27
January
2014

Prostate Cancer Smartphone Apps

Prostate Cancer Smartphone Apps

The first guest blog for February is by Jim Duthie, a Urologist in Tauranga, New Zealand. Jim has written two Apps to make it easier for patients to be actively involved in their prostate cancer management. One app helps track PSA over time along with a history of prostate biopsies and treatments. The other greatly helps consolidate treatment for patients who are on ADT (hormone treatment).


For any question, the clichéd answer is now “There’s an App for that”, referring to the ubiquitous mobile applications for smartphones that seem to solve many of our problems, real or imagined. For medical conditions, this is increasingly the case. The “Medical” category is currently the most rapidly growing domain in the Apple App store. You can now download anything from a nomogram for predicting your risk of heart disease, to the somewhat questionable App that can treat whatever ails you by using your iPhone torch as a form of phototherapy. For me, designing mobile Apps was an effective solution for specific problems facing Urology patients.


Androgen Deprivation Therapy App

The process began with a concern that men undertaking Androgen Deprivation Therapy (ADT) were poorly followed up in terms of the myriad potential side effects that this treatment causes, from bone density to dyslipidaemia, to depression, and hot flushes. It is unclear exactly how many men are receiving ADT, let alone what percentage receive adequate follow up care. As Urologists, we are not experts in managing the complexities of, for example, cardiac risk factors.

Despite best intentions, we also lack the time and expertise to manage depression and cognitive impairment. It makes sense for General Practicioners/Family Physicians (GPs/FPs) to coordinate this follow up, but the physiological effects may seem complex and intimidating for a non-specialist. Perhaps Endocrinologists may be better equipped, but not from the point of view of coordinating patient management, and again a GP/FP usually has a better understanding of psychosocial issues. With this lack of clarity around responsibility it is easy for uncomplaining patients to slip through the cracks. In practice, men receiving ADT may only attract medical attention after suffering a significant complication of their treatment.

To improve this situation, I considered that a centralized ADT database where men are recruited at the time of initiation of therapy, then sent reminders at regular follow up intervals would be ideal, and could additionally provide a bank of men available for clinical trials and retrospective study. Unfortunately, database creation and management is prohibitively expensive, and despite my best efforts such a structure is some way off yet.

I identified the core follow up issue as being getting the right investigations performed at the right time. To achieve this GPs/FPs need to be aware of the necessary tests, and patients informed about when to see their doctor for follow up. The ADT App attempts to achieve this with automated “push notifications” (alerts appearing on the smartphone) when they are due to see their GP, as well as listing recommended investigations according to the elapsed time since commencing treatment. The patient can also read about potential side effects by body system, and follow links for explanations about why the specific tests are required in terms of the physiological effects of androgen deprivation. This is an App aimed at patients, however the intention is that a GP/FP could also have this on their phone as a reference and educational aid.


PSA Manager App

This App addresses a broader group, any man either undertaking prostate cancer treatment or PSA screening. The idea of a “PSA Tracker” is not new. Before the advent of iTunes I encountered a retired accountant who had graphed his PSA over time by hand. An electronic equivalent is easy to achieve, but does it add much to the patient’s care? I thought that an “all in one” manager for prostate cancer screening and treatment would be more useful. The PSA Manager App allows the input of results of prostate biopsies, dates and modalities of treatment for cancer and benign prostate disease including surgery, radiation, and newer novel techniques, and results of imaging investigations such as CT, MRI, or bone scans with a facility for entering a free-text description of the results of these. The data are then presented on a graph with colour-coded markers to represent the timing of the interventions. PSA velocity and doubling time can also be calculated. The intention is to allow men a clear overview of their PSA changes during screening, and if applicable, the evolution and treatment of their prostate cancer.

Identifying barriers to care is an essential part of equitable health delivery, and something I considered at length. The first challenge I identified for men using these Apps, particularly the ADT App, was advanced age. We may think of men on ADT as being elderly, perhaps frail, and probably not expert in using technology. Firstly, this perception ignores the group of men receiving ADT as neoadjuvant/adjuvant treatment for radiation therapy, which constitutes a younger and healthier cohort of men. Secondly, many ADT patients attend clinic with a younger family member, and my experience has been that when I ask if anyone in the family has an iPod, iPad, or iPhone, the answer is usually yes. As long as one tech-savvy person can enter the data, the Apps work well by proxy. In designing the interface, details such as larger buttons to suit male fingers and presbyopic vision were considered.

