Improving survival for patients with prostate cancer diagnosed in the prostate-specific antigen ERA

Epidemiological Determinants of Advanced Prostate Cancer in Elderly Men in the United States

In this study, we examined the effects of individual-level and area-level characteristics on advanced prostate cancer diagnosis among Medicare eligible older men (ages 70+ years). We analyzed patients from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2000-2007) linked to US Census and County Business Patterns data. Cluster-adjusted logistic regression models were used to quantify the effects of individual preventive health behavior, clinical and demographic characteristics, area-level health services supply, and socioeconomic characteristics on stage at diagnosis. The fully adjusted model was used to estimate county-specific effects and predicted probabilities of advanced prostate cancer. In the adjusted analyses, low intensity of annual prostate-specific antigen (PSA) testing and other preventive health behavior, high comorbidity, African American race, and lower county socioeconomic and health services supply characteristics were statistically significantly associated with a higher likelihood of distant prostate cancer diagnosis. The fully adjusted predicted proportions of advanced prostate cancer diagnosis across 158 counties ranged from 3% to 15% (mean: 6%, SD: 7%). County-level socioeconomic and health services supply characteristics, individual-level preventive health behavior, demographic and clinical characteristics are determinants of advanced stage prostate cancer diagnosis among older Medicare beneficiaries; other health care-related factors such as family history, lifestyle choices, and health-seeking behavior should also be considered as explanatory factors.

Racial differences in PSA screening interval and stage at diagnosis

OBJECTIVES

This study examined PSA screening interval of black and white men aged 65 or older and its association with prostate cancer stage at diagnosis.

METHODS

SEER-Medicare data were examined for 18,067 black and white men diagnosed with prostate cancer between 1994 and 2002. Logistic regression was used to assess the association between race, PSA screening interval, and stage at diagnosis. Analysis also controlled for age, marital status, comorbidity, diagnosis year, geographic region, income, and receipt of surgery.

RESULTS

Compared to whites, blacks diagnosed with prostate cancer were more likely to have had a longer PSA screening interval prior to diagnosis, including a greater likelihood of no pre-diagnosis use of PSA screening. Controlling for PSA screening interval was associated with a reduction in blacks' relative odds of being diagnosed with advanced (stage III or IV) prostate cancer, to a point that the stage at diagnosis was not statistically different from that of whites (OR=1.12, 95% CI=0.98-1.29). Longer intra-PSA intervals were systematically associated with greater odds of diagnosis with advanced disease.

CONCLUSIONS

More frequent or systematic PSA screening may be a pathway to reducing racial differences in prostate cancer stage at diagnosis, and, by extension, mortality.

[The hormone refractory prostate cancer - a challenge for the internal specialist]

Prostate cancer is the second-leading cause of cancer-related death among men and the seventh most common cause of death in the United States overall. As prostatic carcinoma is a slowly growing cancer depending on the tumor burden, use of PSA results in early cancer detection. pT2 tumors can be cured with low morbidity by radical prostatectomy. Five years after operation only few patients will experience further PSA recurrences. Adjuvant radiation therapy is effective in about half of patients with pT3 tumors in case of PSA recurrence. Most prostate cancers are androgen-dependent, meaning that they respond to androgen-ablation therapy. However, these tumors eventually become androgen-independent and grow despite androgen ablation. Since androgens are essential to the survival of prostate cells, a major question is how a prostate cell survives after androgen-ablation therapy. The mechanisms by which a prostate cancer cell survives after androgen-ablation therapy are conflicting. Specific targeting of genes involved in such pathways may further increase the chance of inventing new therapeutic options. So far, chemotherapy with docetaxel has been proved to prolong survival time and minimize cancer induced side effects in patients with hormone refractory prostate cancer.

Prostate cancer detection: magnetic resonance (MR) spectroscopic imaging

Magnetic resonance spectroscopic imaging (MRSI) represents a noninvasive technique to extend the diagnostic evaluation of prostatic cancer, beyond the morphologic information provided by MR imaging throughout the detection of cellular metabolites (choline and citrate). MRSI combined with the anatomical information provided by MRI can improve the assessment cancer location and extent within the prostate, extracapsular spread and cancer aggressiveness; both before and after treatment. We review the performance of MRI with MRSI and the role in the detection, localization, staging and management of the patient pre- and posttherapy for prostate cancer.

