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Robitaille M, Ménard C, Famulari G, Béliveau-Nadeau D, Enger SA. 169Yb-based high dose rate intensity modulated brachytherapy for focal treatment of prostate cancer. Brachytherapy 2024; 23:523-534. [PMID: 39038997 DOI: 10.1016/j.brachy.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 04/24/2024] [Accepted: 05/20/2024] [Indexed: 07/24/2024]
Abstract
PURPOSE This study compares conventional 192Ir-based high dose rate brachytherapy (HDR-BT) with 169Yb-based HDR intensity modulated brachytherapy (IMBT) for focal prostate cancer treatment. Additionally, the study explores the potential to generate less invasive treatment plans with IMBT by reducing the number of catheters needed to achieve acceptable outcomes. METHODS AND MATERIALS A retrospective dosimetric study of ten prostate cancer patients initially treated with conventional 192Ir-based HDR-BT and 5-14 catheters was employed. RapidBrachyMCTPS, a Monte Carlo-based treatment planning system was used to calculate and optimize dose distributions. For 169Yb-based HDR IMBT, a custom 169Yb source combined with 0.8 mm thick platinum shields placed inside 6F catheters was used. Furthermore, dose distributions were investigated when iteratively removing catheters for less invasive treatments. RESULTS With IMBT, the urethra D10 and D0.1cc decreased on average by 15.89 and 15.65 percentage points (pp) and the rectum V75 and D2cc by 1.53 and 11.54 pp, respectively, compared to the conventional clinical plans. Similar trends were observed when the number of catheters decreased. On average, there was an observed increase in PTV V150 from 2.84 pp with IMBT when utilizing all catheters to 8.83 pp when four catheters were removed. PTV V200 increased from 0.42 to 2.96 pp on average. Hotspots in the body were however lower with IMBT compared to conventional clinical plans. CONCLUSIONS 169Yb-based HDR IMBT for focal treatment of prostate cancer has the potential to successfully deliver clinically acceptable, less invasive treatment with reduced dose to organs at risk.
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Affiliation(s)
- Maude Robitaille
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada; Medical Physics Unit, Department of Oncology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.
| | - Cynthia Ménard
- Department of Radiation Oncology, CHUM, Montreal, Quebec, Canada
| | - Gabriel Famulari
- Department of Radiation Oncology, Jewish General Hospital, Montreal, Quebec, Canada; Medical Physics Unit, Department of Oncology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | | | - Shirin A Enger
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada; Medical Physics Unit, Department of Oncology, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
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Daskivich TJ, Naser-Tavakolian A, Gale R, Luu M, Friedrich N, Venkataramana A, Khodyakov D, Posadas E, Sandler H, Spiegel B, Freedland SJ. Variation in communication of side effects in prostate cancer treatment consultations. Prostate Cancer Prostatic Dis 2024:10.1038/s41391-024-00806-2. [PMID: 38396054 PMCID: PMC11341774 DOI: 10.1038/s41391-024-00806-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 01/29/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Effective communication of treatment side effects (SE) is critical for shared decision-making (SDM) in localized prostate cancer. We sought to qualitatively characterize how physicians communicate SE in consultations. METHODS We transcribed 50 initial prostate cancer treatment consultations across nine multidisciplinary providers (Urologists, Radiation Oncologists, Medical Oncologists) at our tertiary referral, academic center. Coders identified quotes describing SE and used an inductive approach to establish a hierarchy for granularity of communication: (1) not mentioned, (2) name only, (3) generalization("high"), (4) average incidence without timepoint, (5) average incidence with timepoint, and (6) precision estimate. We reported the most granular mode of communication for each SE throughout the consultation overall and across specialty and tumor risk. RESULTS Among consultations discussing surgery (n = 40), erectile dysfunction (ED) and urinary incontinence (UI) were omitted in 15% and 12%, not quantified (name only or generalization) in 47% and 30%, and noted as average incidence without timeline in 8% and 8%, respectively. In only 30% and 49% were ED and UI quantified with timeline (average incidence with timeline or precision estimate), respectively. Among consultations discussing radiation (n = 36), irritative urinary symptoms, ED, and other post-radiotherapy SE were omitted in 22%, 42%, and 64-67%, not quantified in 61%, 33%, and 23-28%, and noted as average incidence without timeline in 8%, 22%, and 6-8%, respectively. In only 3-8% were post-radiotherapy SE quantified with timeline. Specialty concordance (but not tumor risk) was associated with higher granularity of communication, though physicians frequently failed to quantify specialty-concordant SE. CONCLUSIONS SE was often omitted, not quantified, and/or lacked a timeline in treatment consultations in our sample. Physicians should articulate, quantify, and assign a timeline for SE to optimize SDM.
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Affiliation(s)
- Timothy J Daskivich
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | | | - Rebecca Gale
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael Luu
- Department of Biostatistics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nadine Friedrich
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Abhi Venkataramana
- Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | | | - Edwin Posadas
- Department of Medicine, Division of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Howard Sandler
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Brennan Spiegel
- Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, Divisions of Gastroenterology and Health Services Research, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephen J Freedland
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Section of Urology, Durham VA Medical Center, Durham, NC, USA
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Biran A, Bolnykh I, Rimmer B, Cunliffe A, Durrant L, Hancock J, Ludlow H, Pedley I, Rees C, Sharp L. A Systematic Review of Population-Based Studies of Chronic Bowel Symptoms in Cancer Survivors following Pelvic Radiotherapy. Cancers (Basel) 2023; 15:4037. [PMID: 37627064 PMCID: PMC10452492 DOI: 10.3390/cancers15164037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
Pelvic radiotherapy can damage surrounding tissue and organs, causing chronic conditions including bowel symptoms. We systematically identified quantitative, population-based studies of patient-reported bowel symptoms following pelvic radiotherapy to synthesize evidence of symptom type, prevalence, and severity. Medline, CINAHL, EMBASE, and PsychINFO were searched from inception to September 2022. Following independent screening of titles, abstracts, and full-texts, population and study characteristics and symptom findings were extracted, and narrative synthesis was conducted. In total, 45 papers (prostate, n = 39; gynecological, n = 6) reporting 19 datasets were included. Studies were methodologically heterogeneous. Most frequently assessed was bowel function ('score', 26 papers, 'bother', 19 papers). Also assessed was urgency, diarrhea, bleeding, incontinence, abdominal pain, painful hemorrhoids, rectal wetness, constipation, mucous discharge, frequency, and gas. Prevalence ranged from 1% (bleeding) to 59% (anal bleeding for >12 months at any time since start of treatment). In total, 10 papers compared radiotherapy with non-cancer comparators and 24 with non-radiotherapy cancer patient groups. Symptom prevalence/severity was greater/worse in radiotherapy groups and symptoms more common/worse post-radiotherapy than pre-diagnosis/treatment. Symptom prevalence varied between studies and symptoms. This review confirms that many people experience chronic bowel symptoms following pelvic radiotherapy. Greater methodological consistency, and investigation of less-well-studied survivor populations, could better inform the provision of services and support.
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Affiliation(s)
- Adam Biran
- Centre for Cancer, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE1 7RU, UK; (I.B.); (B.R.); (C.R.); (L.S.)
| | - Iakov Bolnykh
- Centre for Cancer, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE1 7RU, UK; (I.B.); (B.R.); (C.R.); (L.S.)
| | - Ben Rimmer
- Centre for Cancer, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE1 7RU, UK; (I.B.); (B.R.); (C.R.); (L.S.)
| | - Anthony Cunliffe
- NHS Southwest London Clinical Commissioning Group, London SW19 1RH, UK;
| | - Lisa Durrant
- Somerset NHS Foundation Trust, Taunton TA1 5DA, UK;
| | - John Hancock
- North Tees and Hartlepool NHS Foundation Trust, Hartlepool TS24 9AH, UK;
| | - Helen Ludlow
- Llandough, Cardiff and Vale University Health Board, Cardiff CF64 2XX, UK;
| | - Ian Pedley
- Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne NE3 3HD, UK;
| | - Colin Rees
- Centre for Cancer, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE1 7RU, UK; (I.B.); (B.R.); (C.R.); (L.S.)
| | - Linda Sharp
- Centre for Cancer, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE1 7RU, UK; (I.B.); (B.R.); (C.R.); (L.S.)
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Dora C, Clarke GM, Frey G, Sella D. Magnetic Resonance Imaging-Guided Transurethral Ultrasound Ablation of Prostate Cancer: A Systematic Review. J Endourol 2022; 36:841-854. [PMID: 35029127 PMCID: PMC9231661 DOI: 10.1089/end.2021.0866] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose: MRI-guided transurethral ultrasound ablation (TULSA) uses real-time MR thermometry feedback to target prostate disease. We systematically review the literature to synthesize efficacy, functional, and safety outcomes and assess the influence of planned ablation fraction on outcome. Materials and Methods: PubMed, Embase, and the Cochrane Library were searched from inception to June 2021 following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies reporting at least one efficacy, functional, or safety outcome after a single TULSA treatment were included. The relationship of freedom from salvage treatment and potency preservation with planned ablation volume was modeled. Results: Two hundred twenty-four patients were treated in 10 studies with up to a 5-year follow-up, mainly for primary localized prostate cancer (PCa) plus smaller cohorts with recurrent PCa, and locally advanced PCa (LAPC). The prostate-specific antigen decline from baseline up to 2 years, including focal to whole-gland ablation plans, was 54% to 97%. The rate of salvage treatment after one TULSA treatment for primary PCa was 7% to 17%. Continence and potency preservation were from 92% to 100% and from 75% to 98%. Urinary symptoms were stable in men with good voiding function at baseline, and 85% of men with concurrent PCa and lower urinary tract symptoms met the criteria for improvement. Symptom relief in a small cohort of men with LAPC was observed. Grade III adverse events were incurred by 13/224 men (6%), with no rectal injury/fistula or Grade IV complication. The planned ablation fraction was linearly related to salvage-free survival. The relationship between potency preservation and planned ablation fraction followed a sigmoid curve. Conclusions: As an alternative to conventional treatments, TULSA is safe and effective for prostate tissue ablation in men with primary PCa. There is also evidence that TULSA delivers effective relief of urinary symptoms while treating PCa in a single, low-morbidity procedure. The likelihood of freedom from additional treatment or potency preservation is associated with the planned ablation fraction.