Finally, any financial cost will constitute a barrier to some patients. The solution was the make the Apps free to download. This meant securing funding which was generously provided by unrestricted grants from Australian Prostate Cancer Research and Ipsen for the ADT and PSA Manager Apps respectively. Although I receive no reimbursement from the development of either App, I believe patients feel more confident in a product provided solely for their benefit, and I can promote the Apps to them and my colleagues with no financial conflict of interest.


Follow this link to download the ADT App

Follow this link to download the PSA App

Jim Duthie is a Urologist at Tauranga, New Zealand with an interest in Urologic Oncology, Robotic Surgery, and Medical Communication. You can follow @JamesDuthie1 on Twitter.


Categories: Updates, Prostate Cancer, Prostate Surgery

04
January
2014

Radical Prostatectomy or Surveillance in Older Men – Which is Better?

Radical Prostatectomy or Surveillance in Older Men – Which is Better?

This is an abridged, written version of an invited lecture Nick Brook gave to the Clinical Oncology Society of Australia in November 2013. It covers a common clinical dilemma in a changing medical and surgical environment; the older man with organ confined prostate cancer….is surgery or surveillance the best option?

Has anyone noticed a storm of controversy surrounding the diagnosis and treatment of prostate cancer? This centres on concerns about the overtreatment of prostate cancer, and may have particular relevance in older men, who mostly have a shorter life expectancy than their younger counterparts. But men are living longer and in better health, perioperative management has advanced, and minimally invasive surgical treatments have lessened the acute physiological impact of treatment. Dogma has been that there should be a cut-off at 70 years of age when considering curative treatment for prostate cancer, but the tired catchphrase - ‘physiological not chronological age’ - is actually a very useful one, and has relevance to this topic.

Why worry?

It’s worth examining why we worry about treating localised prostate cancer with curative intent in older men. The reasons are four-fold:

  • These men may not benefit from treatment, as they may die of other causes before their prostate cancer becomes clinically relevant
  • Treatment may not be tolerated, and may cause morbidity and, rarely, mortality
  • Most men with curable disease who are left untreated do not die from prostate cancer within 10 years of diagnosis
  • For those who die within 10 years of diagnosis, the disease was probably incurable at diagnosis

These last two points are taken from a recent presentation by Patrick Walsh, and reflect an understanding of the natural history of prostate cancer, and its heterogeneity.

With changes in demographics and treatments, should we be pushing for surgical treatment in older men with localised prostate cancer, or is this overtreatment? Are these men better off on surveillance/watchful waiting? Before we can answer these questions, some basic points need reviewing:

Prostate cancer is not one disease

First, prostate cancer as a disease is heterogeneous in its classification and behavior. Gleason grading is absolutely central to determining how the cancer is likely to behave. We know that this classification trumps other variables in predicting outcomes, whether these are positive margin rates, extra-capsular extension, seminal vesicle invasion, lymph node status, recurrence after treatment, or prostate cancer mortality.

We can use the Albertson tables to indicate likely mortality from prostate cancer and non-prostate cancer causes over a period of time for a given Gleason score and age at diagnosis. It is really quite simple; when we ask “does it matter if we treat or not?”, we get an indication that a man in his early 60s with Gleason 6 disease has a very different proportional chance of dying from prostate cancer in the next 15 years than a man in his early 70s. Likewise, a man in his 70s with Gleason 7 (a weakness of the tables is that 3+4 and 4+3 are combined) is, of course, proportionally more likely to die of another cause than he is to die of prostate cancer, but this is not true for a man in his 60s at diagnosis.

Albertson Table

So, age and Gleason score are combined in these tables to give us a reasonably powerful tool when we grapple with the question of whether to treat or not. These Albertson tables have been around for a long time, have recently been updated, and are greatly underused.

Active surveillance or watchful waiting?

Second, the terms ‘surveillance’ and ‘watchful waiting’ are separate entities that are often confused.

Watchful waiting is based on the premise that some patients will not benefit from treatment of their primary cancer. The decision is made at the outset to forgo definitive treatment, and instead provide palliative intervention for local progression or metastasis if/when it occurs.

Active surveillance is very different, and is based on the understanding that some but not all patients may benefit from localised treatment. The idea is to monitor closely and

  1. identify those men with localised cancers that are likely to progress, providing timely treatment for them
  2. to avoid treatment and associated treatment-related complications in men with cancers that are unlikely to progress
Active surveillance or watchful waiting - Man at a microscope

If we consider again the Albertson tables, we can see why active surveillance makes sense for those cancers that are less likely to cause trouble, but also makes sense for older patients, perhaps with intermediate risk cancer.