[Screening for prostate cancer: arguments "in favour"]

Prostate cancer is a problem of public health; the relevance of its mass screening remains to be demonstrated by the conclusions of ongoing randomized prospective studies of which the preliminary results are promising. Yet, non-randomised and/or retrospective studies report a benefit of screening-related mortality. On such basis, French scientific authorities currently recommend individual screening.

Does year of radical prostatectomy independently predict outcome in prostate cancer?

OBJECTIVES

To examine how the biochemical outcomes after radical prostatectomy (RP) have changed in the prostate-specific antigen (PSA) era when controlling for the effects of other prognostic variables. Since the beginning of the PSA era, the presentation, treatment, and therapeutic outcomes of prostate cancer have evolved.

METHODS

We reviewed the Columbia University Comprehensive Urologic Oncology Database and identified 1319 patients who had undergone RP without adjuvant therapy, performed by three surgeons, between 1988 and 2003 (minimal follow-up of 12 months). Univariate Cox proportional hazards models were used to determine which variables affect the hazard of biochemical failure (BCF), defined as a PSA level of 0.2 ng/mL or greater on at least two occasions, after RP. Multivariate analysis, controlling for the effects of other prognostic variables, was used to determine the effect that the year of surgery had on hazard of BCF.

RESULTS

Univariate analysis confirmed the importance of the year of surgery, preoperative PSA level, pathologic stage, Gleason sum, and surgical margin status in estimating the hazard of BCF (P <0.001). Age at surgery did not have a statistically significant effect. A multivariate Cox model showed that the year of surgery had a highly significant impact on the hazard of BCF even when controlling for PSA, stage, Gleason sum, and surgical margin status.

CONCLUSIONS

Patients undergoing RP in more recent years are at significantly less risk of BCF compared with patients who underwent surgery earlier in the PSA era, even when controlling for the effects of other prognostic variables. The factors that account for this change in outcomes over time have yet to be identified.

Population Screening for Prostate Cancer and Emerging Concepts for Young Men

Prostate cancer is the most common malignancy in American men, accounting for > 29% of all diagnosed cancers and approximately 13% of all cancer deaths. Nearly 1 of every 6 men will be diagnosed with the disease at some time in their lives. In 2003 alone, an estimated 221000 men in the United States will be diagnosed with prostate cancer and > 28000 will die of the disease. An elevated level of prostate-specific antigen (PSA) is correlated with the presence of prostate cancer, and since 1989 we have been living in the "PSA era," in which the PSA screening test is widely used in clinical practice. This article summarizes what has been learned about the use of PSA screening, including the intricacies of free PSA, PSA doubling time, and various factors that may affect PSA and confound screening in young men. Although population-based screening for prostate cancer has yet to be definitively proven to affect disease-specific mortality, PSA testing is detecting cancers in younger men and at earlier stages of disease progression and, partly as a result, 5-year cancer-specific survival is increasing. Even though this lead-time effect may not translate into long-term improvement, these changes are very promising and are a necessary prerequisite to effective screening. For patients at high risk with a family history of the disease and for black men, a strategy consisting of an annual PSA blood test and digital rectal examination for men >or=40 years of age appears to be prudent. Use of age- and race-specific reference ranges for PSA based on sensitivity, or maximal cancer detection, is the most appropriate approach in this high-risk group. Specifically among black men 40-49 years of age, those with a PSA value > 2.0 ng/mL should consider further evaluation. Many men at low/average risk aged 40-49 years also request testing and it is reasonable to offer testing and risk assessment to these young men. The exact screening threshold for total PSA in these men is unknown, but 95% of these men will have a PSA < 2.5 ng/mL. Prostate-specific antigen velocity, percentage of free PSA, and perhaps complexed PSA may be used to help determine risk, but further study of young men is needed. In the future, a risk-stratified approach using molecular biomarkers and/or proteomics in young men is anticipated.

Imaging clinically localized prostate cancer

At this time there is no highly sensitive and specific widespread radiographic test for local staging of prostate cancer. Future developments will likely require a combination of imaging modalities with utilization guided by risk-stratification models (Table 4). Staging data for all imaging tests discussed in this article are summarized in Tables 5 and 6. Clinically, conventional gray-scale TRUS remains the most frequently used tool because of its utility in guiding prostatic biopsies. Modifications of TRUS--including power and color Doppler, 3D imaging, and new ultrasound contrast agents and elastography--show promise in increasing the accuracy of ultrasound. Endorectal MRI may have some value for staging selected patients. The addition of prostatic MRS, which images the differential activity of metabolites, may increase the specificity of MRI. Newer techniques with finer voxel resolution may prove to be clinically useful. A large well-designed study evaluating the utility of MRI/MRS is currently being planned. Cross-sectional imaging of the pelvis with either MRI or CT should be used selectively as should radionuclide bone scans. Similarly, ProstaScint scans should be ordered selectively, either before or after primary therapy, rather than routinely in all patients.