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Affiliation(s)
- Chandler Dora
- Department of Urology, Mayo Clinic Florida, Jacksonville, Florida, USA.,Address correspondence to: Chandler Dora, MD, Department of Urology, Mayo Clinic Jacksonville, 4500 San Pablo Road South, Jacksonville, FL 32224, USA
| | | | - Gregory Frey
- Department of Radiology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - David Sella
- Department of Radiology, Mayo Clinic Florida, Jacksonville, Florida, USA
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Wulff-Burchfield E. Supportive and Palliative Care for Genitourinary Malignancies. Urol Oncol 2022. [DOI: 10.1007/978-3-030-89891-5_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Radiotherapy for elder patients aged ≥80 with clinically localized prostate cancer - Brachytherapy enhanced late GU toxicity especially in elderly. Clin Transl Radiat Oncol 2020; 25:67-74. [PMID: 33102817 PMCID: PMC7569258 DOI: 10.1016/j.ctro.2020.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/25/2020] [Accepted: 09/25/2020] [Indexed: 12/24/2022] Open
Abstract
Background and purpose Elongation of life expectancy had led to marked increase in number of elderly patients with localized prostate cancer. However, the standard treatment for such patients is not well determined because of a high prevalence of comorbidities and slow growth of prostate cancer. The aim of this study is to examine the feasibility of radiotherapy for elderly patients aged ≥80 years. Materials and methods We compared 96 patients aged ≥80 years and 2333 younger patients (aged 60-79 years) using multi-institutional data included cT1-T4N0M0 prostate cancer treated with 902 external beam radiotherapy (EBRT) and 1527 brachytherapy (BT). Results The 5-year biochemical failure-free survival rate was similar between elderly ≥80 years and younger control (91.3% vs. 85.9%, p = 0.6171) (100%, 92.9%, 82.4% and 96.3%, 93.7%, 89% for low, intermediate and high risk group), and for the prostate cancer-specific survival rate (100% and 99.3%, p = 0.6171). The accumulated incidence of late gastrointestinal (GI) at 5 years was also similar between elderly and younger patients (3.5% vs. 2.5%, p = 0.6857). Brachytherapy improved biochemical control rate and reduced GI toxicity compared with EBRT, however, enhanced late genitourinary (GU) toxicity, especially in elderly patients. Elderly received brachytherapy showed highest rate of late GU toxicity grade ≥2 of 22.1% than the younger counterparts of 12.7% at 5 years, whereas younger patients treated with EBRT had 2.4% and elderly EBRT had 2.7% (p < 0.0001). Conclusion Elderly patients aged ≥80 years showed equivalent biochemical control, prostate cancer-related survival, and gastrointestinal toxicity profiles to younger patients. Meticulous care should be required for brachytherapy enhanced late GU toxicity, especially in elderly patients aged ≥80 years.
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Mundet L, Cabib C, Ortega O, Rofes L, Tomsen N, Marin S, Chacón C, Clavé P. Defective Conduction of Anorectal Afferents Is a Very Prevalent Pathophysiological Factor Associated to Fecal Incontinence in Women. J Neurogastroenterol Motil 2019; 25:423-435. [PMID: 31177647 PMCID: PMC6657934 DOI: 10.5056/jnm18196] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/01/2019] [Accepted: 03/26/2019] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Fecal incontinence (FI) is a prevalent condition among women. While biomechanical motor components have been thoroughly researched, anorectal sensory aspects are less known. We studied the pathophysiology of FI in community-dwelling women, specifically, the conduction through efferent/afferent neural pathways. Methods A cross-sectional study was conducted on 175 women with FI and 19 healthy volunteers. The functional/structural study included anorectal manometry/endoanal ultrasound. Neurophysiological studies including pudendal nerve terminal motor latency (PNTML) and sensory-evoked-potentials to anal/rectal stimulation (ASEP/RSEP) were conducted on all healthy volunteers and on 2 subgroups of 42 and 38 patients, respectively. Results The main conditions associated with FI were childbirth (79.00%) and coloproctological surgery (37.10%). Cleveland score was 11.39 ± 4.09. Anorectal manometry showed external anal sphincter and internal anal sphincter insufficiency in 82.85% and 44.00%, respectively. Sensitivity to rectal distension was impaired in 27.42%. Endoanal ultrasound showed tears in external anal sphincter (60.57%) and internal anal sphincter disruptions (34.80%). Abnormal anorectal sensory conduction was evidenced through ASEP and RSEP in 63.16% and 50.00% of patients, respectively, alongside reduced activation of brain cortex to anorectal stimulation. In contrast, PNTML was delayed in only 33.30%. Stools were loose/very loose in 56.70% of patients. Conclusions Pathophysiology of FI in women is mainly associated with mechanical sphincter dysfunctions related to either muscle damage or, to a lesser extent, impaired efferent conduction at pudendal nerves. Impaired conduction through afferent anorectal pathways is also very prevalent in women with FI and may play an important role as a pathophysiological factor and as a potential therapeutic target.
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Affiliation(s)
- Lluís Mundet
- Unitat d'Exploracions Funcionals Digestives, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
| | - Christopher Cabib
- Unitat d'Exploracions Funcionals Digestives, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain
| | - Omar Ortega
- Unitat d'Exploracions Funcionals Digestives, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
| | - Laia Rofes
- Unitat d'Exploracions Funcionals Digestives, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
| | - Noemí Tomsen
- Unitat d'Exploracions Funcionals Digestives, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain
| | - Sergio Marin
- Unitat d'Exploracions Funcionals Digestives, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain
| | - Carla Chacón
- Unitat d'Exploracions Funcionals Digestives, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain
| | - Pere Clavé
- Unitat d'Exploracions Funcionals Digestives, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Catalonia, Spain.,Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd), Instituto de Salud Carlos III, Barcelona, Spain
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Yamazaki H, Masui K, Suzuki G, Nakamura S, Aibe N, Shimizu D, Nishikawa T, Okabe H, Yoshida K, Kotsuma T, Tanaka E, Otani K, Yoshioka Y, Ogawa K. Radiothrerapy for Elderly Patients Aged ≥75 Years with Clinically Localized Prostate Cancer-Is There a Role of Brachytherapy? J Clin Med 2018; 7:jcm7110424. [PMID: 30413025 PMCID: PMC6262433 DOI: 10.3390/jcm7110424] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 11/05/2018] [Accepted: 11/05/2018] [Indexed: 01/20/2023] Open
Abstract
We compared radiotherapy outcomes between 241 elderly patients aged ≥75 years and 867 younger controls (age <75 years) with clinically localized prostate cancer. The elderly group showed an equivalent actuarial seven-year biochemical failure-free survival rate (7y-bNED) (94.9%) to the younger control group (96.4%, p = 0.593). The incidence of late genitourinary (GU) and gastrointestinal (GI) toxicities grade ≥2 was also similar between the elderly and younger cohorts, while no grade ≥4 adverse events occurred. We also examined the role of brachytherapy (BT) in the elderly group, in comparison with image-guided intensity-modulated radiotherapy (IG-IMRT). BT showed superior 7y-bNED (94.1%) than IG-IMRT (84.6%, p = 0.0183) in elderly patients, which was 100% (100% for BT and 100% for IG-IMRT, p > 0.999) for the low-risk group, 94.6% (92.8% and 100%, p = 0.203) for the intermediate-risk group, and 80.5% (91.2% and 73.6%, p = 0.0195) for the high-risk group. BT showed higher GU toxicity and equivalent GI toxicity to IG-IMRT. In conclusion, elderly patients showed bNED and toxicity that were equivalent to those observed in younger controls, and BT is a plausible option also for healthy elderly with potential to improve bNED, with higher but acceptable GU toxicity.
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Affiliation(s)
- Hideya Yamazaki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan.
| | - Koji Masui
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan.
| | - Gen Suzuki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan.
| | - Satoaki Nakamura
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan.
| | - Norihiro Aibe
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan.
| | - Daisuke Shimizu
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan.
| | - Tatsuyuki Nishikawa
- Department of Radiology, Ujitakeda Hospital, Uji-City, Kyoto 611-0021, Japan.
| | - Haruumi Okabe
- Department of Radiology, Ujitakeda Hospital, Uji-City, Kyoto 611-0021, Japan.
| | - Ken Yoshida
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-ku, Osaka 540-0006, Japan.
| | - Tadayuki Kotsuma
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-ku, Osaka 540-0006, Japan.
| | - Eiichi Tanaka
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-ku, Osaka 540-0006, Japan.
| | - Keisuke Otani
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan.
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan.
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan.
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Maenhout M, Peters M, Moerland MA, Meijer RP, van den Bosch MAAJ, Frank SJ, Nguyen PL, van Vulpen M, van der Voort van Zyp JRN. MRI guided focal HDR brachytherapy for localized prostate cancer: Toxicity, biochemical outcome and quality of life. Radiother Oncol 2018; 129:554-560. [PMID: 30131183 DOI: 10.1016/j.radonc.2018.07.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 07/15/2018] [Accepted: 07/19/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE To describe toxicity, biochemical outcome and quality of life after MRI guided focal high dose rate brachytherapy (HDR-BT) in a single fraction of 19 Gy for localized prostate cancer. MATERIALS AND METHODS Between May 2013 and April 2016, 30 patients were treated by MRI-guided focal HDR-BT. Patients with visible tumour on MRI were included. All patients were ≥65 years, T-stage <T3, Gleason ≤7, PSA <10 ng/mL and IPSS <15. Focal irradiation was delivered in a single fraction of 19 Gy to the D95 of the clinical target volume. Toxicity was reported using the Common Terminology Criteria for Adverse Events version 4. Biochemical failure was defined according to the Phoenix criteria and quality of life was measured using validated questionnaires. RESULTS Median follow up was 24 months. One patient developed a grade 2 and 3 GU toxicity after treatment. In the other 29 patients, no grade 2 or higher perioperative complications occurred. Five patients developed a biochemical recurrence. For all measured time points, there was no statistically significant deterioration in quality of life. CONCLUSION Focal MRI guided HDR-BT confers low toxicity rates and maintains quality of life. Biochemical recurrence is rather high, 5 patients developed a biochemical recurrence according to the Phoenix definition. Longer evaluation of these patients is necessary and caution is warranted before implementing focal HDR-BT in patients with localized prostate cancer.
