The evolving role of systemic therapy in high risk prostate cancer: strategies for cure in the 21st century

Comparison of external radiation therapy vs radical prostatectomy in lymph node positive prostate cancer patients

INTRODUCTION

Treatment options for lymph node positive prostate cancer are limited. We retrospectively compared patients who underwent external radiotherapy (ERT) to patients treated by radical prostatectomy (RPX).

MATERIALS AND METHODS

A total of 102 lymph node positive patients from the RPX series at Ulm University were evaluated. In all, 76 patients received adjuvant androgen withdrawal as part of their primary treatment. In the ERT group, 44 patients were treated at the University of Michigan using a fractionated regimen. Of these, 21 patients received early adjuvant hormonal therapy. Patients with neoadjuvant therapy before RPX or ERT were excluded.

RESULTS

In the RPX group, PSA nadir (nadir < or = 0.2 vs > 0.2 ng/ml) showed a strong association with outcome. In the ERT group, pretreatment PSA was an independent predictor of outcome (P = 0.04) and patients with adjuvant hormonal therapy had a significant longer recurrence-free interval compared to patients without adjuvant therapy (P = 0.004). Comparing only patients with adjuvant hormonal treatment after cancer-specific therapy, the ERT-treated patients had a borderline longer PSA recurrence-free survival time compared to the RPX-treated patients (P = 0.05).

CONCLUSIONS

In case of positive lymph nodes, RPX and ERT might be considered and need to be explained to the patient. For future treatment decisions, the presented findings and a potential survival benefit need to be evaluated in a larger prospective setting.

Cancers of the prostate, penis, and testicles: epidemiology, prevention, and treatment

Cancer is a disease that most people fear. Nurses are required to provide information on how to avoid cancer, and, once the diagnosis is made, how to cope with it. Prevention and early detection of the cancers described in this article are in the very early stages of knowledge development, but general health promotion guidance can be offered on how to avoid most cancers (ie, no tobacco use, a high-fiber and low fat diet, exercise, and maintaining a normal weight). Nurses also can advise patients to be screened for colorectal cancer at the appropriate ages and time intervals and to be aware as new developments occur in the scientific base for screenings in the areas of prostate, penile, and testicular cancer. Finally, coping with these forms of cancer often requires the patient to make major lifestyle and psychological changes, especially if surgery in the genital area occurs. Decreased libido, incontinence, and impotence are major complications that can occur with these illnesses. The male cancers described vary tremendously in their prevalence, incidence, mortality, treatment, and survival rates. Within this group, there are remarkably positive outcomes and outcomes much in need of improvement. Penile and testicular cancers are the bright spots in this picture; both are uncommon, and both are eminently treatable. Prostate cancer, on the other hand, is quite common, difficult to screen, difficult to treat without major sexual problems, and yet receives relatively little funding from the NIH. Although as many men die from prostate cancer as women die from breast cancer, NIH funds breast cancer research at much higher levels than prostate cancer. According to the latest data available at the NIH Web site, during the 1990s, the amount of NIH funding varied from four times more for breast cancer (1993) to 2.9 times more in 1999. For fiscal year 2002, NIH is providing $522 million in funding for breast cancer and $278 million for prostate cancer. Private foundation funds for prostate cancer are much smaller than those available for breast cancer. Both types of cancer are extremely important to address, and both should receive adequate research attention. Nurses can advocate for more funding for prostate cancer, from basic science approaches to behavioral science strategies.

Prostate cancer: radical prostatectomy

Today, more men than ever before are being followed after radical prostatectomy. Prognosis and follow-up should be based on the pathologic specimen. Measurable prostate-specific antigen (PSA) after surgery defines failure, with time to detectable PSA and rate of PSA rise being useful prognostic factors. The natural history of untreated biochemical failure is protracted, a fact to be considered in discussions of adjuvant treatment. Early in disease recurrence, imaging studies to locate residual disease rarely are useful clinically. Both adjuvant and salvage radiation to the prostate bed have benefits and risks, but neither is superior in overall prostate cancer survival. The timing of hormone therapy remains largely empiric. The promise of effective cytotoxic chemotherapy still is greater than its actual benefits, although novel cytostatic agents are being developed. The future management of this disease will improve with better molecular definition of risk and therapeutic response.

The rationale for adjuvant chemotherapy for high-risk prostate cancer

PURPOSE OF REVIEW

With the advent of prostate-specific antigen, stage migration has resulted in a shift towards early-stage prostate cancer at diagnosis. Although radical prostatectomy and radical radiotherapy can be curative in organ-confined disease, there remains a significant proportion of early-stage patients who go on to develop progressive, incurable disease. This review will highlight developments in the identification of high-risk patients, and summarize the results of investigations of adjuvant chemotherapy in this setting.

RECENT FINDINGS

The ability to identify patients at high risk of developing progressive disease is improving. Both preoperative and postoperative variables, as well as newer radiographic and molecular tools, can identify at-risk patients who may benefit from adjuvant therapy. Coupled with developments in chemotherapeutic agents for prostate cancer, this provides the rationale for investigating chemotherapy in this setting. Unfortunately, to date, reported trials involving adjuvant chemotherapy in prostate cancer are few, and generally involve small numbers of patients. Some of the studies confirm that certain populations of patients, such as those with node-positive disease, may benefit from systemic therapy. Definitive data, however, will be derived from ongoing randomized trials investigating adjuvant chemotherapy.

SUMMARY

Although definitive data regarding systemic chemotherapy in adjuvant therapy are scarce, the results of the available studies, and the increasing accuracy in delineating the population at risk, have laid the foundation for future and ongoing studies in this area.