Improved prostate cancer-specific survival and other disease parameters: impact of prostate-specific antigen testing

OBJECTIVES

To determine how the implementation of prostate-specific antigen (PSA) testing has affected disease-specific survival and other characteristics of prostate cancer.

METHODS

Data were collected on all patients with prostate cancer diagnosed between 1988 and 1998 and registered in the Center for Prostate Disease Research Database at Walter Reed Army Medical Center. Statistical analyses were used to summarize trends over time in survival, mortality, and clinical stage.

RESULTS

Between 1988 and 1998, a total of 2042 patients with prostate cancer were registered at Walter Reed Army Medical Center. The 5-year disease-specific survival rate was 86.9% and 93.7% for patients diagnosed in the respective year groups of 1988 to 1991 and 1992 to 1994, with follow-up through December 1, 2000 (P < 0.001). Prostate cancer was the cause of death for 37.5% of the patients in 1988 to 1989 versus 15.4% in 1999 to 2000. Marked stage migration has occurred; from 1988 to 1998, the percentage of patients presenting with metastatic disease decreased from 14.1% to 3.3% (P < 0.001).

CONCLUSIONS

A statistically significant improved 5-year disease-specific survival and a decreased chance of dying from prostate cancer has occurred after the widespread implementation of PSA. We suspect that PSA testing has resulted in fewer patients presenting with metastatic disease and more patients presenting with localized disease amenable to curative treatment. This portends well for the use of PSA screening to improve outcomes for prostate cancer. However, randomized trials are needed to confirm the improvements in survival and mortality.

Skeletal fractures negatively correlate with overall survival in men with prostate cancer

PURPOSE

We assessed the correlation of skeletal fracture with survival in men with prostate cancer on chronic androgen suppressive therapy.

MATERIALS AND METHODS

A total of 195 consecutive patients on chronic androgen suppression for prostate cancer were evaluated for the history and type of skeletal fracture. Correlation with overall survival was performed via multivariate analysis.

RESULTS

Of these 195 men 24 reported skeletal fracture since the diagnosis of prostate cancer. Median overall survival was 121 and 160 months in men without and with a history of skeletal fracture since the diagnosis of prostate cancer, respectively (p = 0.04). A history of skeletal fracture was retained as a negative predictor of survival on forward stepwise regression analysis (RR = 7.4, p = 0.007).

CONCLUSIONS

Our results suggest that skeletal fracture in patients with prostate cancer is an independent and adverse predictor of survival. Consideration for screening men at greatest risk via bone mineral density measurements and initiating empirical skeletal therapies (bisphosphonates, estrogens and so forth) may be warranted. This recommendation awaits validation through prospective randomized trials.

Prostate-specific antigen as surrogate for characterizing prostate cancer subgroups

OBJECTIVE

To evaluate how serum prostate-specific antigen (PSA) levels in a population-based cohort of men with prostate cancer vary with age and intensity in the diagnostic activity and to describe the treatment selection processes associated with PSA level.

MATERIAL AND METHODS

All men in the Swedish National Prostate Cancer Register diagnosed during 1996-1997 were included. In 1996 the register included 19 counties, covering 61% of the Swedish male population, and in 1997 21 counties with 79% of the Swedish male population.

RESULTS

A total of 8328 men were registered. PSA levels were missing in 341 cases. With increasing PSA there was a shift towards more advanced and poorly differentiated tumours. PSA at diagnosis increased with age, with the exception of patients younger than 50 years who had higher PSA values. The mean logarithm of PSA correlated negatively with the percentage of localized tumours (p < 0.005) and the age-adjusted incidence (p < 0.05) in each respective county in 1997. PSA was higher in men receiving radiotherapy compared with those treated with radical prostatectomy as well as in the group treated with bilateral orchiectomy compared with those receiving GnRH-analogues.

CONCLUSIONS

If PSA is used as a surrogate measure of extent of tumour volume in a population of prostate cancer patients, our findings indicate that age distribution and differences in incidence (possibly due to variation in diagnostic activity) should be taken into account. In our cohort there was a selection process, probably in part guided by PSA level, when choosing type of curative or palliative treatment.