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Affiliation(s)
- Metha Maenhout
- University Medical Center Utrecht, Department of Radiotherapy, the Netherlands
| | - Max Peters
- University Medical Center Utrecht, Department of Radiotherapy, the Netherlands
| | - Marinus A Moerland
- University Medical Center Utrecht, Department of Radiotherapy, the Netherlands
| | - Richard P Meijer
- University Medical Center Utrecht, Department of Urology, the Netherlands
| | | | - Steven J Frank
- The University of Texas MD Anderson Cancer Center, Department of Radiotherapy, Houston, USA
| | - Paul L Nguyen
- Dana-Farber Cancer Institute, Department of Radiotherapy, Boston, USA
| | - Marco van Vulpen
- University Medical Center Utrecht, Department of Radiotherapy, the Netherlands
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Donis Canet F, Sánchez Gallego MD, Arias Fúnez F, Duque Ruíz G, Laso I, Brasero Burgos J, Lorca Álvaro J, Gómez Dos Santos V, Rodríguez Patrón R, Burgos Revilla FJ. Cryotherapy versus high-intensity focused ultrasound for treating prostate cancer: Oncological and functional results. Actas Urol Esp 2018; 42:355-364. [PMID: 28818491 DOI: 10.1016/j.acuro.2017.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 06/21/2017] [Accepted: 06/22/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT AND OBJECTIVE The increasingly early diagnosis of prostate cancer requires a search for therapeutic alternatives with good oncological results that in turn facilitate a good long-term quality of life. This review analyses 2 minimally invasive therapies for treating localised prostate cancer in terms of oncological and functional results, as well as the complications resulting from the therapies. ACQUISITION OF EVIDENCE A systematic literature review was conducted of the treatment of localised prostate cancer with 2 ablative techniques as the primary therapy: cryosurgery or cryotherapy and high intensity focused ultrasound (HIFU). We included patients who underwent procedures that included the entire gland, with hemiablation or focal therapy, which were indicated for low to intermediate-risk prostate cancer according to the D'Amico criteria. We excluded patients with high-risk prostate cancer and those who underwent any prior treatment for prostate cancer. SYNTHESIS OF THE EVIDENCE After conducting the literature search and excluding the studies that did not meet the protocol criteria, we reviewed a total of 14 studies, with a total of 350 patients treated using cryotherapy and 1107 treated with HIFU. All studies were either prospective or retrospective and were not randomised. The patients' mean age was younger than 75 years. Overall, the rate of disease recurrence in the patients treated with cryotherapy varied between 13.2% and 26%, while the rate for those treated with HIFU varied between 7.3% and 67.9%. The overall demonstrated continence at 12 months was 97.6-100% for cryotherapy and 96-100% for HIFU. In terms of sexual potency rates, cryotherapy showed complete potency at 12 months for 86-100% of the patients treated with focal cryotherapy and slightly lower rates for hemiablation (76.9-100%) and total therapy (39%). HIFU showed potency rates of 89%, 52-80% and 33-78% for focal therapy, hemiablation and total therapy, respectively. CONCLUSIONS Both techniques have comparable functional results, although the somewhat poorer oncological results for HIFU reflect a steeper learning curve, which could lead to its use in centres with high volumes of patients.
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Affiliation(s)
- F Donis Canet
- Departamento de Urología, Hospital Ramón y Cajal, Madrid, España.
| | | | - F Arias Fúnez
- Departamento de Urología, Hospital Ramón y Cajal, Madrid, España
| | - G Duque Ruíz
- Departamento de Urología, Hospital Ramón y Cajal, Madrid, España
| | - I Laso
- Departamento de Urología, Hospital Ramón y Cajal, Madrid, España
| | - J Brasero Burgos
- Departamento de Urología, Hospital Ramón y Cajal, Madrid, España
| | - J Lorca Álvaro
- Departamento de Urología, Hospital Ramón y Cajal, Madrid, España
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Ho CK, Bryant CM, Mendenhall NP, Henderson RH, Mendenhall WM, Nichols RC, Morris CG, Kanmaniraja D, Hamlin DJ, Li Z, Hoppe BS. Long-term outcomes following proton therapy for prostate cancer in young men with a focus on sexual health. Acta Oncol 2018; 57:582-588. [PMID: 29359988 DOI: 10.1080/0284186x.2018.1427886] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND We investigated long-term outcomes for men ≤60 years old treated with proton therapy (PT). METHODS Of 254 men ≤60 years old were treated with proton therapy alone for prostate cancer. Risk stratification included 56% with low-, 42% with intermediate- and 2% with high-risk disease. Patients received 76-82 Gy at 2 Gy/fraction or 70-72.5 Gy at 2.5 Gy/fraction. Before treatment and every 6-12 months for 5 years, patients were evaluated by a physician, answered health-related quality of life surveys, including the EPIC, IIEF and IPSS, and had PSA evaluated. RESULTS Median follow-up for the cohort was 7.1 years; 7-year biochemical-free survival was 97.8%. Eight men (one high-risk; five intermediate-risk and two low-risk) experienced biochemical progression, including one who died of disease 9 years after treatment. Potency (erections firm enough for sexual intercourse) was 90% at baseline and declined to 72% at the first-year follow-up, but declined to only 67% at 5 years. Only 2% of patients developed urinary incontinence requiring pads. The bowel habits mean score declined from a baseline of 96 to 88 at 1 year, which improved over the following years to 93 at 5 years. CONCLUSIONS Young men with prostate cancer continue to have excellent results with respect to 7-year biochemical control and 5-year erectile function, without clinically significant urinary incontinence 5 years after proton therapy. Comparative effectiveness studies of proton therapy with surgery and IMRT are needed.
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Affiliation(s)
- Clement K. Ho
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Curtis M. Bryant
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Nancy P. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Randal H. Henderson
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - William M. Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Romaine C. Nichols
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christopher G. Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Dvaraju Kanmaniraja
- Department of Radiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Derek J. Hamlin
- Department of Radiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Zuofeng Li
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Bradford S. Hoppe
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, USA
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Droz JP, Albrand G, Gillessen S, Hughes S, Mottet N, Oudard S, Payne H, Puts M, Zulian G, Balducci L, Aapro M. Management of Prostate Cancer in Elderly Patients: Recommendations of a Task Force of the International Society of Geriatric Oncology. Eur Urol 2017; 72:521-531. [PMID: 28089304 DOI: 10.1016/j.eururo.2016.12.025] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 12/29/2016] [Indexed: 12/27/2022]
Abstract
CONTEXT Prostate cancer is the most frequent male cancer. Since the median age of diagnosis is 66 yr, many patients require both geriatric and urologic evaluation if treatment is to be tailored to individual circumstances including comorbidities and frailty. OBJECTIVE To update the 2014 International Society of Geriatric Oncology (SIOG) guidelines on prostate cancer in men aged >70 yr. The update includes new material on health status evaluation and the treatment of localised, advanced, and castrate-resistant disease. DATA ACQUISITION A multidisciplinary SIOG task force reviewed pertinent articles published during 2013-2016 using search terms relevant to prostate cancer, the elderly, geriatric evaluation, local treatments, and castration-refractory/resistant disease. Each member of the group proposed modifications to the previous guidelines. These were collated and circulated. The final manuscript reflects the expert consensus. DATA SYNTHESIS Elderly patients should be managed according to their individual health status and not according to age. Fit elderly patients should receive the same treatment as younger patients on the basis of international recommendations. At the initial evaluation, screening for cognitive impairment is mandatory to establish patient competence in making decisions. Initial evaluation of health status should use the validated G8 screening tool. Abnormal scores on the G8 should lead to a simplified geriatric assessment that evaluates comorbid conditions (using the Cumulative Illness Score Rating-Geriatrics scale), dependence (Activities of Daily Living) and nutritional status (via estimation of weight loss). When patients are frail or disabled or have severe comorbidities, a comprehensive geriatric assessment is needed. This may suggest additional geriatric interventions. CONCLUSIONS Advances in geriatric evaluation and treatments for localised and advanced disease are contributing to more appropriate management of elderly patients with prostate cancer. A better understanding of the role of active surveillance for less aggressive disease is also contributing to the individualisation of care. PATIENT SUMMARY Many men with prostate cancer are elderly. In the physically fit, treatment should be the same as in younger patients. However, some elderly prostate cancer patients are frail and have other medical problems. Treatment in the individual patient should be based on health status and patient preference.
