Articles tagged with: Active Surveillance

19
February
2014

A Safer Way to Biopsy the Prostate

A Safer Way to Biopsy the Prostate

Jeremy Grummet is a Urological Surgeon with particular expertise in urological cancer. He has been instrumental in the introduction of transperineal prostate biopsy as an alternative to transrectal biopsy, to reduce infection rates after biopsy. Jeremy is conducting multiple clinical research projects on prostate biopsy and heads the Victorian Transperineal Biopsy Collaboration (VTBC) research group. In this article, Jeremy discusses the techniques and advantages of transperineal biopsy.


What’s wrong with the current standard method of prostate biopsy?

A biopsy is where a sample of tissue is taken for examination under a microscope, usually to determine if cancer is present. As you can see from the diagram below, the easiest way to access the prostate is via the rectum. That’s why we perform a rectal examination - so we can feel the back of the prostate for any suspicious lumps. Most prostate cancers are located towards the back of the prostate (peripheral zone), so a transrectal ultrasound-guided (TRUS) biopsy is a convenient way of sampling this area. Typically, at least 12 cores of tissue are taken during a TRUS biopsy.

TRUS biopsy

The other advantage of the TRUS biopsy is that it can be performed in just a few minutes by giving the patient intravenous sedation or using a local anaesthetic nerve block.

However, passing the needle of the biopsy gun through the wall of the rectum multiple times is problematic. As you’d expect from an organ that stores faeces, the rectum has a high concentration of bacteria. These bacteria don’t cause any problems as long as they stay in the rectum. However, passing the biopsy needle through the wall of the rectum allows these bacteria to access the prostate and its rich blood supply. This in turn can lead to a serious infection in the blood called septicaemia (sepsis). Septicaemia makes patients feel very unwell, requires hospitalization for intravenous antibiotic therapy, and can even be life-threatening.

This risk of sepsis in TRUS biopsy is well-recognised. It is therefore standard to use an antibiotic to help prevent such an infection. Unfortunately, the antibiotic doesn’t always work, so there is still a risk of sepsis, which has been measured at about 1-2%.

Today, there is the additional and growing problem of bacteria developing antibiotic resistance. This has been reported worldwide and was the subject of a major US Government report last year.

Our own research group, the Victorian Transperineal Biopsy Collaboration (VTBC), reviewed the scientific literature, finding that developing resistance is a particular problem for bacteria that live in the rectum, so that the antibiotics we would normally use, such as ciprofloxacin, can sometimes be rendered ineffective. This coincides with reports of increasing rates of TRUS biopsy sepsis even as high as 5%.

Our research has also found that, as a result of the above, some Australian and New Zealand urology practices have resorted to using big-gun broad-spectrum antibiotics on a regular basis to prevent TRUS biopsy sepsis. Whilst this may reduce sepsis for the individual patient, from a public health perspective, it is a step backwards, as widespread use of such antibiotics will lead to even more resistance. Unfortunately, we are already seeing this happening, with hospitals in Australia finding CRE (Carbapenem-Resistant Enterococci) in their wards.


What is transperineal biopsy, and why is it safer?

Fortunately, there is another approach to prostate biopsy which avoids perforation of the rectum altogether. Instead, the biopsy needle can be passed via the skin of the perineum. In men, the perineum is the part of the body between the scrotum and the anus.

TRUS biopsy

As shown in the diagram, the ultrasound probe is still passed into the rectum to provide an image of the prostate. But instead of the biopsy needle passing alongside the probe, it is passed through a grid, which itself is fixed against the probe outside the body. Prior to insertion of the ultrasound probe, the perineal skin is easily prepared in a sterile fashion, just as any other incision site is prepared before surgery to prevent wound infection. (Although worthwhile attempts have been made to sterilize the rectum, this has not been possible.)

Our group studied the experience of transperineal (TP) biopsy around the world and found that in over 6,600 patients, there were only 5 patients re-admitted to hospital for sepsis - a rate of just 0.076%, or less than 1 in a thousand. Furthermore, in our own published experience of 245 TP biopsies our rate of re-admission for infection was zero. (We have now performed over 400 TP biopsies, still without a single episode of infection.)

Based on the published scientific evidence to date then, it appears that TP biopsy is a safer option than TRUS biopsy due to its near-zero sepsis risk. It also gives the advantage of avoiding regular use of heavy-duty antibiotics, thereby avoiding promotion of resistant bacteria, now labelled by the US Government Center for Disease Control as a Serious Threat to population health worldwide. As a result, we now use TP biopsy routinely for all prostate biopsies.


Are there any downsides to the transperineal approach?

Looking at the diagram above, you would expect TP biopsy to be painful, which is why it is typically performed under a general anaesthetic (although methods of using local anaesthetic only have been reported). We routinely perform TP biopsy under GA. As a result, men experience no pain during the procedure, and very little afterwards, so that paracetamol is only required occasionally. Although a general anaesthetic is required, it is of a short duration only (less than 30 minutes) and is very safe.

