Prognostic factor for prostate cancer. Gunma Urological Oncology Study Group

The study of prognostic factors in patients with prostate cancer (Pca) may be of value in understanding the natural history of the disease and may also assist in planning and analyzing the results of clinical trials. Moreover some information through this study would be beneficial to assessing the prognosis and decision of better therapy form of individual patients. The significance of items studied was evaluated from the two view points, survival rate and Pca death rate. Stage, pathological differentiation and acid phosphatase were significantly related to them, in the category grade depending manner. Past history and complication, and age were also significantly related to them but higher category grade as a survival factor showed lower Pca death rates. ESR, gait disturbance and hematuria were related to only survival rate. Any significant relationship was not observed in serum testosterone, voiding disturbance and cancer-pain. Prognostic factors should be clinically used through the well understanding of each characteristics. This paper also showed that statistical significance not always provide a wide difference between categories compared.     

Bladder cancer mortality in The Netherlands, 1955-1988.

In 1955, 234 men and 116 women died from bladder cancer in the Netherlands. In 1988 the numbers were 794 and 317 respectively. After adjusting for the ageing of the Dutch population since 1955, female mortality rates per 10(5) person-years appear to be very stable: 2.9 from 1955 to 1959 and 3.0 from 1985 to 1988. By contrast, an increasing trend exists in males. From 1955 to 1959 and from 1985 to 1988, bladder cancer mortality rates per 10(5) person-years were 7.5 and 12.4 respectively. For men in particular, increasing mortality (and incidence) rates are seen all over the world. In many cases this increasing trend is thought to originate from a higher risk of dying from bladder cancer in successive birth cohorts rather than from a higher risk in successive calendar periods. This so-called cohort effect is explained by changes in smoking behaviour in the male population. Statistical modelling of bladder cancer mortality data from 1955 to 1988 in the Netherlands shows that the increasing temporal trend in men can also be described as a cohort effect. The risk of dying from bladder cancer increases from the 1875 birth cohort to the 1910 birth cohort, but decreases thereafter. It is concluded that this decreasing risk for generations born after 1910 will probably result in a decreasing trend in mortality in the near future, when more and more of these "youngsters" reach the age of 70+.     

Voiding disturbance in elderly males examined by prostate mass screening. Gunma Urological Oncology Study Group]

Information about voiding disturbance was obtained from 34,140 elderly males in Gunma Aged Club Association (Q group) through a questionnaire and from 8,129 males by prostate mass screening for prostate disease (MS group) as to: (1) the characteristics of the subjects examined by the mass screening, (2) the relationship between the voiding disturbance and aging and (3) the frequency of voiding disturbance in the normal elderly males. In MS group, the percentage of young subjects, especially less than 60 years old, who complained voiding disturbance was higher than the expected percentage on the assumption that it increases with aging. The percentage of voiding disturbance in these young subjects was also higher than that of males in the same decade in Q group. In their past and present history, the percentage of benign prostatic hypertrophy (BPH) in these young subjects was higher than the expected percentage on the assumption that the incidence of BPH increases with aging. Judging from these results, it was estimated that they were not satisfied with the medical care by which they were treated or were being treated, and they received this mass screening to obtain consultation for their complains. Loss of the force was related with the prostate size estimated by digital rectal examination but not with aging. However, nocturia was well related with aging but not with the prostate size. Hesitancy, strain and dribbling were not apparently related with either the prostate size or aging. It was demonstrated that frequency of nocturia was 0 to 1 in less than 60 years old normal males, 0 to 2 in 60 to 79 years old ones and 0 to 3 in over 80 years old ones. The other symptoms studied in each decade were also analyzed and discussed.     