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Affiliation(s)
- Jean-Pierre Droz
- Cancer-Environment Research Unit, Centre Léon-Bérard and Claude-Bernard Lyon 1 University, Lyon, France.
| | - Gilles Albrand
- Groupement Hospitalier Sud des Hospices Civils de Lyon, Hôpital Antoine Charial, Francheville, France
| | - Silke Gillessen
- Department of Oncology/Hematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Simon Hughes
- Oncology Management Offices, Guy's Hospital, London, UK
| | - Nicolas Mottet
- Department of Urology, Saint-Etienne University Hospital, Saint-Priest en Jarez, France
| | - Stéphane Oudard
- Oncology Department, Georges Pompidou Hospital, René-Descartes Faculty, Paris 5 University, Paris, France
| | - Heather Payne
- Department of Oncology, University College London Hospitals, London, UK
| | - Martine Puts
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Gilbert Zulian
- Hôpital de Bellerive, Geneva University Hospitals, Geneva, Switzerland
| | - Lodovico Balducci
- H. Lee Moffitt Cancer Center and Research Institute, University of South Florida College of Medicine, Tampa, FL, USA
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Misra-Hebert AD, Kattan MW. Prostate Cancer Screening: A Brief Tool to Incorporate Patient Preferences in a Clinical Encounter. Front Oncol 2016; 6:235. [PMID: 27867909 PMCID: PMC5095121 DOI: 10.3389/fonc.2016.00235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/21/2016] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anita D Misra-Hebert
- Department of Internal Medicine, Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic , Cleveland, OH , USA
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Eton DT, Lai JS, Cella D, Reeve BB, Talcott JA, Clark JA, McPherson CP, Litwin MS, Moinpour CM. Data Pooling and Analysis to Build a Preliminary Item Bank. Eval Health Prof 2016; 28:142-59. [PMID: 15851770 DOI: 10.1177/0163278705275338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Assessing bowel function (BF) in prostate cancer can help determine therapeutic trade-offs. We determined the components of BF commonly assessed in prostate cancer studies as an initial step in creating an item bank for clinical and research application. We analyzed six archived data sets representing 4,246 men with prostate cancer. Thirty-one items from validated instruments were available for analysis. Items were classified into domains (diarrhea, rectal urgency, pain, bleeding, bother/distress, and other) then subjected to conventional psychometric and item response theory (IRT) analyses. Items fit the IRT model if the ratio between observed and expected item variance was between 0.60 and 1.40. Four of 31 items had inadequate fit in at least one analysis. Poorly fitting items included bleeding (2), rectal urgency (1), and bother/distress (1). A fifth item assessing hemorrhoids was poorly correlated with other items. Our analyses supported four related components of BF: diarrhea, rectal urgency, pain, and bother/distress.
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Affiliation(s)
- David T Eton
- Northwestern University School of Medicine, Evanston, IL 60201, USA.
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Kathriarachchi V, Shang C, Evans G, Leventouri T, Kalantzis G. Dosimetric and radiobiological comparison of CyberKnife M6™ InCise multileaf collimator over IRIS™ variable collimator in prostate stereotactic body radiation therapy. J Med Phys 2016; 41:135-43. [PMID: 27217626 PMCID: PMC4871003 DOI: 10.4103/0971-6203.181638] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The impetus behind our study was to establish a quantitative comparison between the IRIS collimator and the InCise multileaf collimator (MLC) (Accuray Inc. Synnyvale, CA) for prostate stereotactic body radiation therapy (SBRT). Treatment plans for ten prostate cancer patients were performed on MultiPlan™ 5.1.2 treatment planning system utilizing MLC and IRIS for 36.25 Gy in five fractions. To reduce the magnitude of variations between cases, the planning tumor volume (PTV) was defined and outlined for treating prostate gland only, assuming no seminal vesicle or ex-capsule involvement. Evaluation indices of each plan include PTV coverage, conformity index (CI), Paddick's new CI, homogeneity index, and gradient index. Organ at risk (OAR) dose sparing was analyzed by the bladder wall Dmax and V37Gy, rectum Dmax and V36Gy. The radiobiological response was evaluated by tumor control probability and normal tissue complication probability based on equivalent uniform dose. The dose delivery efficiency was evaluated on the basis of planned monitor units (MUs) and the reported treatment time per fraction. Statistical significance was tested using the Wilcoxon signed rank test. The studies indicated that CyberKnife M6™ IRIS and InCise™ MLC produce equivalent SBRT prostate treatment plans in terms of dosimetry, radiobiology, and OAR sparing, except that the MLC plans offer improvement of the dose fall-off gradient by 29% over IRIS. The main advantage of replacing the IRIS collimator with MLC is the improved efficiency, determined from the reduction of MUs by 42%, and a 36% faster delivery time.
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Affiliation(s)
| | - Charles Shang
- Department of Physics, Florida Atlantic University, Boca Raton, FL, USA; Lynn Cancer Institute, Boca Raton Regional Hospital, Boca Raton, FL, USA
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Patabendi Bandarage VRK, Billah B, Millar JL, Evans S. Prospective evaluation of patient-reported quality of life outcomes after external beam radiation treatment for prostate cancer in Victoria: A cohort study by the Victorian Prostate Cancer Registry. J Med Imaging Radiat Oncol 2016; 60:420-7. [DOI: 10.1111/1754-9485.12433] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 12/08/2015] [Indexed: 11/29/2022]
Affiliation(s)
| | - Baki Billah
- School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
| | - Jeremy L Millar
- School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
- Alfred Health Radiation Oncology; Alfred Health; Melbourne Australia
| | - Sue Evans
- School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
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Zelefsky MJ, Poon BY, Eastham J, Vickers A, Pei X, Scardino PT. Longitudinal assessment of quality of life after surgery, conformal brachytherapy, and intensity-modulated radiation therapy for prostate cancer. Radiother Oncol 2016; 118:85-91. [PMID: 26780999 DOI: 10.1016/j.radonc.2015.11.035] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 11/05/2015] [Accepted: 11/14/2015] [Indexed: 11/16/2022]
Abstract
PURPOSE We evaluated quality-of-life changes (QoL) in 907 patients treated with either radical prostatectomy (open or laparoscopic), real-time planned conformal brachytherapy, or high-dose intensity-modulated radiotherapy (IMRT) on a prospective IRB-approved longitudinal study. METHODS Validated questionnaires given pretreatment (baseline) and at 3, 6, 9, 12, 15, 18, 24, 36, and 48 months addressed urinary function, urinary bother, bowel function, bowel bother, sexual function, and sexual bother. RESULTS At 48 months, surgery had significantly higher urinary incontinence than others (both P<.001), but fewer urinary irritation/obstruction symptoms (all P<.001). Very low levels of bowel dysfunction were observed and only small subsets in each group showed rectal bleeding. Brachytherapy and IMRT showed better sexual function than surgery accounting for baseline function and other factors (delta 14.29 of 100, 95% CI, 8.57-20.01; and delta 10.5, 95% CI, 3.78-17.88). Sexual bother was similar. Four-year outcomes showed persistent urinary incontinence for surgery with more obstructive urinary symptoms for radiotherapy. Using modern radiotherapy delivery, bowel function deterioration is less-often observed. Sexual function was strongly affected in all groups yet significantly less for radiotherapy. CONCLUSIONS Treatment selection should include patient preferences and balance predicted disease-free survival over a projected time vs potential impairment of QoL important for the patient.
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Affiliation(s)
- Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA.
| | - Bing Ying Poon
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - James Eastham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Xin Pei
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Peter T Scardino
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
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18
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Alcover J, Filella X. Identification of Candidates for Active Surveillance: Should We Change the Current Paradigm? Clin Genitourin Cancer 2015; 13:499-504. [DOI: 10.1016/j.clgc.2015.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 06/05/2015] [Accepted: 06/09/2015] [Indexed: 10/23/2022]
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Improving sexual health in men with prostate cancer: randomised controlled trial of exercise and psychosexual therapies. BMC Cancer 2014; 14:199. [PMID: 24641777 PMCID: PMC3995188 DOI: 10.1186/1471-2407-14-199] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 02/28/2014] [Indexed: 11/17/2022] Open
Abstract
Background Despite being a critical survivorship care issue, there is a clear gap in current knowledge of the optimal treatment of sexual dysfunction in men with prostate cancer. There is sound theoretical rationale and emerging evidence that exercise may be an innovative therapy to counteract sexual dysfunction in men with prostate cancer. Furthermore, despite the multidimensional aetiology of sexual dysfunction, there is a paucity of research investigating the efficacy of integrated treatment models. Therefore, the purpose of this study is to: 1) examine the efficacy of exercise as a therapy to aid in the management of sexual dysfunction in men with prostate cancer; 2) determine if combining exercise and brief psychosexual intervention results in more pronounced improvements in sexual health; and 3) assess if any benefit of exercise and psychosexual intervention on sexual dysfunction is sustained long term. Methods/Design A three-arm, multi-site randomised controlled trial involving 240 prostate cancer survivors will be implemented. Participants will be randomised to: 1) ‘Exercise’ intervention; 2) ‘Exercise + Psychosexual’ intervention; or 3) ‘Usual Care’. The Exercise group will receive a 6-month, group based, supervised resistance and aerobic exercise intervention. The Exercise + Psychosexual group will receive the same exercise intervention plus a brief psychosexual self-management intervention that addresses psychological and sexual well-being. The Usual Care group will maintain standard care for 6 months. Measurements for primary and secondary endpoints will take place at baseline, 6 months (post-intervention) and 1 year follow-up. The primary endpoint is sexual health and secondary endpoints include key factors associated with sexual health in men with prostate cancer. Discussion Sexual dysfunction is one of the most prevalent and distressing consequences of prostate cancer. Despite this, very little is known about the management of sexual dysfunction and current health care services do not adequately meet sexual health needs of survivors. This project will examine the potential role of exercise in the management of sexual dysfunction and evaluate a potential best-practice management approach by integrating pharmacological, physiological and psychological treatment modalities to address the complex and multifaceted aetiology of sexual dysfunction following cancer. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12613001179729.
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20
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Dirix P, Joniau S, Van den Bergh L, Isebaert S, Oyen R, Deroose CM, Lerut E, Haustermans K. The role of elective pelvic radiotherapy in clinically node-negative prostate cancer: A systematic review. Radiother Oncol 2014; 110:45-54. [DOI: 10.1016/j.radonc.2013.06.046] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 06/19/2013] [Accepted: 06/23/2013] [Indexed: 01/18/2023]
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Abstract
Sexual dysfunction is one of the most common, distressing and persistent adverse effects of prostate cancer treatment, and has a profound effect on quality of life for the patient and his partner. Current health-care provisions are inadequate to address the demand for the management of sexual dysfunction, with approximately half of prostate cancer survivors reporting unmet sexual health-care needs. Management strategies predominately involve pharmacological interventions to address the direct physiological effects of prostate cancer treatment on erectile function. However, the aetiology of sexual dysfunction is multifaceted and considerable physiological and psychological adverse effects of prostate cancer treatments, which are not addressed by pharmacological intervention, contribute to sexual dysfunction. Exercise has established efficacy for improving many of these factors in men with prostate cancer, including changes in body composition (especially to counteract body feminization), fatigue, physical function, risk of comorbid conditions, depression, anxiety and quality of life. Emerging evidence indicates that exercise also has a positive effect on sexual desire and sexual activity in men with prostate cancer.