A number of different active surveillance protocols are in use. They vary slightly (some have stricter criteria), and include the Johns Hopkins, Toronto, Miami, and UCSF protocols. The one we are encouraged to use in Australia as part of an international protocol study is PRIAS (Prostate Cancer Research International Active Surveillance).

Results of active surveillance

What do we know about outcomes from active surveillance? Klotz’s group in Toronto reported on 450 men followed with active surveillance, about 50% of whom were over 70 years at diagnosis, most with 3+3=6 but 17% of men had 3+4=7. Importantly 10-year cancer specific survival was 97%. There was no difference in prostate cancer mortality for those men on AS over or under 70 years of age at diagnosis. Obviously though, non-prostate cancer death in those over 70 at diagnosis and commencement of AS was much greater than those under the age of 70. This provides further evidence that age does matter; we already know our older patients are more likely to die of other causes. It also substantiates the idea that for carefully selected patients, AS is a sensible option.

What factors should we consider when choosing radical prostatectomy or ‘surveillance’ in older men?

When we are considering RRP in older men, there are three key questions we should consider:

  1. In this man’s lifetime, will cancer control be an issue, i.e. do we need to perform radical prostatectomy to control his cancer or will surveillance (or watchful waiting) suffice?
  2. Is the perioperative risk higher than is acceptable, and is it higher than in younger men? Does his age/co-morbidity preclude safe surgery?
  3. Is his risk of long-term side effects that affect quality of life (incontinence and erectile dysfunction) too high, and is this higher than in younger men?

Let’s look at some evidence for these three areas:

Cancer Control

The two randomised studies that we have were of watchful waiting (rather than surveillance) versus radical prostatectomy:

The Scandinavian Prostate Cancer Group 4 Study randomised 695 men, 75 years old or less, with localised prostate cancer to radical prostatectomy or watchful waiting (not surveillance). The intervention for progression in the WW group was hormone ablation. Median follow-up was 12.8 years. Briefly, compared to watchful waiting, radical prostatectomy reduced prostate cancer deaths in men under 65 years (51% RR reduction, p=0.008), but not in those over 65 years (17% RR reduction, NS). Likewise, occurrence of metastasis (itself, an important endpoint) was significantly reduced in the radical prostatectomy group in under 65s, but not in the over 65s. This randomised study suggests that age does matter when considering the effect of RRP on cancer control.

The PIVOT study (Prostate Intervention Versus Observation Trial) looked at a similar number of men, randomised to RRP or observation (essentially watchful waiting, with palliative therapy or chemotherapy on progression). At 12 year follow up, there was no benefit of radical prostatectomy over observation, and there was no age effect. This study has been heavily criticised as it was underpowered (the study was initially powered for 2000 men but only 731 were randomised), and for the very small number of prostate cancer deaths in each arm. There were far fewer deaths overall in PIVOT, and the men as a cohort had more co-morbid conditions than SPCG4. Difference in outcomes from the two studies may also be because the SPCG4 men were mostly PSA naïve, whereas the PIVOT cohort came from the early PSA testing era.

Perioperative risk in older men

Can we safely take older men through an operation and the perioperative period? Do the (generally) age-associated co-morbidities impart too much risk?

An excellent retrospective study from Ontario of 11,000 men who underwent RRP helps address this question. Importantly, it showed the following:

  • Increasing age is associated with increased medical/surgical complications
  • There is a small but significant increase in 30-day mortality with age, even when adjusted for comorbidity
  • The number of co-morbidities is more important than age in determining mortality risk.

My reading of this is that age does matter, but medical fitness is more important in determining post radical prostatectomy complications and death. Older men who are fit (with minimal co-morbidities) are low risk and can be considered for surgery.

Long term side effects that affect quality of life – continence and erectile function in older men.

Lets conclude by looking at the potential long-term side effects of radical prostatectomy (incontinence and erectile dysfunction) that can have a major impact on quality of life. Is there any evidence for an age effect?