局限性前列腺癌治疗进展

局限性前列腺癌的治疗近年发展很快,本文就局限性前列腺癌初次治疗前危险分类,治疗方法的合理选择,初次治疗后肿瘤的生化进展及临床复发处理的进展作一综述。     

The case for no initial treatment of localized prostate cancer

This contribution summarizes the evidence from the natural history and pathology of this disease that, given the high incidence of latent cancer, a policy of radical treatment at diagnosis will represent over-treatment in the majority of cases. As yet, neither radical prostatectomy nor radical radiotherapy has been shown to be effective in managing the poorly differentiated tumor in the patient with "localized" disease. For the patient with well-differentiated disease, there is little evidence that early treatment is mandatory, because the majority of these patients will not die of prostatic cancer. The adoption of a policy of diagnosis followed by active surveillance would spare many patients the hazard and discomfort of a major operation or of a course of radiotherapy, would minimize expenditure, and would ensure that treatment was given only to those patients in whom progression had been demonstrated. Such an approach is almost certain to be as effective as treatment at diagnosis. Confirmation of this view is likely to be obtained from the existing studies of immediate versus delayed orchiectomy or LHRH therapy currently being undertaken by the Urological Working Party of the Medical Research Council in the United Kingdom and the Urological Group of the EORTC within Europe.     

Neodymium-YAG laser in the treatment of localized prostate cancer

The combination of transurethral resection and subsequent Neodymium-YAG laser irradiation has been practiced for radical treatment of localized prostate cancer since 1981. One hundred and eighteen patients have been treated and the observation time ranges 6-98 months. The treatment is performed endoscopically in two separate steps. The procedure is simple and complications are few. One hundred and four patients are evaluated as disease-free survivors. The overall actuarial disease-free survival rate is 88% in the 4-8 year period. The results compare satisfactorily with results obtained by other methods. Recently published results from other clinics confirm the laser to be promising in the treatment of localized prostate cancer.     

Regional variation in the surgical treatment of early breast cancer.

A questionnaire survey of consultant surgeons in England was undertaken to establish the preferred surgical management of early breast cancer. The Regional Health Authority in which each surgeon worked was recorded to document regional variation. The 14 Regional Health Authorities were divided into three geographical areas: north, central and south. The main finding was that proportionately more surgeons in the north would recommend mastectomy (P < 0.0001) rather than conservative surgery compared with those in the central and southern areas. The nature of the study does not allow explanations for such variation.     

Surgical treatment for limited small-cell lung cancer. The University of Toronto Lung Oncology Group experience.

Since 1977, 119 patients with limited small-cell lung cancer have undergone combined modality therapy including surgery at our institution. Seventy-nine patients (58 male, 21 female; median age 63 years) had surgery first, and 67 of these had adjuvant chemotherapy. Forty (27 male, 13 female; median age 59 years) had chemotherapy first, and 94% had a complete or partial response before the operation. Pretreatment staging revealed 69 stage I, 27 stage II, and 23 stage III tumors. Twenty-six patients required pneumonectomy, 88 lobectomy, and five had no resection. Four patients had gross and six had microscopic residual disease. Postoperative pathologic examination showed small-cell lung cancer only (n = 95), non-small-cell lung cancer (n = 3), mixed (n = 17), and no residual tumor (n = 4). Postoperative staging revealed 35 stage I, 36 stage II, and 48 stage IIIa tumors. The median survival of the entire group is 111 weeks and the projected 5-year survival rate is 39%. No survival difference was seen between patients treated with chemotherapy before the operation and those undergoing an initial operation followed by chemotherapy (p = 0.756). The median survival for patients with pathologic stage I disease has not been reached, and the projected 5-year survival rate is 51%. This is significantly better than for the patients with stage II (median 82 weeks, p = 0.001) or stage III (median 83 weeks, p = 0.001) disease, who have projected 5-year survival rates of 28% and 19%, respectively. Seven of the 12 patients who had no adjuvant chemotherapy remain alive at 6 to 48+ months. Sixty-seven patients have died (11 had no evidence of disease). Only 10 patients had a relapse in the primary site alone, seven at the primary and distant sites, and 39 only in distant sites. In summary, resection improves control at the primary site, and a significant proportion of patients with stage I (N0) disease achieve long-term survival and cure with combined modality therapy including surgery. Stage II and IIIa patients have survival predictions similar to stage IIIa non-small-cell lung carcinoma treated surgically.     