Clinical predictors of androgen-independent prostate cancer and survival in the prostate-specific antigen era

OBJECTIVES

To further characterize and identify novel predictors of androgen-independent prostate cancer (AIPC) and survival in the prostate-specific antigen (PSA) era.

METHODS

A total of 184 consecutive patients with prostate cancer receiving chronic androgen suppression were assessed for the development of AIPC and overall survival.

RESULTS

The median time to development of AIPC was 44 months (Stage M+ = 24 months; Stage M0 = 63 months, P = 0.000001). The 10-year overall survival rate for Stage M0 or M+ disease was 89% and 55%, respectively. AIPC developed significantly more commonly in patients with a higher nadir PSA level (greater than 1 ng/dL), a longer time to reach nadir PSA (greater than 3 months), a larger body mass index (greater than 27 kg/m2), greater pretherapy PSA level, and when evidence of metastatic disease was identified (logistic regression analysis). Overall survival was significantly associated with advanced stage (skeletal metastases), pretreatment PSA level, and history of skeletal fracture (multivariate Cox regression analysis).

CONCLUSIONS

In the PSA era, longer intervals of androgen suppression therapy in nonmetastatic, biochemically recurrent prostate cancer have translated into a change in the duration of androgen-dependent prostate cancer. Although the duration of androgen dependence remains variable, prolonged--possibly "curative"--control exists in a subset of patients. Obese men developed AIPC significantly sooner than did slender men. A skeletal fracture was a significant negative predictor of overall survival. These observations form the basis for nomogram predictions of AIPC in the PSA era.

[The Will-Rogers phenomenon. Stage migration in bronchogenic carcinoma after applying certainty criteria]

OBJECTIVE

To quantify changes in tumor-node-metastasis (TNM) staging (numerical migration) and survival (prognostic migration) that arise when certainty criteria are applied to a patient population with non-small cell lung cancer (NSCLC) treated surgically.

METHODS

The population consisted of 1,844 patients with NSCLC who underwent surgery between 1993 and 1996 at hospitals participating in the Bronchogenic Carcinoma Co-operative Group of the Spanish Society of Pneumology and Thoracic Surgery (GCCB-S). For every patient, surgical-pathological TNM staging (p) was based on two classifications: initial staging by each participating GCCB-S center (pTNM-i) and a second classification bearing greater classificatory certainty (pTNM-cc) resulting from the application of stricter criteria. Numerical migration was said to have occurred in cases where the two classifications did not coincide, and the possible prognostic migration under the new staging was then assessed.

RESULTS

The results revealed great numerical migration in the pN0 classification (from 1,091 cases to 665). The changes did not result in prognostic migration either for the group as a whole or for pT1-2N0M0 cases. However, for pT3N0M0 cases, median survival increased by 13 months. The difference in three-year survival (S3) for pT3N0M0-i without certainty confirmation [S3 = 0.30 (95%CI 0.18-0.42), n=59] and pT3N0M0-cc [S3=0.54 (95%CI = 0.44-0.64), n = 92] was significant (log-rank, p = 0.035). Such behavior was not observed for pT1-2N0M0.

CONCLUSIONS

The numerical migration observed as a result of applying surgical-pathological classificatory certainty criteria is relevant but the prognostic repercussion is scarce, except in cases classified as pT3N0M0, in which a significant positive prognostic migration is observed (the "Will Rogers phenomenon").