Many of the papers reporting side effects from radical prostatectomy are set about with bias, uncertainties and confusing definitions of continence and erectile function. However, a stand out paper from Massachusetts General Hospital looked at 430 men treated for localised prostate cancer with different modalities, and reported pre- and 36-month post-treatment sexual and continence function. Importantly, the authors stratified post-op outcomes according to pre-treatment function. Looking at erectile function, for nerve sparing radical prostatectomy (the gold-standard for erectile preservation), we see a remarkable reduction in sexual function. For those men with normal erectile function pre-op, only 8% were normal 36 months post-operatively. 28% of men deteriorated from normal to intermediate function, and 64% went from normal to poor. If we look at those who were intermediate before surgery, the figures post-op figures are worse. The paper did not examine an age effect, but we can extrapolate from population studies of non-prostate cancer men. We know that erectile function deteriorates with age, and it is therefore likely that a cohort of older men will have worse pre-op function, and are therefore more likely to have worse post-surgery erectile function.

Illustration of a man's body with the prostate highlighted

Admittedly there are weaknesses in this argument; the extrapolation and presumption, and the possibility that men with poor erectile function pre-operatively may not be concerned about post-operative erectile function, i.e. that factor may not affect their quality of life.

The paper reports a much less severe reduction in continence after surgery. However, but the outcomes are poorer for men who had less-than normal continence pre-operatively.

Some recent data is available on the effect age on continence after robotic radical prostatectomy; this indicates that although early continence 3-6 months after surgery is slower to recover in men >70 years, after that time the results are equal to men <70 years.

Summary

This is a complex dilemma and a common clinical issue we struggle with regularly. As life expectancy increases, the likelihood of prostate cancer clinical progression increases. Less invasive surgery and improved perioperative management have expanded the pool of men that can be safely treated. We need to carefully examine the rationale for radical prostatectomy, watchful waiting and surveillance in this dynamic demographic of ‘older’ men, but we are becoming more sophisticated in our decision making in this area.

For cancer control, one randomised trial suggests that men over the age of 65 do not benefit from RRP compared to WW. In carefully selected men, true active surveillance seems safe, and it is likely to be particularly safe for men over 70. We may even be able to extend surveillance criteria in these older men. In terms of surgical safety, age does matter but it is not as important as co-morbidity. For those long-term side effects of radical prostatectomy that impact on quality of life, it is likely that older men have worse potency outcomes than younger men. Low-level evidence indicates that continence outcomes may be equivalent in older and younger men.

You can follow Nick Brook on:

You can navigate Nick’s website by clicking the ‘Home’ link at the top of this page, or by following this link www.nickbrookurology.com

Categories: Prostate Cancer

02
January
2014

Salvage radical prostatectomy

Salvage radical prostatectomy

This is Professor David Gillatt's second blog on the site. Here, he talks about the indications for salvage radical prostatectomy for prostate cancer, its indications and some of the difficulties encountered in this rarely performed surgery.


David, can you explain what salvage prostate cancer surgery is?

As we all recognise, unfortunately, in a minority of cases treated for prostate cancer the disease will recur despite that treatment. When a man has had radiation treatment for what appears to be prostate cancer confined to the prostate or its immediate surrounds, some will in time show evidence of the cancer reappearing and starting to progress. This will also happen in the less common situation of the cancer being treated with other local therapies such as cryotherapy, high intensity focussed ultrasound or brachytherapy. The disease comes back either because the treatment failed to control the cancer within the prostate or there was disease already microscopically beyond the gland which will eventually lead to spread. If the recurrent cancer is still within the prostate and detected early it may still be at a curable stage. This is the point at which we can consider salvaging the situation by surgically removing the prostate and the recurrent cancer therein.

If a patient has failed another treatment, what are the factors determining suitability for salvage surgery?

Salvage surgery is a local therapy and as such it will only remove or cure a cancer if still within the prostate. Therefore a judgement needs to be made when recurrence has occurred as to whether the disease has a high likelihood of being localised or are there features that suggest the probability of at least micrometastatic cancer.

Recurrence usually is suspected because the serum PSA begins to rise after falling to low levels after initial therapy. A variety of definitions of recurrent cancer after radiation have been used; the ASCO (American Society of Clinical Oncology) defined failure as the lowest PSA (nadir) after therapy plus 2 units of PSA is the most commonly accepted. This is applied by many to all forms of local therapy, apart from surgery, for prostate cancer.

If recurrence is suspected in my view a thorough search for obvious metastatic disease, including CT chest/abdomen/pelvis, isotope bone scan and occasionally PET scanning is mandatory. MRI and occasionally Choline PET scanning may define local recurrence. Antibody labelled isotope scanning (Prostascint for example) has been evaluated but is not in routine usage. The presence of obvious metastatic disease or locally advanced T3/4 N+ cancer will usually be a contraindication to salvage surgery.