Clinical study of leuprolide depot formulation in the treatment of advanced prostate cancer.The Leuprolide Study Group

In a phase III, open, multicenter study we evaluated the safety and efficacy of the depot formulation of leuprolide (7.5 mg. injected intramuscularly every 4 weeks) in patients with stage D2 prostate cancer who had not previously received systemic treatment. Serum testosterone, luteinizing hormone and plasma leuprolide levels were monitored during the 24-week study period. Median interval to onset of castrate testosterone levels was 21 days and mean testosterone levels decreased to within the castrate range by week 3 of treatment. After onset of castrate levels there were no escapes (defined as 2 consecutive values of greater than 50 ng./dl.) of testosterone levels during the 24 weeks. Suppression of testosterone did not differ significantly from that observed in patients receiving the daily subcutaneous injection of leuprolide acetate in the first 24 weeks of another study. Objective response (no progression) to treatment occurred in 81% of 53 evaluable patients and adverse (related and unrelated) events were reported in 45 of the 56 patients. The response rate and incidence of adverse events in this study did not differ significantly from those occurring with the daily formulation. We conclude that the depot formulation of leuprolide is safe and effective in the treatment of advanced prostatic cancer, and that the safety and efficacy of this formulation do not differ significantly from those of the daily subcutaneous formulation.     

Recommendations for the treatment of localized prostate cancer by permanent interstitial brachytherapy

The increasing use of interstitial brachytherapy for the treatment of prostate cancer has made it necessary to discuss and establish guidelines for the application of this treatment modality. A group of experts representing the four professional and scientific societies of urologic surgeons and radiation oncologists in Germany was formed by the German Society of Urology (Deutsche Gesellschaft für Urologie, DGU), the Association of German Urologists (Berufsverband der Deutschen Urologen e.V., BDU), the German Society for Radiation Oncology (Deutsche Gesellschaft für Radioonkologie, DEGRO) and the Association of German Radiotherapists (Berufsverband der Deutschen Strahlentherapeuten, BVDSt). This group has formulated a consensus statement consisting of recommendations and guidelines for the indications, planning, implementation and follow-up of permanent interstitial brachytherapy by seed implantation for the treatment of localized prostate cancer. These recommendations also define the responsibilities of the two medical disciplines involved in the use of this interdisciplinary treatment.     

Transrectal high-intensity focused ultrasound in the treatment of localized prostate cancer

The literature concerning the efficacy and safety of transrectal high-intensity focused ultrasound (HIFU) for the treatment of localized prostate cancer still comprises a relatively small number of articles. The main studies have been published by four teams using an apparatus available in Europe for several years. The recently presented results of the European Multicentre Study and the study by Gelet and associates based on 242 patients with a follow-up of more than 1 year show that HIFU is a valid alternative for the management of welldifferentiated and moderately differentiated localized prostate cancer with an initial PSA 10 years. In two studies, the combination of transurethral resection of the prostate and HIFU limited the risk of postoperative urinary retention without inducing a higher complication rate. In a series of patients presenting recurrence after external-beam radiotherapy, HIFU was found to be a useful therapy, with >80% negative biopsies. The best indications for HIFU are men over the age of 65, those who are not candidates for radical prostatectomy, obese patients, or patients with comorbidities likely to make surgery more difficult. The learning curve for this technique is relatively short, between 10 and 15 patients, for urologists experienced in transrectal ultrasonography. One of the advantages of HIFU is that it can be repeated in the case of recurrence or to re-treat a prostatic site, it involves no radiation, and patients do not suffer from long-term irritative urinary symptoms.     

