scanner. The percentage of patients with overall quality scores of ≥3 (diagnostically acceptable) were 68% for T2W, 81% for DWI, and 60% for both T2W and DWI. Ninety-three percent of the 45 patients who underwent DCE had diagnostically acceptable studies. By scanner age, the percentage of patients with diagnostically acceptable T2W scores was 53% for scanners ≥7 years and 80% when <7 years (p=0.006). Comparing individual sites, the mean overall quality scores were 2.9 (range 2.2-4.2) for T2W, 3.2 (1.8-4.7) for DWI, and 3.4 (2.5-4.7) for DCE.

CONCLUSION

There is wide variation in compliance with recognised technical standards and image quality across sites. If MRI is to replace biopsy in selected low-risk patients, improvements in image quality may be required.

Uretric Obstruction in Gardener's Syndrome

Desmoid tumours in Gardener's syndrome are a rare cause of ureteric obstruction. We report two cases of ureteric obstruction caused by desmoids, in a mother and daughter.

Radical prostatectomy for locally advanced and metastatic prostate cancer

The management of advanced prostate cancer remains challenging. Traditionally, radical prostatectomy was discouraged in patients with locally advanced or node positive disease owing to the increased complication rate and treatment related morbidity. However, technical advances and refinements in surgical techniques have enabled the outcomes for patients with high risk prostate cancer to be improved. More recently, the concept of cytoreductive prostatectomy has been described where surgery (often Combined with an extended lymph node dissection) is performed in the setting of metastatic disease. Indirect evidence suggests an advantage using the cytoreductive approach. Hypothetical explanations for this observed benefit include decreased tumour burden, immune modulation, improved response to secondary treatment and avoidance of secondary complications attributable to local tumour growth. Nevertheless, prospective trials are required to investigate this further.

Hyperglycaemia-induced resistance to Docetaxel is negated by metformin: a role for IGFBP-2

The incidence of many common cancers varies between different populations and appears to be affected by a Western lifestyle. Highly proliferative malignant cells require sufficient levels of nutrients for their anabolic activity. Therefore, targeting genes and pathways involved in metabolic pathways could yield future therapeutics. A common pathway implicated in energetic and nutritional requirements of a cell is the LKB1/AMPK pathway. Metformin is a widely studied anti-diabetic drug, which improves glycaemia in patients with type 2 diabetes by targeting this pathway. We investigated the effect of metformin on prostate cancer cell lines and evaluated its mechanism of action using DU145, LNCaP, PC3 and VCaP prostate cancer cell lines. Trypan blue dye-exclusion assay was used to assess levels of cell death. Western immunoblotting was used to determine the abundance of proteins. Insulin-like growth factor-binding protein-2 (IGFBP-2) and AMPK genes were silenced using siRNA. Effects on cell morphology were visualised using microscopy. IGFBP-2 gene expression was assessed using real-time RT-PCR. With DU145 and LNCaP cells metformin alone induced cell death, but this was reduced in hyperglycaemic conditions. Hyperglycaemia also reduced the sensitivity to Docetaxel, but this was countered by co-treatment with metformin. LKB1 was required for the activation of AMPK but was not essential to mediate the induction of cell death. An alternative pathway by which metformin exerted its action was through downregulation of IGFBP-2 in DU145 and LNCaP cells, independently of AMPK. This finding could have important implications in relation to therapeutic strategies in prostate cancer patients presenting with diabetes.

Falling bladder cancer incidence from 1990 to 2009 is not producing universal mortality improvements

Objective

The objective of this article is to obtain up-to-date epidemiological statistics of bladder cancer in England.

Methods

We collected incidence from the National Cancer Data Repository (NCDR), survival from the national Cancer Information System (CIS), ethnicity information from the Hospital Episode Statistics (HES), mortality and smoking rates from the Office for National Statistics (ONS).