A biopsy is again essential to define local recurrence and may be done once imaging has confirmed that the disease has not obviously spread. Confirmation of local recurrence in the absence of spread may be an indication for salvage surgery.

One further factor that must be taken into account is the behaviour of the patient’s PSA. The PSA velocity or doubling time give an indication of how much risk of progression the cancer poses to the individual over their lifetime. A rapid doubling of PSA, less than every 3 months, confers a high risk of the cancer spreading and resulting in early death. A slow doubling, more than one to two years, indicates a risk as low as perhaps 10 % of the cancer progressing over the next 10 years or more. As with many stages of prostate cancer there is a balance between needing to treat successfully those at high risk of causing damage and death and not over treating those with a very low risk of progress.

In summary a man with prostate cancer previously treated with radiation with PSA evidence of recurrence requires specialist assessment. A variety of factors including the stage of the cancer, the PSA behaviour and the life expectancy of the individual need to be considered before embarking on salvage surgery.

Obviously, this is difficult surgery. Can you outline the side effects of the operation?

This type of surgery, whether performed by the open route, laparoscopically or with robotic assistance is undoubtedly far more difficult and complex than primary radical prostatectomy. The effect of radiation, or indeed HIFU or cryotherapy, results in marked tissue reaction around the prostate. The prostate lies very close to many important organs and the effect of radiation is to make dissection of these areas more difficult and the risk of injury to other structures much more likely. Even when injury does not occur the healing of tissues is less certain following radiation. Collateral radiation effects on the distal urethral sphincter, neurovascular bundles and bladder neck may also make functional recovery slower and long term side effects more likely.

The rectum lies close to the posterior prostate and will often be quite stuck after radiation. Surgical dissection needs to be very careful in this region as injury to the rectum increases the risk of infection, fistula (a connection between the bowel and bladder resulting in urine leaking into the rectum) and the need for a colostomy. While this complication is still uncommon it is more so than after radical prostatectomy with no prior radiation. Incontinence is common in the short term after radical prostatectomy, resolving relatively rapidly in most. After salvage radical prostatectomy, the risk of incontinence is much higher, the time to recovery longer and long-term problems more common. At least 30-40% of men may experience long-term continence issues, some requiring correction, after salvage prostatectomy.

Sexual dysfunction, mainly erectile problems, are very common after salvage prostatectomy as the bundles may well have been compromised by the radiation before embarking upon a difficult salvage procedure. Because of fibrosis (scarring) around the bladder neck subsequent contractures requiring dilatation are common and in some will further increase the chance of long-term continence problems.

Can the operation be performed by laparoscopic or robotic methods?

The answer is yes; salvage prostatectomy can be performed by any of the recognised methods of radical prostatectomy. Is there evidence in favour of one procedure over another? – There is no evidence as there have been no trials comparing the techniques in this situation. As with many difficult procedures the likelihood of a successful outcome will in large part depend upon the experience of the surgical team dealing with the operation.

You are a high volume prostate cancer surgeon, but this is quite a rare operation. How many of these salvage prostatectomy operations do you perform per year?

Salvage prostatectomy is an uncommon operation even in very large busy prostate cancer centres. Even in US centres where 3-6,000 or more robotic prostatectomies have been performed the number of salvage cases is often far less than 100. The Bristol experience has been around 2000 open radical prostatectomies of which around 65 were salvage and over 1000 robotic cases, in 21 cases these were salvage cases. Our outcomes including functional recovery have been very good. However as these numbers suggest, most specialist units are very selective about to whom they offer salvage radical prostatectomy.

One interesting question is should we be considering more men for salvage RP? Undoubtedly the answer is yes. The perceived morbidity of all salvage treatments and the uncertainty as to which men most benefit from this approach has led many oncologists to take an observational approach. It is the urological cancer surgeons’ role to convince our Medical and Radiation oncological colleagues that appropriate salvage surgery can deliver a high chance of cure to men with locally recurrent prostate cancer at risk of progression in their lifetime with acceptable functional outcomes. It is my belief that minimally invasive surgery, in particular robotically assisted LP, offers the opportunity for the experienced prostate cancer surgeon to deliver salvage surgery safely, effectively and with rapid recovery times.

Categories: Other

15
December
2013

The Role of the Clinical Psychologist in Prostate Cancer

The Role of the Clinical Psychologist in Prostate Cancer

This week’s Guest Post is by Dr Addie Wootten, a Clinical Psychologist with Australian Prostate Cancer Research and The Department of Urology, Royal Melbourne Hospital. She talks about the psychological impact of prostate cancer on men, and what can be done to help.