The impact of cancer treatment on quality of life outcomes for patients with localized prostate cancer

PURPOSE: We evaluated the impact of localized prostate cancer treatment on general, cancer specific and symptom domains of quality of life for up to 5 years after diagnosis. MATERIALS AND METHODS: A total of 842 men from the Health Professionals Followup Study, diagnosed between 1993 and 1998, were included in cross-sectional analyses of quality of life associated with prostate cancer treatment. A subset of 146 men diagnosed after 1995 were followed prospectively. Quality of life was assessed with the Medical Outcomes Study Short-Form 36 Health Status Survey, Cancer Rehabilitation Evaluation System Short Form and University of California Los Angeles Prostate Cancer Index by mailed questionnaires. Primary treatment modality was taken from medical records and patient self-report. RESULTS: Significant treatment differences were observed in all quality of life measures, with the largest occurring in sexual, urinary and bowel symptoms. Bowel function was significantly worse in patients who received external radiation and brachytherapy compared with prostatectomy (p <0.05). Although they had better or equivalent urinary and sexual function (p <0.05), patients treated with external radiation, hormones or watchful waiting had lower generic quality of life scores in multiple domains compared with those who underwent prostatectomy. Patients who had brachytherapy had similar generic quality of life outcomes compared with prostatectomy in all domains. CONCLUSIONS: Our findings suggest that important differences in quality of life go beyond known physical symptoms associated with various prostate cancer treatment options, many of which involve making a trade-off. It is important for patients with prostate cancer and health care providers to consider these differences while making treatment decisions.     

A competing-risks analysis of survival after alternative treatment modalities for prostate cancer patients: 1988-2006

Background

The efficacy of prostate cancer (PCa) treatment modalities is a subject of continuous debate.

Objective

We tested the hypothesis that significant differences in survival rates may exist among PCa patients treated with radical prostatectomy (RP), radiation therapy (RT), and observation.

Design, setting, and participants

We focused on 404 604 patients with clinically localized PCa within 17 Surveillance, Epidemiology and End Results registries.

Measurements

Competing-risks survival analyses were used to estimate cancer-specific mortality (CSM) and other-cause mortality (OCM) rates. Patients were stratified according to treatment type, age group, and PCa risk group (high risk: T2c and/or Gleason score 8–10; low to intermediate risk: all others).

Results and limitations

The 10-yr CSM and OCM rates were 6.1% and 29.2%, respectively. In RP, RT, and observation patients, CSM rates were 3.6%, 6.5%, and 10.8% (p < 0.001), respectively; OCM rates were 17.1%, 32.4%, and 48.9% (p < 0.001), respectively. In low- to intermediate-risk patients, the lowest CSM (1.3–3.7%) and OCM (6.9–31.6%) rates within all age categories except octogenarians (8.9% and 62.8%, respectively) were recorded in RP. In high-risk patients, the lowest CSM (5.8–7.2%) and OCM (8.7–16.1%) rates in patients aged ≤69 yr were also recorded in RP. RT was equally favorable to RP in the 70–79 age category and appeared ideal in all octogenarian patients.

Conclusions

Our results showed that RP provides the most favorable survival rates in most patients. The exception is octogenarian men, in whom RT provides the best results. Finally, the least-favorable outcomes were recorded after observation. However, these findings must be interpreted within the context of the limitations of observational data.     

Histopathological evaluation of radical prostatectomy in the treatment of localized prostate cancer

Incidence of prostate cancer has risen dramatically in the past decade. Radical prostatectomy is indicated in patients who have disease localized to the prostate. The aim of the study is to make histopathological evaluation of radical prostatectomy in the treatment local prostate cancer. Authors analyzed 49 cases of radical prostatectomy due to cancer localized to the prostate in period 1996-2000 in Clinic of Urology in Clinical Center of Serbia, Belgrade. The average age of the patients was 65, 6 years (range 44-76, pick 61-70). The most cases 25 (51%, p < 0.001) we found in pT2a N0M0, in pT2b N1M0 9 (18.36%), in pT3bN0M0 10 (20.4%), in pT3bN1M0 3 (6.12%), in pT4aN0M0 2 (4.08%). Nodal status positive was in 12 cases: 9 (18%) in pT2bN1M0- iliac 3 (right 2, left 1), obturatory 6 (right 1, left 5) and 3 cases in pT3bN1M0-iliac left 1 and obturatory 2 (1 right and 1 left). We found Gleason score 8 in 9 cases (18.36%) in pT2bN1M0 versus 7 cases (14.5%) without nodal metastases. Gleason score 9 we found in 3 cases (6.1%) in pT3bN1M0 versus one case without nodal metastases (difference is not significant). Gleason score 3 was in 6.1%, 4 in 12.2%, 5 in 8.1%, 6 in 16, 3%, 7 in 24.5%. Grade 1 of tumors we found in 9 cases (18%), grade 2 in 11 (22%), grade 3 in 29 (60%). HG PIN was in 18 cases (36.7%), LG PIN in 10 (20.4%). In all cases was elevated PSA: 4-10 mmol/L in 24 pts, 11-20 in 15 pts and > 20 in 10 pts. Radical prostatectomy is most adequate method in surgical treatment cancer localized in the prostate. Pelvic lymphadenectomy is necessary for staging purposes in adenocarcinoma of the prostate. Early detection adenocarcinoma of the prostate is important factor in decreasing rate of death.     