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22
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Lilleby W, Stensvold A, Dahl AA. Intensity-modulated radiotherapy to the pelvis and androgen deprivation in men with locally advanced prostate cancer: a study of adverse effects and their relation to quality of life. Prostate 2013; 73:1038-47. [PMID: 23532709 DOI: 10.1002/pros.22651] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 01/14/2013] [Indexed: 11/05/2022]
Abstract
BACKGROUND To study, adverse effects, quality of life (QoL), fatigue, and mental distress when intensity-modulated radiotherapy combined with androgen deprivation was applied to the whole pelvis as management of men with locally advanced prostate cancer. METHODS In this prospective follow-up study 91 patients were treated by modern pelvic intensity-modulated radiotherapy and followed for 12 months. The patients completed a questionnaire with well-established instruments for adverse effects on urinary, bowel, and sexual function and bother, QoL, fatigue, and mental distress before treatment, and at 3 and 12 months follow-up. RESULTS After pelvic intensity-modulated radiotherapy the mean levels of sexual urinary and bowel function and bother were significantly reduced from baseline. Only urinary bother improved from 3 to 12-month follow-up. The levels of fatigue and QoL increased significantly from baseline to 3-month. Mental distress, fatigue, and QoL were significantly associated with both urinary and bowel function and bother at most time points, while so was not observed for sexual bother and function. CONCLUSIONS Men treated with pelvic intensity-modulated radiotherapy and androgen deprivation have significant reductions of all types of function and bother at 3 months, with minimal improvement to 12 months except for urinary bother. Fatigue possibly due to pelvic intensity-modulated radiotherapy increased at follow-ups.
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Affiliation(s)
- Wolfgang Lilleby
- Department of Oncology and Radiotherapy, Oslo University Hospital, Radiumhospitalet, Oslo, Norway.
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Steer AN, Aherne NJ, Gorzynska K, Hoffman M, Last A, Hill J, Shakespeare TP. Decision Regret in Men Undergoing Dose-Escalated Radiation Therapy for Prostate Cancer. Int J Radiat Oncol Biol Phys 2013; 86:716-20. [DOI: 10.1016/j.ijrobp.2013.03.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 03/02/2013] [Accepted: 03/05/2013] [Indexed: 11/16/2022]
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Thong MSY, Mols F, Stein KD, Smith T, Coebergh JWW, van de Poll-Franse LV. Population-based cancer registries for quality-of-life research. Cancer 2013; 119 Suppl 11:2109-23. [PMID: 23695923 DOI: 10.1002/cncr.28056] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 01/22/2013] [Accepted: 01/31/2013] [Indexed: 12/22/2022]
Affiliation(s)
- Melissa S. Y. Thong
- Center of Research on Psychology in Somatic Diseases (C o RPS) Tilburg University; Tilburg the Netherlands
- Comprehensive Cancer Center South (CCCS); Eindhoven Cancer Registry; Eindhoven the Netherlands
| | - Floortje Mols
- Center of Research on Psychology in Somatic Diseases (C o RPS) Tilburg University; Tilburg the Netherlands
- Comprehensive Cancer Center South (CCCS); Eindhoven Cancer Registry; Eindhoven the Netherlands
| | - Kevin D. Stein
- Behavioral Research Center; American Cancer Society; Atlanta Georgia
- Rollins School of Public Health; Emory University; Atlanta Georgia
| | - Tenbroeck Smith
- Behavioral Research Center; American Cancer Society; Atlanta Georgia
| | - Jan-Willem W. Coebergh
- Comprehensive Cancer Center South (CCCS); Eindhoven Cancer Registry; Eindhoven the Netherlands
- Department of Public Health; Erasmus University Medical Center; Rotterdam the Netherlands
| | - Lonneke V. van de Poll-Franse
- Center of Research on Psychology in Somatic Diseases (C o RPS) Tilburg University; Tilburg the Netherlands
- Comprehensive Cancer Center South (CCCS); Eindhoven Cancer Registry; Eindhoven the Netherlands
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Abstract
Historical data for older men with high-risk nonmetastatic prostate cancer treated with radiotherapy alone have demonstrated a 10-year prostate-cancer-specific mortality of around 30%. The development of dose escalation, using techniques such as intensity-modulated radiotherapy, has enabled more targeted delivery of treatment with improved efficacy and a reduction in the risk of toxicity compared with conventional radiotherapy. The combination of radiotherapy and androgen-deprivation therapy (ADT) has been shown to improve overall survival compared with radiotherapy or ADT alone without a significant increase in toxicity in patients with minimal comorbidities. There is evidence that patient age has only a marginal effect on genitourinary and gastrointestinal toxicities following radiotherapy. Further research has shown that although age does have an effect on the likelihood of sexual dysfunction after radiation therapy, there is no significant difference in the proportion of men aged ≥ 75 years who feel that sexual dysfunction is a moderate or serious problem before or 24 months after diagnosis. Radical radiotherapy is effective and well tolerated in senior men with high-risk prostate cancer and should be offered in combination with long-term ADT to patients with minimal comorbidities. In case of significant comorbid conditions, shorter durations of ADT may be considered.
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Affiliation(s)
- Heather A Payne
- University College London Hospitals, London NW1 2PG, United Kingdom.
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ACR Appropriateness Criteria® definitive external beam irradiation in stage T1 and T2 prostate cancer. Am J Clin Oncol 2012; 34:636-47. [PMID: 22101389 DOI: 10.1097/coc.0b013e3182354a65] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE : External beam radiation therapy is a standard of care treatment for men who present with clinically localized (T1-T2) prostate cancer. The purpose of this review was to provide clarification on the appropriateness criteria and management considerations for the treatment of prostate cancer with external beam radiation therapy. METHODS : A panel consisting of physicians with expertise on prostate cancer was assembled and provided with a number of clinical scenarios for consensus treatment and management guidelines. Prostate cancer patient vignettes were presented along with specific management recommendations based on an extensive review of the modern external beam radiotherapy literature. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances, where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. RESULTS : Modern external beam radiation therapy series demonstrate favorable biochemical control rates for patients with localized prostate cancer. Morbidity profiles are also favorable and it is clear that this is enhanced by modern techniques like 3-dimensional conformal radiation therapy and intensity-modulated radiation therapy. An active area of investigation is evaluating the use of hypofractionated dosing. CONCLUSIONS : Continued investigation to refine patient selection, external beam radiation technology application, and alternative dosing schedules should result in further improvements in biochemical outcome and decreased morbidity with external beam radiation treatment for localized prostate cancer.
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Kikuchi E, Nakashima J, Ando T, Nagata H, Miyajima A, Nakagawa K, Marumo K, Oya M. [Prospective survey of erectile dysfunction after external beam radiotherapy for prostate cancer]. Nihon Hinyokika Gakkai Zasshi 2011; 102:575-580. [PMID: 21846064 DOI: 10.5980/jpnjurol.102.575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE We prospectively evaluated the effect of external beam radiotherapy on erectile function in patients with localized or locally advanced prostate cancer using the Japanese version of the International Index of Erectile Function (IIEF) survey. PATIENTS AND METHODS From 2000 to 2007, we identified 55 patients who underwent external beam radiotherapy at our institution for localized or locally advanced prostate cancer and could respond to the IIEF survey. The patients did not receive neo- and/or adjuvant hormone therapy and they were followed-up for at least 12 months after radiotherapy. Mean patient age was 69 years and the mean PSA level before radiotherapy was 24.9 ng/ml. RESULTS First we evaluated the change of the erectile function domain score over time before and after radiotherapy. The population of severe erectile dysfunction (ED) increased while those with no or mild ED decreased after radiotherapy. The erectile function and intercourse satisfaction domain score of the IIEF declined significantly after radiotherapy, however, the orgasmic function, sexual desire, and overall satisfaction domain scores did not change after external beam radiation. Of the 34 patients who had erectile function at baseline, 10 patients could maintain erectile function 12 months after radiotherapy. Though there were no significant differences in clinical features between patients who could maintain erectile function and those who had worsening erectile function 12 months after radiotherapy, the sexual desire domain score before radiotherapy was significantly higher in patients who could maintain erectile function than their counterparts. CONCLUSION Using the IIEF survey, external beam radiation was found to affect erectile function in patients with localized or locally advanced prostate cancer.
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Affiliation(s)
- Eiji Kikuchi
- Department of Urology, Keio University School of Medicine
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Harrington CB, Hansen JA, Moskowitz M, Todd BL, Feuerstein M. It's not over when it's over: long-term symptoms in cancer survivors--a systematic review. Int J Psychiatry Med 2010; 40:163-81. [PMID: 20848873 DOI: 10.2190/pm.40.2.c] [Citation(s) in RCA: 457] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND The number of cancer survivors is steadily increasing. Following completion of primary cancer treatment and many years thereafter, specific symptoms continue to negatively affect cancer survivors. The purpose of this article is to review the evidence of symptom burden following primary treatment for cancer in survivors of the most common types of cancer (breast, gynecological, prostate, and colorectal). METHODS A systematic review of literature published between the years 2000-2008 that reported late-effects and/or long-term psychosocial symptoms associated with cancer survivorship post-completion of primary cancer treatment was conducted. The symptoms include physical limitations, cognitive limitations, depression/anxiety, sleep problems, fatigue, pain, and sexual dysfunctions. RESULTS Symptom burden associated with cancer survivorship was consistent among the four most common types of cancer (breast, gynecological, prostate, and rectal/colon), despite various types of treatment exposure. Generally, across the cancer groups, depressive symptoms, pain, and fatigue were commonly found in cancer survivors. CONCLUSIONS Based on longitudinal and cross-sectional evidence, cancer survivors can experience symptoms for more than 10 years following treatment. These symptoms were present in survivors of all four cancer types who underwent a wide variety of treatment. The results indicate that these symptoms should be evaluated and managed to optimize long-term outcomes.