The Psychological impact of prostate cancer

A prostate cancer diagnosis, like all diagnoses of cancer, can have a significant impact on psychological and emotional wellbeing. Many men speak about the shock, fear, uncertainty and anxiety they experienced when told they had prostate cancer. Many men also speak about the diagnosis as feeling like it ‘came out of the blue’ as many men are diagnosed with localised prostate cancer without any symptoms of warning. Unfortunately many men experience periods of depression or anxiety following a diagnosis of prostate cancer and emerging data indicates that men with prostate cancer have a higher risk of suicide than other men their age. This indicates the significant emotional impact that prostate cancer can have on some men.

Prostate cancer can have a very personal impact

While the initial shock of a cancer diagnosis can take its toll it is often the side-effects of prostate cancer treatment that men find the most challenging. Unfortunately all treatment options come with their share of side effects, but different treatments will have different side-effects. All treatments will have an impact on sexual and erectile functioning including changes or loss of ejaculation, changes in orgasm sensation, loss of penile length and changes to penile sensitivity but at different levels and rates depending on the treatment type. These side effects can have a significant personal impact for many men as well as a direct impact on their intimate relationships.

For many men the loss of sexual functioning can be even more difficult because of remaining normal sexual desire and this can compound the significant loss and associated impact on masculinity and self-esteem. Urinary incontinence can also have a very personal impact in terms of self-esteem, ability to maintain social connections and the experience of anxiety. Self-esteem, masculine identity and self-confidence can be significantly impacted on by the experience of prostate cancer and treatment side effects.

Managing these challenges

We know from the research literature that one of the biggest predictors of psychological distress post prostate cancer treatment is unrealistic expectations pre-treatment. That is, men who are not fully informed and counseled, pre-treatment, about the impact of treatment on their physical functioning (particularly the sexual impact) will experience much higher levels of distress post-treatment. While this isn’t rocket science the delivery of adequate information and support prior to treatment in preparation for these side-effects surprisingly doesn’t occur all the time. Many men report feeling ill-informed, and unsupported, in navigating life with these side effects.

So what role does a psychologist play in prostate cancer?

As a clinical psychologist I have the privilege of hearing the very personal experiences of men affected by prostate cancer and their partner or spouse. My role in working with these men and couples is to explore the personal impact of their experience and help them weave a new way of living, whether that be a new way of being intimate, a new outlook on life or a new level of emotional awareness.

A large part of my role is to help men and their partners explore what it might mean to experience the side effects of treatment before they have treatment. I try and speak with both members of the couple before treatment to help them plan and prepare for life after treatment and to ensure they fully understand how this might impact on them personally and as a couple. These issues are also the focus of much of my work after treatment.

A clinical psychologist will also be looking out for symptoms of anxiety and depression and other mental health concerns and will provide psychological counseling that focuses on reducing these symptoms and improving emotional wellbeing.

How to access a psychologist

Seeing a psychologist is not routine in most practices but there are many psychologists available in Australia. Ask your specialist or nurse for a referral. If they don’t know of anyone in your local area, check with your GP. If you still can’t find the right person there is an excellent listing of psychologists on the Australian Psychological Society website

To get a rebate back through Medicare you will need a referral from your GP with a mental health care plan. This care plan entitles you to up to 10 rebateable sessions per year.

New online support

I have been working to develop easily accessible psychological support for men following treatment for prostate cancer and I am currently running a study evaluating the benefits of an online support program called My Road Ahead. I am currently looking for men who have had treatment for localised prostate cancer to participate. To learn more go to myroadahead

Another new online program I have been working on is called PROSTMATE. This is an online prostate cancer portal that provides tailored information, a place to record treatments, appointments and track progress and also offers web-based consultations with prostate cancer nurses and psychologists. Follow this link to learn more about PROSTMATE

Acknowledgement

I would like to acknowledge the men and their partners who I have worked with over the years who have helped me understand the personal loss and the impact of prostate cancer; I would particularly like to acknowledge James Waller in sharing his insights.

You can follow Addie Wootten @addiewootten on Twitter.