Practitioners of TP biopsy initially reported a higher risk of acute urinary retention (unable to pass urine) with this approach. However, with further experience, and by deliberately avoiding the area around the urethra, this rate dropped so that it is now similar to the risk seen in TRUS biopsy (around 2%). Although a catheter has been used by some doctors, as shown in the diagram above, it is unnecessary.

Due to anecdotal experience, some urologists have been concerned that TP biopsy may lead to erectile dysfunction by damaging the erectile nerves or to more difficult surgery if cancer is found and the prostate needs to be removed. However, evidence to date, albeit scant, does not support either of these concerns.


Is it as good as TRUS at cancer detection?

According to the scientific literature, TP biopsy is at least equivalent to TRUS biopsy in its ability to detect cancer. Some research has also found improved detection of cancers at the front of the prostate (anterior). This may be due to the typically easy access TP biopsy provides to all areas of the prostate, particularly anteriorly. Conversely, it can often be difficult to reach the anterior prostate via TRUS biopsy, especially in large glands.


What other advantage might TP biopsy provide?

In TP biopsy, the ultrasound probe is stabilized by equipment that is fixed to the operating table. The grid through which the biopsy needle is passed is, in turn, stabilized against the ultrasound probe. This set-up permits accurate and reproducible biopsy needle placement.

In the past, TP biopsies were taken in a systematic fashion only, evenly sampling various areas of the prostate. Whilst this is still performed routinely, in addition we are now often performing targeted biopsies of suspicious lesions if found on a prostate MRI. The stable arrangement of TP biopsy therefore permits accurate targeting of such lesions, with the potential to further improve the accuracy of cancer detection.


You can read more about Jeremy Grummet by clicking this link

There is more information on transperineal biopsy on the AUA site.

And you can follow @JGrummet on Twitter.


Categories: Updates, Prostate Cancer, Prostate Surgery

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

01
October
2013

Melbourne Consensus Statement on Prostate Cancer Testing

Melbourne Consensus Statement on Prostate Cancer Testing

This is the fourth in a series of posts by highly respected guest authors in Urology. Drs. Matt Cooperberg and Declan Murphy answer questions on the recently released Melbourne Consensus Statement on Prostate Cancer Testing


Matthew Cooperberg is Associate Professor of Urology and Epidemiology & Biostatistics at the UCSF Helen Diller Family Comprehensive Cancer Center. He is a urologic oncologist specialising in prostate cancer management. Matt is a highly published academic surgeon, having written/co-authored 130 peer-reviewed journal articles and 12 book chapters. He is Associate Editor for European Urology and sits on multiple other editorial boards.

Declan Murphy is Uro-Oncologist and Associate Professor of Surgery at the University of Melbourne, Peter MacCallum Cancer Centre. He is an Associate Editor at the BJUI and holds other senior editorial positions at European Urology and Nature Reviews Urology.


Declan, what was the rationale behind writing the Melbourne PSA Consensus Statement?

“The Melbourne Statement was a response to the very confused landscape we found ourselves in after the release of the USPSTF Recommendation last year and to a lesser extent, the AUA PSA Guideline a few months ago. While the USPSTF recommendation was frankly ridiculous and unworkable (PSA is not going to go away), the AUA Guideline did have some merit. However we felt that it did not adequately address some areas, e.g. how should we approach the average man in his 40’s who does not want to die of prostate cancer? Knowing that we would have a gathering of highly respected experts in prostate cancer in Melbourne in August 2013 we decided to release a simple document, which would provide straightforward guidance for GPs and others.”


Matt, has the statement been well received by Urologists, Patients and GPs/Family Doctors in the US?

“I was quite impressed with the press coverage in Australia and even in the U.S. when it was presented at the PCWC conference in Melbourne. We’ll see how much more discussion it generates when the final document is published in British Journal of Urology International. Ultimately, though, at least in the U.S., urologists’ recommendations don’t carry much weight with the primary care providers who are really making PSA testing decisions. They give far more credence to the USPSTF, unfortunately. Likewise in Australia, the RCGP Red Book is the bible for many GPs and it is very anti-PSA testing. Nevertheless we have had much positive feedback from GPs already.”


Matt, the USPSTF position statement essentially came out against PSA testing. Has this had a measurable impact on PSA testing in the US?

“This is hard to say so far. In 2009 the USPSTF came out against testing among older men, and multiple papers have shown that the recommendation had virtually no impact on PSA testing rates in the older population. However, this time it seems to be different. While there are no published data yet, multiple anecdotes seem to suggest that many primary care providers are simply abandoning PSA testing—equally for younger men in good health as for older ones with significant comorbidity. It is very much a case of throwing the baby out with the bath water.”