Prostate cancer screening in the Tyrol, Austria: experience and results

This article summarises the experience and results of different prostate carcinoma screening projects using total prostate specific antigen (PSA) and per cent free PSA as the initial test. Of the 21078 volunteers 1618 (8%) had elevated PSA levels. Of these men 778 (48%) underwent biopsies; 197 (25%) biopsies were positive for prostate carcinoma and 135 (17%) underwent radical prostatectomy. 95 were found to be organ-confined. A PSA cut-off of 2.5 ng/ml in men aged 45-49 years and of 3.5 ng/ml in men aged 50-59 years resulted in an 8% increase in the detection rate of organ-confined disease. 284/2272 men (13%) had elevated PSA levels and prostate carcinoma was detected in 62 men (3%). All patients underwent radical prostatectomy and histological examination revealed organ-confined tumour in all but 8 men. 98/340 men (29%) had biopsies positive for carcinoma; 28 of these patients (29%) had carcinoma that originated in the transition zone only. In the retrospective study, receiver operating characteristic curve analysis showed that by using a per cent free PSA of less than 18% as a biopsy criterion, 37% of the negative biopsies could be eliminated although 94% of all carcinomas would still be detected. In the first prospective study, 106/158 men (67%) with elevated PSA levels below 10.0 ng/ml were further evaluated and 37 (35%) prostate carcinomas were detected. By using a per cent free PSA of <22% as a biopsy criterion, 30% of the negative biopsies could be eliminated although 98% of the carcinomas would still be detected. In the second prospective study, 120/465 men (26%) with total PSA levels between 1.25 and 6.49 ng/ml and a per cent free PSA<18% were further evaluated and 27 (23%) were found to have prostate carcinomas. Receiver operating characteristic curve analysis for PSA transition zone (TZ) density showed that by using a PSA transition zone density of >22 ng/ml/cc as a biopsy criterion, 24.4% of negative biopsies could be avoided without missing a single carcinoma. In the prescreening era the incidence of T1a Grade 1 and 2 carcinomas was 3.1% and the incidence of T1a and T1b Grade 3 carcinoma was 2.3% whereas in the years after the establishment of PSA-based screening the incidence was 4.6 and 1.03% respectively. The rate of organ-confined tumours increased from 28.7% in 1993 to 65.7% in 1997. In this evaluation a new approach, to proceed with a prostate biopsy based upon the individual risk of having prostate cancer rather than a single PSA cut-off point was developed. High total PSA levels, PSA density and PSA transition zone density correlated significantly with high Gleason scores, capsular penetration, a high percentage of cancer in the prostatectomy specimen and a high cancer volume. In this evaluation all of the 95 patients with PSA levels below 3.99 ng/ml who underwent radical prostatectomy showed clinically significant, organ-confined prostate cancer with negative surgical margins. The results of this evaluation suggest that older men have larger tumour volumes compared with younger men with the same PSA levels. These data suggest that PSA-based screening with low PSA cut-off values increase the detection rate of clinically significant, organ confined and potentially curable prostate cancer. Per cent free PSA and PSA transition zone density provide an additional diagnostic benefit over total PSA.

Prostate carcinoma trends in three counties in Sweden 1987-1996: results from a population-based national cancer register. South-East Region Prostate Cancer Group

BACKGROUND

To detect changes in the incidence rate and management of prostate carcinoma, all cases of the disease diagnosed in the southeast region of Sweden between 1987-1996 were recorded.

METHODS

The register is based on Swedish personal registration numbers, thereby minimizing the number of dropouts. All cases of prostate carcinoma detected in the southeast region have been recorded according to a defined protocol that has been updated successively to match recent views regarding the disease. To ensure a high number of presented cases, the National Cancer Register was checked for missing cases.

RESULTS

Six thousand seven hundred eighty-two cases of prostate carcinoma were registered in the region between 1987-1996. The age-adjusted incidence rate reached a peak in 1993, followed by a slight decrease. The mean age at diagnosis throughout the period was 74.2 years, with a peak age of 74.8 years in 1992. The number of incidental tumors followed the development of the number of transurethral resections of the prostate performed in the region, with a peak in 1991. The percentage of patients receiving gonadotropin-releasing hormone (GnRH) analogues increased from 3.9% to 37.8% whereas the percentage of patients treated with orchiectomy decreased from 40.0% to 12.8% and the percentage of those treated with radical prostatectomy decreased from 11.1% to 2.5%.

CONCLUSIONS

A diminishing pool of latent tumors may explain the decreasing incidence rate and lower age at diagnosis observed after 1993. Orchiectomy is rapidly being superseded by GnRH analogues. In contrast to trends reported in the U.S., the percentage of men with prostate carcinoma undergoing total prostatectomy appears to be declining in Sweden.

Sensitivity and specificity of sextant biopsies in the detection of prostate cancer: preliminary report

OBJECTIVES

To determine the true-negative and false-negative rates of sextant prostate biopsies, the most common method of prostate cancer diagnosis.

METHODS

Forty-three men scheduled for prostatectomy as part of a surgical procedure for bladder pathologic findings agreed to participate in this study. All patients had normal digital rectal examination findings. Immediately before prostatectomy all patients underwent sextant biopsies. The location, amount, and Gleason grade of any cancer identified on the biopsies were recorded. After surgery, the prostate was serially sectioned. The location, grade, and volume of any prostatic adenocarcinoma identified was recorded and compared with the results of the biopsy specimens.