Categories: Other

28
November
2013

Percutaneous Stone Surgery in the Supine Position

Percutaneous Stone Surgery in the Supine Position

This week’s Guest Post is by Denby Steele, an Adelaide Urologist, an expert in the management of complex kidney stone disease and pioneer of supine PCNL in Australia

"Marberger, Clayman and Whickam, in different parts of the world, were instrumental with the development of percutaneous stone surgery in the late 1970’s and early 1980’s, and for many years this has been performed in the prone position. Extracorporeal shock lithotripsy in the early 1990’s and flexible ureteroscopic laser lithotripsy in the later 1990’s have provided less invasive alternatives for upper tract stone surgery but percutaneous surgery still offers an excellent minimally invasive option, particularly for larger stones.

"Traditionally, percutaneous stone surgery has been performed in the prone position but since the first description of this in the supine position by Valdivia et al in the Journal of Urology in 1998, there have been pockets of interest and increasing expertise in surgery in this position.

"My series of 322 cases published in the Journal of Endourology in 2007 is still the second largest published series, but there are increasing reports from around the world and numerous reviewers and commentators have highlighted the advantages of surgery in this position. Randomised trials have proven the safety, efficacy and time saving.

The supine position for Percutaneous Stone Surgery (PCNL) by urologist Denby Steel

"The supine position was presumably neglected because of fear of colonic injury, but it has been shown radiologically that the colon floats further away from the kidney in the supine position, exposing a greater area for safe percutaneous puncture. With the patient tilted over a 3 litre bag under the flank it is possible to puncture even more posteriorly than some prior prone punctures. There have been no reports of colonic perforation in the supine position in the literature.

"There has been debate about which position is best, but this will depend on the sex of the patient, body habitus, whether concomitant rigid lower tract instrumentation is required, stone burden and position of the colon relative to the kidney. I recommend a 3 litre (1 litre in small patients) saline bag under the ipsilateral flank, a pillow under the ipsilateral leg for males, and lithotomy position for females or males requiring a rigid cystoscopy or ureteroscopy. The ipsilateral arm is always brought across the chest. The flank and perineum are prepared and draped together for a single stage procedure starting with flexible cystoscopy and ureteric catheterisation over a glide wire. The image intensifier is angled back 5 – 10 degrees to allow for the patient tilt. Kidney puncture, tract dilatation and stone surgery are then performed in the standard fashion. I tend to leave a ureteric stent afterwards and drain the bladder but do not leave a nephrostomy tube.

"The supine position is very attractive to nursing staff, anaesthetists and surgeons, and offers the following advantages:

  • Reduced manual handling with no position change
  • No dangerous prone position
  • No patient shoulder strain
  • Single set up and draping
  • Easy concomitant rigid cystoscopy and ureteroscopy
  • Comfortable surgery in the sitting position
  • Reduced radiation to the surgeon as hands not under the image intensifier
  • Increased safety as it is easy to pass a wire through the puncture and out the urethra
  • Stone fragments will spontaneously exit the obliquely placed sheath
  • Reduced operating theatre time
Urologist Denby Steel performing Percutaneous Stone Surgery (PCNL) using the supine position.

"I have performed percutaneous surgery in the supine position in all 680 cases since 1999 and regularly lecture and run workshops in Australia and overseas to promote and teach this simple and improved technique."

Denby Steele is a Urologist in private practice in North Adelaide South Australia, a Senior Visiting Urologist at the Royal Adelaide Hospital, the inaugural Chairman of the Endourology Special Advisory Group of the Urological Society of Australian and New Zealand, the immediate past Chairman of the SA & NT branch of the Urological Society of Australian and New Zealand and an examiner in Urology for the Royal Australian College of Surgeons.

Categories: Other

25
November
2013

Cytoreductive Nephrectomy In Clinical Practice

Cytoreductive Nephrectomy In Clinical Practice

David Nicol is a Consultant Urological Surgeon at the Royal Marsden Hospital in London where he is also Chief of Surgery. His clinical work deals with complex kidney and testis cancer including surgery in patients with advanced and metastatic disease. Here, he explains the use of cytoreductive nephrectomy in metastatic kidney cancer.

David, can you explain what is meant by cytoreductive nephrectomy?

Cytoreductive nephrectomy refers to the removal of the primary kidney tumour in patients who have metastatic disease. Historically it had been noted that occasional patients experienced spontaneous regression of metastatic disease when this was performed. This however only occurred in a very small number of cases and general opinion was that cytoreductive nephrectomy as the overwhelming majority died within 12-18 months from metastatic disease. In the late 1980’s and early 1990’s, drugs which stimulated the immune system(immunotherapy) had an effect on metastatic kidney cancer.