Results

Incidence of bladder cancer has fallen continuously. Mortality has reduced less, leading to worsening survival. Bladder cancer mainly affects men, the most deprived, and the elderly. The gender gap is decreasing, and the deprivation gap is unchanged. Mortality is unchanged in the youngest, oldest and least deprived females. Mortality has recently increased in the oldest males. The highest incidence and mortality is found in industrial areas. This study is limited by i) its retrospective design using existing databases, allowing identification of associations and statistical differences, but not causation; and ii) very restricted ethnicity data.

onclusion

Reductions in bladder cancer incidence and mortality in England coincide with a decrease in high-risk occupations and public health measures to reduce smoking. Some risk factors in modern living may as yet be unidentified. It remains paramount to ensure equity of access and treatment regardless of gender, age, region and social deprivation to further improve mortality.

Erectile function post robotic radical prostatectomy: technical tips to improve outcomes?

Robotic surgery is becoming more and more commonplace. At the same time, so are complications, especially related to erectile function. The population being diagnosed with cancer is younger, with more aggressive cancers and higher expectations for good erectile function postoperatively. We conduct a retrospective analysis of literature over 20 years for Embase and Medline. Search terms used include (Robotic) AND (prostatectomy) AND (erectile function). There are a variety of multifactorial causes, resulting in worsening ED post-robotic radical prostatectomy; however, there are a number of treatments that can support this. There is much we can do to help prevent patients getting postoperative erectile dysfunction post-radical surgery. However, part of this is management of realistic patient expectations.

The impact of socio-economic deprivation on incidence, treatment and mortality from prostate cancer in England, 1990–2010

Objective:

To explore any association between socio-economic deprivation and prostate cancer diagnosis and/or treatment.

Patients and methods:

Data was extracted as follows: We gained the incident cases and staging from the National Cancer Data Repository, survival from the Cancer Information System, mortality from the Office for National Statistics, treatment data from Hospital Episode Statistics and National Clinical Analysis and Specialised Applications Team. Our analysis regarding socio-economic deprivation was controlled for age distribution.

Results:

We recorded 518,453 diagnoses of prostate cancer; 174,579 prostate cancer deaths; 33,889 prostatectomies and 21,351 radiotherapy treatments. Incidence is increasing in all groups, but the highest is amongst the least deprived. Mortality is decreasing, with survival consistently better in the least deprived. Prostatectomies are more frequent in the least deprived; however, this gap is narrowing.

Conclusions:

Prostate cancer incidence, survival and treatment are associated with socio-economic deprivation. Prostatectomy rates show a decrease in the gap of inequality. Multiple potential confounding factors, such as rates of prostate specific antigen (PSA) testing and access to health care are associated with socio-economic deprivation. The unifying influences of Improving Outcomes Guidance and the National Treatment Guidelines are intended to counteract the above inequalities. Particularly in prostate cancer, where long-term gain depends on multiple factors, individualised treatment decisions are paramount.

Prostate cancer and supportive care: a systematic review and qualitative synthesis of men's experiences and unmet needs

Prostate cancer is the second most common cancer in men worldwide, accounting for an estimated 1.1 million new cases diagnosed in 2012 (www.globocan.iarc.fr). Currently, there is a lack of specific guidance on supportive care for men with prostate cancer. This article describes a qualitative systematic review and synthesis examining men's experience of and need for supportive care. Seven databases were searched; 20 journal articles were identified and critically appraised. A thematic synthesis was conducted in which descriptive themes were drawn out of the data. These were peer support, support from partner, online support, cancer specialist nurse support, self‐care, communication with health professionals, unmet needs (emotional support, information needs, support for treatment‐induced side effects of incontinence and erectile dysfunction) and men's suggestions for improved delivery of supportive care. This was followed by the development of overarching analytic themes which were: uncertainty, reframing, and the timing of receiving treatment, information and support. Our results show that the most valued form of support men experienced following diagnosis was one‐to‐one peer support and support from partners. This review highlights the need for improved access to cancer specialist nurses throughout the care pathway, individually tailored supportive care and psychosexual support for treatment side effects.