RESULTS

There were 33 patients without prostate cancer in either the biopsies or the prostatectomy specimen. No patients had cancer on the biopsies and no cancer in the prostatectomy specimen. In 6 patients, cancer was found in both the biopsies and the prostatectomy specimens; these cancers were 0.9, 2.1, 2.8, 3. 1, 4.2, and 6.5 cc in volume. In the remaining 4 patients, there was no cancer on the biopsies but the prostatectomy specimen revealed cancers of 0.05, 0.1, 0.3, and 2.5 cc. The overall sensitivity for sextant biopsies was 60.0%, with a specificity of 100%. When only cancers greater than 2 cc or cancers in the peripheral zone were considered, the sensitivity rose to 83.3% and 71.4%, respectively, with a minimal decrease in specificity (97.3% and 97.2%, respectively). In contrast, when transition zone cancers were evaluated, the sensitivity fell to 33.3%.

CONCLUSIONS

Sextant biopsies are fairly sensitive for the detection of tumors greater than 2 cc and those in the peripheral zone; however, repeat biopsies should be strongly considered in patients with a high clinical suspicion for prostate cancer and negative initial sextant biopsies.

Screening for prostate cancer: the roles of science, policy, and opinion in determining what is best for patients

Controversy over screening for prostate cancer involves both scientific and policy considerations. The principal scientific questions are whether tumors detected by screening are clinically significant, whether screening generates too many false-positive results, and whether early detection lowers morbidity or mortality. Both screening and treatment of prostate cancer can be harmful, making the tradeoff between benefits and risks especially relevant. Studies suggest that this judgment is highly personal, depending on the relative importance that individuals assign to potential outcomes. Opinions and policy considerations also influence views about the appropriateness of screening. Chief among these are personal beliefs about benefits and harms, medicolegal concerns, patient expectations, resource constraints, and opportunity costs. Appropriate policy must discriminate between what is best for populations and for individual patients. The lack of evidence of benefit and the potential harms argue against a societal policy of routine screening. Individual patients who could benefit from screening should be informed about the potential benefits and harms and invited to make a personal choice based on their priorities and concerns.

Radiolabeled monoclonal antibody indium 111-labeled CYT-356 localizes extraprostatic recurrent carcinoma after prostatectomy

OBJECTIVES

The sites of recurrent carcinoma of the prostate were localized with radiolabeled monoclonal antibody, and these sites were correlated with the response of patients treated with pelvic radiation after prostatectomy.

METHODS

Radionuclide scans were performed with indium 111-labeled CYT-356, a monoclonal antibody that binds to prostate epithelial cells, in 48 men diagnosed with recurrent carcinoma detected by prostate-specific antigen (PSA) screening after radical retropubic prostatectomy.

RESULTS

In 48 patients with recurrent carcinoma detected by PSA screening following radical retropubic prostatectomy, 73% had monoclonal antibody activity beyond the prostatic fossa, and only 3 patients (6%) had activity in the prostatic fossa alone; 65% had monoclonal antibody activity in pelvic lymph nodes despite the fact that lymph node dissections were pathologically negative at the time of prostatectomy in 90% of the patients; and 23% of patients had monoclonal antibody activity in abdominal and extrapelvic retroperitoneal nodes. Of 48 patients, 13 underwent external beam radiation therapy after monoclonal antibody scans. Six patients had scans showing activity beyond the field of radiation, and radiation therapy failed in 4 of these patients. Seven patients had scans with no activity beyond the field of radiation therapy, and radiation therapy failed in only 2 of these patients.

CONCLUSIONS

The scans frequently show monoclonal antibody uptake in pelvic, abdominal, and extrapelvic retroperitoneal sites beyond the region of limited obturator node dissections and may account for the understaging and subsequent failure of radical prostatectomy in some patients. The monoclonal antibody scan seems to be a good predictor of which patients will respond to radiation therapy after radical prostatectomy, but because these patients often have nodal activity beyond the radiated field, this initial response may not be curative.

Prostate cancer screening and management

Several other newer therapeutic modalities are being investigated to determine their potential role in the treatment of prostate cancer. Cryotherapy, microwave hyperthermia, laser therapy, and high-intensity focused ultrasound have all been introduced in recent years. Each of these techniques is based on a different principle, yet they all attempt to kill prostate cancer cells in a minimally invasive manner. Insufficient follow-up data are available to allow strong recommendations regarding these treatments.