Regional variation in incidence of primary total hip arthroplasties and revisions in Denmark, 1996-2002

BACKGROUND: We examined incidence rates (IR) of total hip arthroplasty (THA) in Denmark according to county and type of hospital, and investigated possible factors associated with any variations. METHODS: Through the Danish Hip Arthroplasty Registry, we identified all cases of primary THAs (n = 37,144) and revisions (n = 6,446) between 1996 and 2002. Unadjusted and age- and gender-standardized, hospital type- and county-specific IRs were calculated. Using multiple regression analysis, we examined possible factors associated with the variations. RESULTS: Over the study period, age- and sex-standardized IRs of primary THAs for university and other hospitals increased by 10% and 40%, respectively. IRs of revisions increased for other hospitals by 33%, but decreased for university hospitals by 30%. Unadjusted IRs varied among counties (n = 15), which remained despite age- and gender-standardization. The IR ratio was 1.4 (95% CI: 1.3-1.6) when comparing the counties with the highest and lowest IRs. No association was found between IRs of THA and the number of orthopedic surgeons per 100,000 inhabitants, proportion of patients with primary arthrosis, preoperative Harris Hip Score, hospital costs, the counties'Gross Domestic Product, or population density. INTERPRETATION: Substantial regional differences in the IRs of THA procedures were found. We found no associations between IRs and a range of patient- and healthcare system-related factors.     

Transrectal high-intensity focused ultrasound for the treatment of localized prostate cancer: Eight-year experience

Objective:   To report on the long-term results of high-intensity focused ultrasound in the treatment of localized prostate cancer.
Methods:   A total of 517 men with stage T1c–T3N0M0 prostate cancer treated with Sonablate devices (Focus Surgery, Indianapolis, IN, USA) between January 1999 and December 2007 were included in the study. Biochemical failure was defined according to the Phoenix definition (prostate-specific antigen nadir + 2 ng/mL).
Results:   The median follow-up period for all patients was 24.0 months (range, 2 to 88). The biochemical disease-free rate (BDFR) in all patients at 5 years was 72%. The BDFR in patients with stage T1c, T2a, T2b, T2c and T3 groups at 5 years were 74%, 79%, 72%, 24% and 33%, respectively ( P  < 0.0001). BDFR in patients in the low, intermediate and high-risk groups at 5 years were 84%, 64% and 45%, respectively ( P  < 0.0001). The BDFR in patients treated with or without neoadjuvant hormonal therapy at 7 years were 73% and 53% ( P  < 0.0001), respectively. In multivariate analysis, pretreatment prostate-specific antigen levels (hazard ratio 1.060; P  < 0.0001; 95% confidence interval 1.040–1.080), neoadjuvant hormonal therapy (hazard ratio 2.252; P  < 0.0001; 95% confidence interval 1.530–3.315) and stage ( P  = 0.0189) were demonstrated to be statistically significant variables. Postoperative erectile dysfunction was noted in 33 out of 114 (28.9%) patients who were preoperatively potent.
Conclusions:   High-intensity focused ultrasound therapy appears to be minimally invasive, efficacious and safe for patients with localized prostate cancer, particularly those with low- and intermediate-risk cancer.