Audit of PSA requesting practices in primary care compared to guidelines established by the Prostate Cancer Risk Management programme in the Avon region of the South West of England

Background

There is considerable challenge in transmitting the complicated information contained in the Prostate Cancer Risk Management (PCRM) programme in the primary care setting. 1 The practices surrounding requesting of PSA should be clearly understood by both GP and patient before requesting this investigation, and in order to further understand the needs and requirements of primary care practitioners in this regard we undertook an audit comparing practices in the Avon region of the Southwest of England compared to the guidelines of the PCRM programme. 1

Methods

Our study identified a consistent year-on-year increase in PSA requests over the study period across all age categories and regions of the southwest of England.

Results

Questionnaire review of practices surrounding the PCRM programme revealed overall good practice but with space for improvement surrounding advice regarding the limitations of prostate biopsy and the relevance of testing in the elderly.

Conclusions

Despite requesting practices generally conforming to NICE guidelines, nearly half of all abnormal primary-care PSA tests are repeated. Requests in some cases may fall short of best practice.

Hyperglycaemia-induced chemoresistance of prostate cancer cells due to IGFBP2

Clinically relevant prostate cancer (PCa) is more frequent in Westernised societies and increasingly men have co-morbidities associated with a Western lifestyle, primarily diabetes, characterised by hyperinsulinaemia and hyperglycaemia. IGFs and their binding proteins (IGFBPs) are important mediators of the effects of nutrition on growth and play a key role in the development of PCa. We used DU145, PC3 and LNCaP PCa cell lines to examine how hyperglycaemia altered their response to docetaxel. Trypan Blue dye-exclusion assay was used to determine the percentage of cell death. Protein abundance was determined using western immunoblotting. Levels of IGFBP2 were measured using an ELISA. IGFBP2 gene silencing was achieved using siRNA technology. DNA methylation was assessed using combined bisulphide restriction analysis. Acetylation status of histones H3 and H4 associated with IGFBP2 gene was assessed using chromatin immunoprecipitation assay. Hyperglycaemia reduced docetaxel-induced apoptosis by 40% for DU145 cells and by 88% for LNCaP cells. This reduced cell death was mediated by a glucose-induced up-regulation of IGFBP2, as silencing IGFBP2 negated the survival effect of high glucose. Glucose increased IGFBP2 via increasing the acetylation of histones associated with the IGFBP2 gene promoter. This finding could have important implications in relation to therapeutic strategies as epigenetic modulation could be reversible.

Management of prostate cancer

Prostate cancer is diagnosed in 37 000 new patients a year, and causes 10 000 deaths each year in the UK (Cancer Research UK, 2011). Diagnoses are increasingly the result of screening using measurement of prostate- specific antigen levels. The natural history of early disease is unclear. Autopsy studies before prostate-specific antigen screening showed an actual latent prevalence (not diagnosed during life) of around 30% at the age of 50 years and 75% at the age of 80 years, and many of these demonstrated local invasion (Franks, 1954). One of the main current challenges in urology is distinguishing indolent prostate cancers from potentially lethal ones. The specificity of the prostate-specific antigen test for clinically significant disease remains disappointingly low and population screening is not encouraged (Ilic et al, 2011). However, prostate-specific antigen testing is often done in good faith, but pre-test counselling is essential. Thus, prostate-specific antigen testing should only be undertaken by the patient's GP or on the advice of a urologist.

Correlation of elevated alkaline phosphatase (ALP) and survival in metastatic castration-resistant prostate cancer (CRPC) treated with docetaxel chemotherapy: Results of SWSW Uro-oncology Group study from three U.K. centers

206

Background: Treatment with docetaxel in CRPC based on the results of the TAX 327 study has been recommended by NICE guidance in UK. Paucity of UK data on any significant difference in median survival of CRPC patients receiving chemotherapy with normal or elevated ALP is a possible contributory factor to the delayed consideration of chemotherapy in CRPC. We therefore analysed differences in survival in metastatic CRPC patients with normal or elevated ALP treated with docetaxel chemotherapy in 3 cancer centres in UK with a contemporary referral population.