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Madu CO, Lu Y. Novel diagnostic biomarkers for prostate cancer. J Cancer 2010; 1:150-77. [PMID: 20975847 PMCID: PMC2962426 DOI: 10.7150/jca.1.150] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 10/04/2010] [Indexed: 01/08/2023] Open
Abstract
Prostate cancer is the most frequently diagnosed malignancy in American men, and a more aggressive form of the disease is particularly prevalent among African Americans. The therapeutic success rate for prostate cancer can be tremendously improved if the disease is diagnosed early. Thus, a successful therapy for this disease depends heavily on the clinical indicators (biomarkers) for early detection of the presence and progression of the disease, as well as the prediction after the clinical intervention. However, the current clinical biomarkers for prostate cancer are not ideal as there remains a lack of reliable biomarkers that can specifically distinguish between those patients who should be treated adequately to stop the aggressive form of the disease and those who should avoid overtreatment of the indolent form. A biomarker is a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention. A biomarker reveals further information to presently existing clinical and pathological analysis. It facilitates screening and detecting the cancer, monitoring the progression of the disease, and predicting the prognosis and survival after clinical intervention. A biomarker can also be used to evaluate the process of drug development, and, optimally, to improve the efficacy and safety of cancer treatment by enabling physicians to tailor treatment for individual patients. The form of the prostate cancer biomarkers can vary from metabolites and chemical products present in body fluid to genes and proteins in the prostate tissues. Current advances in molecular techniques have provided new tools facilitating the discovery of new biomarkers for prostate cancer. These emerging biomarkers will be beneficial and critical in developing new and clinically reliable indicators that will have a high specificity for the diagnosis and prognosis of prostate cancer. The purpose of this review is to examine the current status of prostate cancer biomarkers, with special emphasis on emerging markers, by evaluating their diagnostic and prognostic potentials. Both genes and proteins that reveal loss, mutation, or variation in expression between normal prostate and cancerous prostate tissues will be covered in this article. Along with the discovery of prostate cancer biomarkers, we will describe the criteria used when selecting potential biomarkers for further development towards clinical use. In addition, we will address how to appraise and validate candidate markers for prostate cancer and some relevant issues involved in these processes. We will also discuss the new concept of the biomarkers, existing challenges, and perspectives of biomarker development.
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Affiliation(s)
- Chikezie O Madu
- Department of Pathology and Laboratory Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
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Wiegner EA, King CR. Sexual function after stereotactic body radiotherapy for prostate cancer: results of a prospective clinical trial. Int J Radiat Oncol Biol Phys 2010; 78:442-8. [PMID: 20137864 DOI: 10.1016/j.ijrobp.2009.07.1748] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Revised: 07/26/2009] [Accepted: 07/29/2009] [Indexed: 11/16/2022]
Abstract
PURPOSE To study the sexual quality of life for prostate cancer patients after stereotactic body radiotherapy (SBRT). METHODS AND MATERIALS Using the Expanded Prostate Cancer Index Composite (EPIC)-validated quality-of-life questionnaire, the sexual function of 32 consecutive patients who received prostate SBRT in a prospective Phase II clinical trial were analyzed at baseline, and at median times of 4, 12, 20, and 50 months after treatment. SBRT consisted of 36.25 Gy in five fractions of 7.25 Gy using the Cyberknife. No androgen deprivation therapy was given. The use of erectile dysfunction (ED) medications was monitored. A comprehensive literature review for radiotherapy-alone modalities based on patient self-reported questionnaires served as historical comparison. RESULTS Median age at treatment was 67.5 years, and median follow-up was 35.5 months (minimum 12 months). The mean EPIC sexual domain summary score, sexual function score, and sexual bother score decreased by 45%, 49%, and 25% respectively at 50 months follow-up. These differences reached clinical relevance by 20 months after treatment. Baseline ED rate was 38% and increased to 71% after treatment (p = 0.024). Use of ED medications was 3% at baseline and progressed to 25%. For patients aged <70 years at follow-up, 60% maintained satisfactory erectile function after treatment compared with only 12% aged ≥70 years (p = 0.008). Penile bulb dose was not associated with ED. CONCLUSIONS The rates of ED after treatment appear comparable to those reported for other modalities of radiotherapy. Given the modest size of this study and the uncertainties in the physiology of radiotherapy-related ED, these results merit further investigations.
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Affiliation(s)
- Ellen A Wiegner
- Department of Radiation Oncology, Stanford University School of Medicine, CA, USA
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Singh RK, Sudhakar A, Lokeshwar BL. Role of Chemokines and Chemokine Receptors in Prostate Cancer Development and Progression. ACTA ACUST UNITED AC 2010; 2:89-94. [PMID: 20808724 DOI: 10.4172/1948-5956.1000030] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Prostate cancer (PC) is the second leading cause of cancer deaths in men in America and Western Europe. Epidemiological studies suggest that prostate cancer incidences increased in last few years in Asian. The causes or consequences of increasing trend of prostate cancer incidence are not completely known. Emerging evidences suggest that among the many risk factors, inflammation is the major risk factor for developing prostate cancer and its progression to metastasis. It is proposed that exposure to environmental factors such as infectious agents, dietary agents and saturated lipids leads to injury of the prostate due to chronic inflammation and regenerative risk factor lesions referred to as proliferative inflammatory atrophy (PIA). These phenomena predominantly control by a number of proinflammatory macro molecules such as chemokines, and their receptors. Some recent studies suggest that many of these pro-inflammatory chemokines and their receptors are the products of protooncogenes in many cancers including that of the prostate. This review will focus on the current biology of chemokines and chemokine receptors in prostate cancer. An understanding of this axis may enable researchers to develop targeted strategies for prostate cancer.
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Affiliation(s)
- Rajendra K Singh
- Department of Urology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA
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Namiki S, Ishidoya S, Ito A, Tochigi T, Numata I, Narazaki K, Yamada S, Takai Y, Arai Y. Five-year follow-up of health-related quality of life after intensity-modulated radiation therapy for prostate cancer. Jpn J Clin Oncol 2009; 39:732-8. [PMID: 19666904 DOI: 10.1093/jjco/hyp086] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE We evaluated health-related quality of life (HRQOL) in patients with localized prostate cancer who underwent intensity-modulated radiation therapy (IMRT) or three-field conformal radiotherapy (3DCRT). METHODS A total of 97 patients underwent 3DCRT and 36 underwent IMRT for localized prostate cancer between 2002 and 2004. We measured the general and disease-specific HRQOL with the Medical Outcomes Study 36-Item Health Survey and University of California, Los Angeles Prostate Cancer Index, respectively. RESULTS There were no significant differences in the pre-operative characteristics of the two groups. The patients in the 3DCRT group were more likely to receive hormonal therapy compared with the IMRT group before and after radiation therapy (P < 0.001 and P = 0.011, respectively). With regard to general HRQOL domains, both the 3DCRT and IMRT group scores showed no significant difference between baseline and any of the observation periods. At 60 months after treatment, the 3DCRT group had significantly worse bowel function and bother scores than baseline (both P < 0.001). On the other hand, there were no significant differences between the baseline and any of the post-treatment time periods in the IMRT group. In the 3DCRT group, sexual function remained substantially lower than the baseline level (P = 0.023). The IMRT group tended to show a decrease in sexual function, which was not statistically significant (P = 0.11). CONCLUSIONS IMRT can provide the possibility to deliver a high irradiation dose to the prostate with satisfactory functional outcomes for long-term periods.
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Affiliation(s)
- Shunichi Namiki
- Department of Urology, Tohoku University Graduate School of Medicine, 1-1 Seiryomachi, Aoba-ku, Sendai 980-8574, Japan.
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Albertsen PC. Is screening for prostate cancer with prostate specific antigen an appropriate public health measure? Acta Oncol 2009; 44:255-64. [PMID: 16076698 DOI: 10.1080/02841860410002815] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Screening and treatment for prostate cancer is controversial. In the absence of randomized trials, several prominent medical organizations in the United States and Europe have formulated policies that range from enthusiastic support to significant skepticism concerning the efficacy of screening and subsequent treatment for prostate cancer. Sharp rises in the incidence of prostate cancer have occurred whenever PSA testing has been introduced on a wide scale. Unfortunately, it is unclear whether declines in prostate cancer mortality can be attributed to PSA testing. Other explanations include the early use of anti-androgen therapy or changes in environmental factors such as diet. Repeated testing for serum PSA has produced significant shifts in the types of cases being identified and has raised the possibility of significant over-diagnosis of this disease. The European screening trial and the PLCO trial in the US will hopefully provide some insights into the value of population-based testing.
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Affiliation(s)
- Peter C Albertsen
- Department of Surgery, University of Connecticut Health Center, Farmington, 06030-3955, USA.