Small trials with 2 agents interferon-alpha (IFN-a) and interleukin-2 (IL-2) showed response rates better than what had been observed with conventional cytotoxic chemotherapy. Analysis of these studies suggested that patients who had a nephrectomy performed prior to treatment resulted in a better response to both INF-a and IL-2. The basis for this was uncertain with possibilities including a selection bias with only fitter patients, who would otherwise expect to live longer, having nephrectomy. Alternatively it was also proposed that cytoreductive nephrectomy may exert some biological effect improving the effectiveness of immunotherapy and thus overall survival.

Which patients with metastatic kidney cancer are suitable for cytoreductive nephrectomy?

Cytoreductive nephrectomy is really only an appropriate option for patients who are otherwise well. Patients whose performance status is impaired are at high risk of complications from major surgery and also generally have poor survival that is not improved with cytoreductive nephrectomy. Therefore patients who have noted significant weight loss, are anemic or who feel tired and generally unwell are not considered candidates for cytoreductive nephrectomy. Some patients may present with significant symptoms including pain and bleeding for which nephrectomy is recommended. This is regarded as a palliative intervention to control symptoms rather than a cytoreductive nephrectomy which is performed with the expectation that it may improve survival.

Can you outline the evidence that cytoreductive nephrectomy can be beneficial in some patients?

There are 2 trials – one performed in Europe and another in the United States that have demonstrated a survival benefit with cytoreductive nephrectomy in patients who are subsequently treated with IFN-a. These were both randomised controlled trials - in which patients, who all received IFN-a were randomly allocated to either cytoreductive nephrectomy or no surgery. Comparing the 2 groups which were of equal size revealed that patients undergoing cytoreductive nephrectomy had a median survival of 14 months compared to 8 months without. These studies also reinforced the lack of benefit in patients with poor performance status.

This is obviously difficult surgery. Are complication rates much higher compared to other forms of kidney cancer surgery?

Patients with metastatic kidney cancer usually have quite large primary tumours with a rich blood supply being a common feature. Both of these factors can make surgery very difficult and associated with a higher risk of complications, particularly major bleeding, compared to other forms of kidney cancer surgery. Most patients with kidney cancer have relatively small tumours and are able to have surgery performed either laparoscopically or robotically with low risk of complications. In contrast cytoreductive nephrectomy, in almost all cases, requires major open surgery as minimally invasive procedures are usually neither feasible nor safe. Patients with metastatic cancer are also generally at higher risk of complications with major surgery. Deep venous thrombosis and pulmonary embolism are 2 specific examples of this.

A relatively new treatment for metastatic kidney cancer is a class of drugs called tyrosine kinase inhibitors (TKIs). Is there any evidence that cytoreductive nephrectomy followed with TKIs is beneficial for patient outcomes and survival?

The treatment of metastatic kidney cancer has rapidly changed and now IFN-a and IL-2 are rarely used. Both agents have been largely replaced by a new group of drugs – termed targeted therapies due to their effect as tyrosine kinase inhibitors (TKIs). These drugs have a completely different mechanism of action – rather than stimulating the immune system they target tumour blood vessels. Essentially they reduce the blood flow to tumours.

At this point in time it is unknown whether or not cytoreductive nephrectomy improves the outcome in patients treated with TKI’s. It is important to note that the previous studies on cytoreductive nephrectomy only addressed the question as to whether or not this improved survival when patients were treated with IFN-2. Accepting the lack of clear evidence at this time it can still be considered in some patients. For example a patient who is otherwise well presenting with a kidney cancer and small volume metastatic disease I would suggest a cytoreductive nephrectomy as their initial management. The patient would then be observed, avoiding drug treatment until they show clear evidence of substantial progression of their metastatic disease. The rationale behind this is that TKI’s can have significant toxicity and also that resistance to treatment inevitably develops. By removing the kidney and delaying drug therapy the patient avoids toxicity of treatment and also emergence of resistance at a time when their metastatic disease may be stable or only slowly progressing(ie reserving it for maximum effect when it is really needed).

A different approach to cytoreductive nephrectomy would be considered in the patient with high volume or symptomatic metastatic disease. In this scenario I would not recommend cytoreductive nephrectomy as an initial step. Rather the patient should consider commencing a TKI from the outset. Surgery could delay therapy during which time his disease may progress with an overall deterioration in his condition such that he is never suitable for a TKI (as again these drugs only appear of benefit in patients with good performance status).

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  • Nick Brook Urology
    Calvary North Adelaide Hospital
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    North Adelaide,
    Adelaide SA 5006
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