Matt, if the reductions in metastasis and prostate cancer mortality with PSA testing are so large, why does the consensus not support a population-wide screening programme?

“That term (population-wide screening) tends to imply reflexive PSA testing without any a priori discussion with the individual man. Enough controversy and confusion exists regarding both screening and prostate cancer treatment—and overtreatment is still enough of a problem in the U.S. and elsewhere—that we should not be screening men without warning them of the possible outcomes of testing. The relative cancer-specific mortality reductions are large, but the absolute reductions are not with 10-15 year follow-up, thus leading to calculations of relatively high numbers needed to screen and diagnose to prevent one cancer death. Though these numbers fall substantially with longer follow-up (a horizon of 30 years or more is entirely appropriate for a 50 year old man facing a screening decision), most men with prostate cancer die of cardiac disease, just like those without prostate cancer.”


Declan, are there any improvements or changes to the document planned?

“The document is set to evolve. One of the benefits of publishing it as a blog at bjui.org was to get it into circulation very quickly and also to allow others to comment. Within 72 hours the Melbourne Statement had become the most-read and most-commented blog at BJUI. The print version will appear in the BJUI in coming months.”


Matt, what is the future for PSA testing in your view?

“It’s very hard to say. I think many of us know the way PSA screening should evolve: men should be offered testing at a relatively young age—with the express understanding that testing is intended to detect high-risk prostate cancer, and that if a low-risk tumour is identified, it does not need immediate treatment. Those with low baseline PSAs can be re-screened less frequently than they are now. Evolving biomarkers will help determine who needs a biopsy and who needs treatment, but PSA is not going anywhere as a first screen. From what I understand, most national policies are evolving toward some variation on a “smarter screening” approach. Unfortunately, in the U.S. it will likely require a legislative remedy to force the USPSTF to accept actual expert opinion before the policy is corrected. There is a bill working its way through Congress to do just this, but it is not a quick process.

"In the meantime, the best we as urologists can do is to implement smarter screening in practice, to strive to reduce overtreatment and to improve quality of treatment when it is needed, to continue to advocate for USPSTF reform, and to reach out to local groups of primary care providers to educate them that the truth about PSA—which, as is usually the case in medicine, is neither black nor white. Only through understanding the truth in the shades of grey can we at once maximise the benefits of screening and minimize its harms.”


You can follow both Declan Murphy @declangmurphy and Matt Cooperberg @dr_coops on Twitter.


Categories: Prostate Cancer

23
September
2013

Management of Localised Kidney Cancer

Management of Localised Kidney Cancer

Alexander Kutikov, MD is a Surgical Oncologist and Associate Professor of Urologic Oncology at the Fox Chase Cancer Center in Philadelphia. He is a highly published author and experienced presenter on the topic of Urological Cancer, and is very active in Social Media in Urology. In this Guest Post, Alex gives a concise account of the diagnosis and treatment options for localised kidney cancer. He explains what you need to know, and what you should ask your surgeon.

You can read more about Alex by clicking this link : Alexander Kutikov MD, and you can follow him on twitter @uretericbud.

Details of the Fox Chase Cancer Center can be found here : Fox Chase Cancer Center.

The Kidneys

"If you or your loved one has been diagnosed with a kidney tumor / mass, reliable information regarding this condition is often difficult to obtain. It is important that you have a good understanding of the diagnostic and treatment options available in order to make an educated choice on how to best proceed with your treatment.

"Generally, when patients are diagnosed with a kidney mass, it is apparent on imaging studies whether the tumor is localized to the kidney or if it has spread beyond the kidney to other parts of the body. For patients with localized disease, surgical resection remains the gold standard, and is largely superior to therapies such as cryotherapy or radiofrequency ablation.

"The following points are important to remember:

1. Understand that not All Kidney Tumors are Malignant.

2. Understand Goals of Treatment:

Surgical Oncologists
  • Primary treatment goal: Oncologic cure - cancer control must never be compromised and surgical resection is the gold standard treatment for patients with kidney tumors. Yet, for some patients "active surveillance" is often an ideal initial option of choice (Small renal masses progressing to metastases under active surveillance: a systematic review and pooled analysis).

  • Secondary treatment goal: Kidney preservation - years of experience with kidney (aka: nephron) preserving surgery (partial nephrectomy) demonstrates that this approach is oncologically safe and is associated with long-term benefits to overall health. A standardized system to classify features of kidney tumors as they relate to ability to safely perform partial nephrectomy was developed at Fox Chase Cancer Center in 2009 (The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth.) and is currently used by kidney surgeons all over the globe.

  • Tertiary treatment goal: Utilization of minimally invasive surgical approaches - . Both transperitoneal and retroperitoneal minimally-invasive (laparoscopic / robotic) surgical approaches are currently utilized by expert kidney surgeons. Finding the right surgeon may help avoid a large painful incision, albeit traditional open kidney surgery continues to play an important role in management of some patients with large / anatomically complex kidney tumors.