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Quality of life in patients with locally advanced prostate cancer given endocrine treatment with or without radiotherapy: 4-year follow-up of SPCG-7/SFUO-3, an open-label, randomised, phase III trial. Lancet Oncol 2009; 10:370-80. [DOI: 10.1016/s1470-2045(09)70027-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Andriole GL, Crawford ED, Grubb RL, Buys SS, Chia D, Church TR, Fouad MN, Gelmann EP, Kvale PA, Reding DJ, Weissfeld JL, Yokochi LA, O'Brien B, Clapp JD, Rathmell JM, Riley TL, Hayes RB, Kramer BS, Izmirlian G, Miller AB, Pinsky PF, Prorok PC, Gohagan JK, Berg CD. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med 2009; 360:1310-9. [PMID: 19297565 PMCID: PMC2944770 DOI: 10.1056/nejmoa0810696] [Citation(s) in RCA: 1959] [Impact Index Per Article: 130.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The effect of screening with prostate-specific-antigen (PSA) testing and digital rectal examination on the rate of death from prostate cancer is unknown. This is the first report from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial on prostate-cancer mortality. METHODS From 1993 through 2001, we randomly assigned 76,693 men at 10 U.S. study centers to receive either annual screening (38,343 subjects) or usual care as the control (38,350 subjects). Men in the screening group were offered annual PSA testing for 6 years and digital rectal examination for 4 years. The subjects and health care providers received the results and decided on the type of follow-up evaluation. Usual care sometimes included screening, as some organizations have recommended. The numbers of all cancers and deaths and causes of death were ascertained. RESULTS In the screening group, rates of compliance were 85% for PSA testing and 86% for digital rectal examination. Rates of screening in the control group increased from 40% in the first year to 52% in the sixth year for PSA testing and ranged from 41 to 46% for digital rectal examination. After 7 years of follow-up, the incidence of prostate cancer per 10,000 person-years was 116 (2820 cancers) in the screening group and 95 (2322 cancers) in the control group (rate ratio, 1.22; 95% confidence interval [CI], 1.16 to 1.29). The incidence of death per 10,000 person-years was 2.0 (50 deaths) in the screening group and 1.7 (44 deaths) in the control group (rate ratio, 1.13; 95% CI, 0.75 to 1.70). The data at 10 years were 67% complete and consistent with these overall findings. CONCLUSIONS After 7 to 10 years of follow-up, the rate of death from prostate cancer was very low and did not differ significantly between the two study groups. (ClinicalTrials.gov number, NCT00002540.)
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Kakizoe T, Mucci LA, Albertsen PC, Droller MJ. Screening for bladder cancer: theoretical and practical issues in considering the treated and untreated natural history of the various forms of the disease. ACTA ACUST UNITED AC 2009:191-212. [PMID: 18815934 DOI: 10.1080/03008880802284936] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Screening is used to detect disease earlier in its course, allow earlier treatment, and presumably decrease morbidities and potential mortality associated with the later expression of more advanced disease and presumably more complex treatments consequently required. Judicious screening in bladder cancer depends on an understanding of how the different forms of bladder cancer express their biological potential, whether the tools available for screening have sufficient sensitivity and specificity to have accurate predictive value in accurately diagnosing and assessing each cancer diathesis earlier in its course, and how this may influence the morbidities and mortality associated with each. The principles of screening, potential biases that can affect their accuracy and the interpretation of outcomes, tools currently available for screening, their efficacies and pitfalls, and lessons learned from studies of the role of screening in prostate cancer will be reviewed to offer an understanding of the potential role that screening may play in the different forms of bladder cancer in the context of their preclinical and treated natural history.
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Affiliation(s)
- Tadao Kakizoe
- National Cancer Center, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan.
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Bhatnagar V, Frosch DL, Tally SR, Hamori CJ, Lenert L, Kaplan RM. Evaluation of an internet-based disease trajectory decision tool for prostate cancer screening. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2009; 12:101-108. [PMID: 18637139 DOI: 10.1111/j.1524-4733.2008.00407.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To evaluate the application of a chronic disease model (CDM) for prostate cancer to visual analog scale (VAS) and time trade-off (TTO) decision tools. METHODS A total of 138 men (mean age 58 years) viewed a CDM module for prostate cancer with and without prostate specific antigen (PSA) screening. Participants rated their hypothetical quality of life with potential prostate cancer treatment complications using a CDM-based VAS decision tool. They were then asked to estimate how many years they would be willing to trade to be free of treatment complications using a CDM-based TTO decision tool. The consistency between VAS and TTO scores and the relationship between scores and preferences for PSA screening test and hypothetical treatment choice for prostate cancer were then evaluated. RESULTS There was a significant relationship between the VAS and TTO ratings (regression P < 0.001). The TTO tool was sensitive to age. Mean scores with standard deviations for those less than 58 years compared to those 58 years and more were 7.78 (1.75) and 8.41 (1.52), respectively (P = 0.04). Using the VAS tool, men who chose PSA screening had higher quality of life ratings compared to men who did not choose PSA screening: 7.73 (1.78) and 6.59 (2.39), respectively (P = 0.01). Similar results were found with the TTO decision tool: 8.33 (1.45) and 7.04 (2.00), respectively (P = 0.005). Men who would hypothetically prefer treatment for moderately differentiated prostate cancer also had higher TTO scores compared to men who preferred watchful waiting: 8.54 (1.39) and 7.85 (1.73), respectively (P = 0.04). CONCLUSION CDM-based for prostate cancer, VAS and TTO ratings were consistent and were concordant with patient preferences for screening; TTO ratings were also concordant with treatment choice. The use of the CDM-based TTO ratings to adjust for quality of life in decision analytic modeling needs to be explored.
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Affiliation(s)
- Vibha Bhatnagar
- Department of Family and Preventive Medicine, School of Medicine, University of California, San Diego, San Diego, CA 92131, USA.
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Mols F, Korfage IJ, Vingerhoets AJJM, Kil PJM, Coebergh JWW, Essink-Bot ML, van de Poll-Franse LV. Bowel, urinary, and sexual problems among long-term prostate cancer survivors: a population-based study. Int J Radiat Oncol Biol Phys 2008; 73:30-8. [PMID: 18538503 DOI: 10.1016/j.ijrobp.2008.04.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2008] [Revised: 04/04/2008] [Accepted: 04/07/2008] [Indexed: 11/25/2022]
Abstract
PURPOSE To obtain insight into the long-term (5- to 10-year) effects of prostate cancer and treatment on bowel, urinary, and sexual function, we performed a population-based study. Prostate-specific function was compared with an age-matched normative population without prostate cancer. METHODS AND MATERIALS Through the population-based Eindhoven Cancer Registry, we selected all men diagnosed with prostate cancer between 1994 and 1998 in the southern Netherlands. In total, 964 patients, alive in November 2004, received questionnaire; 780 (81%) responded. RESULTS Urinary problems were most common after a prostatectomy; bowel problems were most common after radiotherapy. Compared with an age-matched normative population both urinary and bowel functioning and bother were significantly worse among survivors. Urinary incontinence was reported by 23-48% of survivors compared with 4% of the normative population. Bowel leakage occurred in 5-14% of patients compared with 2% of norms. Erection problems occurred in 40-74% of patients compared with 18% of norms. CONCLUSIONS These results form an important contribution to the limited information available on prostate-specific problems in the growing group of long-term prostate cancer survivors. Bowel, urinary, and sexual problems occur more often among long-term survivors compared with a reference group and cannot be explained merely by age. Because these problems persist for many years, urologists should provide patients with adequate information before treatment. After treatment, there should be an appropriate focus on these problems.
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Affiliation(s)
- Floortje Mols
- CoRPS-Center of Research on Psychology in Somatic Diseases, Tilburg University, Tilburg, The Netherlands
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Mols F, Aquarius AE, Essink-Bot ML, Aaronson NK, Kil PJM, van de Poll-Franse LV. Does diabetes mellitus as a comorbid condition affect the health-related quality of life in prostate cancer survivors? Results of a population-based observational study. BJU Int 2008; 102:1594-600. [PMID: 18522628 DOI: 10.1111/j.1464-410x.2008.07812.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the health-related quality of life (HRQoL) of long-term, disease-free prostate cancer survivors and compare it with that of prostate cancer survivors with diabetes mellitus (DM), and a Dutch normative population, as comorbidity can have a major impact on HRQoL in cancer survivors. PATIENTS AND METHODS The Eindhoven Cancer Registry was used to select all men diagnosed with prostate cancer from 1994 to 1998. Questionnaires on HRQoL (Short Form 36) and prostate specific problems (University of California, Los Angeles Expanded Prostate Cancer Index) were sent to 964 patients, and 780 (81%) responded. Excluding patients with disease progression, the sample comprised 525 with prostate cancer and 65 with both prostate cancer and DM. Survivors with DM were more likely to have other comorbid conditions at the time of survey besides DM than were those without DM (74% vs 60%, P = 0.05). At 5-10 years after diagnosis, patients with DM reported worse General Health Perceptions than patients without DM or the normative population (means 52, 61 and 63; P < 0.001). Patients with DM also reported worse Vitality scores (59 vs 63; P < 0.001) than the normative population. Regression analysis indicated that DM was negatively associated with General Health Perceptions (beta = -0.13; P < 0.01) and Vitality (beta = -0.12; P < 0.01). Survivors with DM did not report worse urinary and bowel function or bother, nor more sexual problems than those without DM. CONCLUSIONS Except for general health perceptions and vitality, the HRQoL of prostate cancer survivors with or without DM was comparable to a normative population. Survivorship selection can possibly explain, in part, why patients with DM did not report worse generic or disease-specific HRQoL than those without DM, as had been expected.
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Affiliation(s)
- Floortje Mols
- CoRPS - Center of Research on Psychology in Somatic diseases, Tilburg University, Tilburg, The Netherlands.
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Should men over the age of 65 years receive PSA screening? Argument against. NATURE CLINICAL PRACTICE. UROLOGY 2008; 5:232-3. [PMID: 18349860 DOI: 10.1038/ncpuro1079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Accepted: 02/01/2008] [Indexed: 11/09/2022]
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Abstract
Given the lack of unequivocal survival data clearly favoring one treatment over another for localized prostate cancer, patients strongly consider quality-of-life effects when choosing treatment for this common malignancy. In the past 15 years, a sizeable body of literature assessing health-related quality-of-life (HRQOL) outcomes in localized prostate cancer has emerged. The goal of this article is to review the quality-of-life experience after treatment for localized prostate cancer. Specifically, I will briefly discuss how quality of life is measured and then review the quality of life effects of each of the commonly used treatment strategies in localized prostate cancer. Finally, I attempt to directly compare the quality-of-life effects of the various treatments to assist clinicians in advising patients with newly diagnosed localized prostate cancer.