Methods: Survival data were collected on consecutive cases of metastatic CRPC treated with at least 1 cycle of docetaxel chemotherapy in these 3 centres. Variables analysed included: presence or absence of pain, PSADT, Gleason score, Haemoglobin, Alkaline phosphatase and number of previous lines of hormone therapy.

Results: Median overall survival in 170 eligible patients was 18.1 months (15.3-20.7) with median follow-up of 30.1 months. 84 cases had normal ALP and 86 cases had elevated ALP at time of commencing docetaxel chemotherapy. Median survival was 14.1 months (95% CI= 11.1-17.1) in the elevated ALP group and 22.2 months (95% CI= 17.5- 26.9) in the normal ALP group. The difference between group medians was significant (p<0.001). In multivariate analysis, elevated ALP was a significant prognostic factor for outcome after docetaxel chemotherapy in metastatic CRPC.

Conclusions: Regular monitoring of ALP along with PSA monitoring can be a relatively simple way of ensuring that patients with metastatic CRPC are referred for chemotherapy appropriately. To our knowledge this is the first UK data on the impact of ALP level on survival in this group of patients after docetaxel chemotherapy. It is important that decision regarding chemotherapy is based on the parameters of disease progression and regular ALP monitoring may be a relatively simple and practical way of ensuring the right timescales for referral for chemotherapy in metastatic CRPC.

[Table: see text]

Clinical presentation and initial management of black men and white men with prostate cancer in the United Kingdom: the PROCESS cohort study

Background:

In the United States, Black men have a higher risk of prostate cancer and worse survival than do White men, but it is unclear whether this is because of differences in diagnosis and management. We re-examined these differences in the United Kingdom, where health care is free and unlikely to vary by socioeconomic status.

Methods:

This study is a population-based retrospective cohort study of men diagnosed with prostate cancer with data on ethnicity, prognostic factors, and clinical care. A Delphi panel considered the appropriateness of investigations and treatments received.

Results:

At diagnosis, Black men had similar clinical stage and Gleason scores but higher age-adjusted prostate-specific antigen levels (geometric mean ratio 1.41, 95% confidence interval (95% CI): 1.15–1.73). Black men underwent more investigations and were more likely to undergo radical treatment, although this was largely explained by their younger age. Even after age adjustment, Black men were more likely to undergo a bone scan (odds ratio 1.37, 95% CI: 1.05–1.80). The Delphi analysis did not suggest differential management by ethnicity.

Conclusions:

This UK-based study comparing Black men with White men found no evidence of differences in disease characteristics at the time of prostate cancer diagnosis, nor of under-investigation or under-treatment in Black men.

Reactive oxygen species and erectile dysfunction: possible role of NADPH oxidase

Erectile dysfunction (ED) is a widespread condition, the incidence of which is increasing globally. ED is also indicative of underlying vasculopathy and represents a predictor of more serious cardiovascular disorders. Understanding the aetiology of ED may therefore provide invaluable pointers to the pathobiology of other cardiovascular diseases (CVDs) and syndromes. It follows, too, that therapeutic interventions that are successful in treating ED may, ipso facto, be effective in treating the early stages of conditions that include atherosclerosis, angina, plaque rupture and diabetic angiopathy. One common pathological denominator in both CVD and ED is oxidative stress, that is, the overproduction of reactive oxygen species (ROS), in particular, superoxide (O(2)(*-)) and hydrogen peroxide (H(2)O(2)). In this review, therefore, we consider the aetiology and pathobiology of O(2)(*-) in promoting ED and focus on NADPH oxidase as an inducible source of O(2)(*-) and H(2)O(2). Therapeutic strategies aimed at reducing oxidative stress to improve erectile function are also discussed.