3. Be Prepared During Your Visit.

Here are some questions to pose to your treating physician when you or your family member is diagnosed with a renal mass:

  • Understand characteristics of your mass: size of tumor, clinical stage of tumor, RENAL nephrometry score. If your tumor has been resected, be sure to obtain information regarding pathologic stage, grade and histology. Pathology review by expert pathologists at times can make a critical difference in guiding further treatments.
  • Why or why not do a biopsy?
  • Treatment Options:
    • Active Surveillance - am I a candidate?
    • Medical Therapy (generally reserved for tumors that have spread)
    • Renal mass ablation (generally reserved for frail patients whose surgical risks are prohibitive).
    • Surgery
      • partial nephrectomy: is your surgeon familiar and experienced with kidney preservation techniques? Is he/she comfortable performing partial nephrectomy minimally-invasively, thus accelerating your recovery and minimizing pain?
      • radical nephrectomy: if radical nephrectomy is offered, be sure to establish that partial nephrectomy is not possible at a more experienced center. If kidney preservation is not possible, can radical nephrectomy be performed with minimally-invasive techniques?
  • Risks of treatment: be sure to understand risks associated with each option.

"In summary, kidney cancer is curable in the majority of cases and its treatment is rapidly evolving. Finding an expert urologic surgeon who not only understands this complex disease, but also possesses the needed surgical skills to appropriately manage this condition is critical to successful outcomes."

This post was adapted by Alex Kutikov from an original Fox Chase Cancer Center Cancer Conversations blog post which appears at: Understanding Your Kidney Cancer Treatment Options

Categories: Updates

14
September
2013

Urology Cancer Surgery - Present and Future

Urology Cancer Surgery - Present and Future

Continuing the series of Guest Posts by highly regarded Urologists, Benjamin Davies from UPMC answers questions on Urologic Cancer Surgery

Dr. Benjamin Davies is a Urological Surgeon specialising in cancer management. He is an Assistant Professor in Urology at the University of Pittsburgh Medical Centre and the Director of the Urologic Oncology Fellowship. He is a respected clinician scientist and is considered a pioneer for urologists in social media, particularly Twitter.

In this post, Ben Davies answers questions on the current practice and future development of urological cancer surgery


Ben, what was your motivation to concentrate on urology cancers?

I think I was frankly attracted to tumour biology first and then I was introduced to the actual surgery. Once I started being a surgeon I quickly forgot about the basic science biology and become engrossed in large cancer surgeries and robotically enhanced ones as well. I like the direct impactful role that surgery offers to the patient right then and there. No waiting for medication to work or waiting for lab work….it’s operate and hopefully cure. Concrete work.


What is the hardest part of your job?

Sick patients are the absolutely most challenging. It’s simply not a 9-5 job. When I have a patient that is struggling I tend to really take it personally (which of course you shouldn’t) and you can easily become very stressed. Learning to manage the stress is part of becoming a successful physician but is definitely the most challenging.


Female urological system

What have been the biggest developments in urologic cancer in the past few years?

I think two things are the biggest developments:

1. Robotic surgery has significantly aided our surgical approach to prostate cancer care. It has without a doubt decreased the side effect profile of a rather morbid procedure.

2. Genomic testing is finally coming online. We have all been waiting for real genomic testing to help us with our care and the new prostate cancer tests (while still at the beginning of their testing) are promising.



What is the most important preventative measure in urological cancer?

Do not smoke. It is an absolute tragedy to smoke. Just stop it.


Ten years ago, an old boss of mine said to me …”Brook, in years to come you will look back on a holocaust of radical prostatectomies.” Is there is any truth in this?

Of course he was right!! We have done a major disservice in over-treating prostate cancer patients. And as a result our large US screening studies are flawed and we now have to deal with the consequences of bad data. The PSA screening debate has turned against us because we over-treated low volume, low risk prostate cancer without any pause and many times just for money. Hopefully the new generation of urologists has been sufficiently educated to stop the nonsense.


In ten years time, what will prostate cancer treatment look like?

Easy. After your MRI-guided biopsy you will get a genomic profile and risk stratification of your disease. If you are healthy man, then you will be offered a robotic prostatectomy at a centre of excellence.


Male urological system

Prostate cancer receives a huge amount of publicity and funding. Which urology cancer gets a rough deal, and what can be done to improve this?

The absolute worst is bladder cancer! The patient population that is affected is older, sicker, and has lower socioeconomic means. What to do?? The Bladder Cancer Advocacy Network is beginning to generate better lobbying efforts and academics certainly need to bring this issue to the fore more often.


You can read more about Ben Davies on the UPMC site, and follow him at @daviesbj on Twitter


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