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Moinpour CM, Hayden KA, Unger JM, Thompson IM, Redman MW, Canby-Hagino ED, Higgins BA, Sullivan JW, Lemmon D, Breslin S, Crawford ED. Health-Related Quality of Life Results in Pathologic Stage C Prostate Cancer From a Southwest Oncology Group Trial Comparing Radical Prostatectomy Alone With Radical Prostatectomy Plus Radiation Therapy. J Clin Oncol 2008; 26:112-20. [DOI: 10.1200/jco.2006.10.4505] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To compare short- and long-term effects of adjuvant treatment versus observation after surgery on health-related quality of life (HRQL) of prostate cancer patients. Patients and Methods The Southwest Oncology Group (SWOG) intergroup trial compared radical prostatectomy (RP) plus observation versus RP plus adjuvant radiation therapy (RT). Two-hundred seventeen of 425 therapeutic trial patients were eligible and registered to the HRQL study. Patients completed the SWOG Quality of Life Questionnaire (emotional, physical, social, and role function; general symptom status; treatment/disease-specific symptoms; and global HRQL [GHRQL]) at baseline, 6 weeks, 6 months, and annually for 5 years. Prespecified outcomes were three genitourinary symptoms (bowel function tenderness, frequent urination, and erectile dysfunction [ED]) and measures of physical and emotional function. Adjustments were made for the baseline score. Results Patients receiving adjuvant RT reported worse bowel function (through approximately 2 years) and worse urinary function. There were no statistically significant differences for ED. GHRQL was initially worse for the RP+RT arm but improved over time and was better at the end of the period than the GHRQL reported for RP alone (treatment arm × time interaction, P = .0004). Symptom distress was significantly worse for the RP+RT arm compared with the RP alone arm, but the treatment arms did not differ with respect to other general measures of HRQL. Conclusion The addition of RT to surgery resulted in more frequent urination, as well as early report of more bowel dysfunction, although bowel function differences disappeared over the 5-year period. The addition of RT did not negatively impact ED.
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Affiliation(s)
- Carol M. Moinpour
- From the Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Katherine A. Hayden
- From the Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Joseph M. Unger
- From the Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Ian M. Thompson
- From the Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Mary W. Redman
- From the Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Edith D. Canby-Hagino
- From the Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Betsy A. Higgins
- From the Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jerry W. Sullivan
- From the Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Dianne Lemmon
- From the Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Sheila Breslin
- From the Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - E. David Crawford
- From the Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA
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Petersen S, Jongen J, Petersen C, Sailer M. Radiation-induced sequelae affecting the continence organ: incidence, pathogenesis, and treatment. Dis Colon Rectum 2007; 50:1466-74. [PMID: 17661143 DOI: 10.1007/s10350-007-0296-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Incontinence is a late complication that causes symptoms years after radiation treatment and is difficult to deal with; it poses a particular challenge for care-providing physicians. REVIEW This review looks at our current knowledge of the incidence, symptoms, and treatment of fecal incontinence induced by radiation treatment. An approximate estimation based on retrospective data suggests an incidence of fecal incontinence of up to one-third of patients. The mechanism that causes incontinence are changes in anal resting tone, squeeze pressure, and rectal volume or rectal compliance. The other associated aspects of incontinence include such further disorders as proctitis, colitis, and other disturbances involving the lower digestive tract. The therapeutic options mainly comprise the treatment of associated aspects, such as proctitis or diarrhea. CONCLUSION Surgical treatment should be the absolute exception. If the creation of a stoma is being considered, a resective procedure offering freedom from symptoms seems to be the more advantageous option.
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Affiliation(s)
- Sven Petersen
- Department of Surgery, Bethesda General Hospital Hamburg Bergedorf, Glindersweg 80, 21029, Hamburg, Germany.
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47
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Pauly KB, Diederich CJ, Rieke V, Bouley D, Chen J, Nau WH, Ross AB, Kinsey AM, Sommer G. Magnetic resonance-guided high-intensity ultrasound ablation of the prostate. Top Magn Reson Imaging 2007; 17:195-207. [PMID: 17414077 DOI: 10.1097/rmr.0b013e31803774dd] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES This paper describes our work in developing techniques and devices for magnetic resonance (MR)-guided high-intensity ultrasound ablation of the prostate and includes review of relevant literature. METHODS Catheter-based high-intensity ultrasound applicators, in interstitial and transurethral configurations, were developed to be used under MR guidance. Magnetic resonance thermometry and the relevant characteristics and artifacts were evaluated during in vivo thermal ablation of the prostate in 10 animals. Contrast-enhanced MR imaging (MRI) and diffusion-weighted MRI were used to assess tissue damage and compared with histology. RESULTS During evaluation of these applicators, MR thermometry was used to monitor the temperature distributions in the prostate in real time. Magnetic resonance-derived maximum temperature thresholds of 52 degrees C and thermal dose thresholds of 240 minutes were used to control the extent of treatment and qualitatively correlated well with posttreatment imaging studies and histology. The directional transurethral devices are selective in their ability to target well-defined regions of the prostate gland and can be rotated in discrete steps to conform treatment to prescribed boundaries. The curvilinear applicator is the most precise of these directional techniques. Multisectored transurethral applicators, with dynamic angular control of heating and no rotation requirements, offer a fast and less complex means of treatment with less selective contouring. CONCLUSIONS The catheter-based ultrasound devices can produce spatially selective regions of thermal destruction in prostate. The MR thermal imaging and thermal dose maps, obtained in multiple slices through the target volume, are useful for controlling therapy delivery (rotation, power levels, duration). Contrast-enhanced T1-weighted MRI and diffusion-weighted imaging are useful tools for assessing treatment.
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Affiliation(s)
- Kim Butts Pauly
- Department of Radiology, Stanford University, Stanford, CA 94305-5488, USA.
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Abstract
Prostate cancer incurs a substantial incidence and mortality burden, similarly to breast cancer, and it ranks among the top ten specific causes of death in the United States. It is inherent as we maximize the detection of early prostate cancer that we increase the detection of both nonaggressive (slow growing) and aggressive (faster growing) prostate cancers. The evidence clearly supports the use of PSA screening in conjunction with DRE as a means of early detection of prostate cancer. Widespread implementation of prostate cancer screening in the United States has led to the phenomenon of stage migration with more cancers being detected at a lower stage. Such a trend has decreased the incidence of metastatic disease at diagnosis and paralleled the decrease of the mortality rate from prostate cancer. Our understanding of the natural history of prostate cancer is progressing over time, but the question of its length is unanswerable. The relatively long doubling time (on average) of early prostate cancer of 3 to 4 years or more indicates a relatively good prognosis for many men with this disease, even without early detection and treatment. Unfortunately, the poor specificity of the PSA test in men with benign prostatic hyperplasia (BPH) leads to high rates of prostate biopsy and attendant illnesses and costs. Early detection is more apt to detect a slow-growing prostate cancer than a faster growing cancer that is associated with a more rapid course of progression to metastatic disease. Hence, the launching of mass screening programs for the early detection of prostate cancer is premature. However, in the absence of solid evidence of benefit, one reasonable approach to screening at the individual level is to involve the patient in decisions about whether or not to perform a PSA test. Thus, "offering" PSA testing must be accompanied by informed discussion within the context of an ongoing patient-physician relationship. This is to be distinguished from the use of PSA testing for the purpose of "mass screening." Concepts that must be explored with the patient include: 1. The long-term ramifications of screening 2. The relatively high probability of further evaluation and biopsy with positive results 3. Potentially difficult decisions that may arise about using treatments that are associated with considerable morbidity and uncertain benefits (at the time) if cancer is discovered We should identify a future path that is evidence-based, focused on the issues that make a difference to patients, and results in better and longer lives of those with the disease and those who are at risk of getting it. If that path leads to treating fewer patients in the future, even if sometimes more aggressively, we should pursue it definitely and consequently.
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Affiliation(s)
- P Tenke
- Department of Urology, Jahn Ferenc South-Pest Hospital, Budapest, Hungary
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Bangma CH, Roemeling S, Schröder FH. Overdiagnosis and overtreatment of early detected prostate cancer. World J Urol 2007; 25:3-9. [PMID: 17364211 PMCID: PMC1913182 DOI: 10.1007/s00345-007-0145-z] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2007] [Accepted: 01/06/2007] [Indexed: 11/28/2022] Open
Abstract
Early detection of prostate cancer is associated with the diagnosis of a considerable proportion of cancers that are indolent, and that will hardly ever become symptomatic during lifetime. Such overdiagnosis should be avoided in all forms of screening because of potential adverse psychological and somatic side effects. The main threat of overdiagnosis is overtreatment of indolent disease. Men with prostate cancer that is likely to be indolent may be offered active surveillance. Evaluation of active surveillance studies and validation of new biological parameters for risk assessment are expected.
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Affiliation(s)
- C H Bangma
- Department of Urology, Erasmus University Medical Centre, PO Box 2040, 3000 DR Rotterdam, Netherlands.
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50
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Alfano CM, Rowland JH. Recovery issues in cancer survivorship: a new challenge for supportive care. Cancer J 2006; 12:432-43. [PMID: 17034679 DOI: 10.1097/00130404-200609000-00012] [Citation(s) in RCA: 153] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The growing population of cancer survivors represents a clear challenge to clinicians and researchers to look beyond the search for a cure and to address the multifaceted needs of those living with and beyond a cancer diagnosis. Common sequelae that disrupt the psychosocial aspects of life for adult cancer survivors after primary treatment include: fatigue; cognitive changes; body image; sexual health and functioning; infertility; fear of recurrence; PTSD and stress syndromes; family/caregiver distress; socioeconomic issues; and distress, anxiety, and depression. Psychosocial interventions, particularly group-based interventions and physical activity programs, have shown great promise in improving these outcomes. Future research will identify even better targeted, more efficacious, and more cost effective programs and disseminate them into cancer care settings. Healthcare providers must realize that they serve as vital gatekeepers to services that will help optimize cancer survivors' psychosocial as well as physical outcomes. Addressing these issues in the post-treatment period represents the new challenge to supportive care.
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Affiliation(s)
- Catherine M Alfano
- The Ohio State University Comprehensive Cancer Center & School of Public Health, Columbus, Ohio 43210, USA.
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