Optimal Nutrition Should Improve the Outcome and Costs of Radical Cystectomy

INTRODUCTION

Nutritional support has been demonstrated to improve recovery from radical cystectomy, but is expensive and when used inappropriately may actually increase the costs and morbidity of surgery. We sought to establish national patterns of practice with regard to feeding following cystectomy in the UK.

AIMS AND METHODS

Following consultation with the specialist nutrition team, a questionnaire was designed to investigate the feeding strategy after cystectomy and dispatched by post to all UK urologists.

RESULTS

The majority (60%) of respondents employed a traditional strategy of resting the bowel and feeding orally after bowel recovery. A minority used either early total parenteral nutrition (TPN; 18.5%) or enteral nutrition (6.5%), but a larger proportion (29%) felt enteral nutrition was the 'optimal' feeding regime. Only 30% used guidelines and 52% felt trials would help to establish a nutrition strategy following cystectomy.

CONCLUSION

There is little evidence that TPN improves the outcome of cystectomy and it may actually increase morbidity and costs, whereas enteral nutrition may improve recovery. Despite this evidence TPN is widely used by urologists whereas enteral nutrition is used infrequently. Implementation of an evidence-based feeding regime after cystectomy is likely to reduce the morbidity and financial costs of cystectomy.

Serum Amino-Terminal Propeptide of Type 1 Procollagen (P1NP) in Prostate Cancer: A Potential Predictor of Bone Metastases and Prognosticator for Disease Progression and Survival

INTRODUCTION

To determine if amino-terminal propeptide of type 1 procollagen (P1NP) is reliable as a predictor of prostate cancer bone metastases and assess its value as a prognostic indicator of disease progression and survival.

MATERIALS AND METHODS

A cohort of patients with prostate cancer between January 1999 and July 2001 were recruited. Prostate-specific antigen (PSA) and P1NP levels were measured. Two years following completion of recruitment, patient notes were reviewed for symptoms of bone metastases and survival.

RESULTS

24 negative and 12 equivocal or positive bone scans were reported for 36 recruited patients. Mean PSA values for patients with negative, equivocal and positive scans were 18.3, 24.9 and 122.5 ng/ml while mean P1NP for the same groups were 38.2, 73.4 and 119.9 ng/ml. For patients with equivocal and positive scan, mean P1NP with and without bone symptoms were 111.5 and 65.7 ng/ml while for surviving and dead patients the values were 63.9 and 120.8 ng/ml, respectively.

CONCLUSIONS

Though this study involved a small number of patients, it demonstrates P1NP's potential as a predictor of bone metastases and a prognosticator for disease progression and survival.

Prostasomes--their effects on human male reproduction and fertility

The prostate is a glandular male accessory sex organ vital for normal fertility. It provides the prostatic component of seminal plasma which nourishes and protects sperm following ejaculation. Prostasomes are small (40-500 nm) membrane-bound vesicles produced by epithelial cells lining the prostate acini and are a component of prostatic secretions. Although the existence of these particles has been known for many years, their full function and relevance to reproductive health are largely unknown. Proteomic studies have shown a wide range of proteins (enzymes, structural proteins and novel, unannotated proteins) present in or on the surface of prostasomes providing them with a diverse nature. Interestingly prostasomes are able to fuse with sperm, this event and the associated transfer of proteins lies at the heart of many of their proposed functions. Sperm motility is increased by the presence of prostasomes and their fusion prevents premature acrosome reactions. Prostasomes have been shown to aid protection of sperm within the female reproductive tract because of immunosuppressive, antioxidant and antibacterial properties. Clinically these functions imply a role for prostasomes in male factor infertility. However, the very functions that promote fertility may have negative connotations in later life; recent work has suggested that prostasomes are involved in prostate cancer. Clearly more work is needed to clarify the role of these novel particles and their impact on men's health.