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Thread: (F) Treatment Decisions Comparisons Trends

  1. #31
    Definitive Radiation Therapy and Survival in Clinically Node-Positive Prostate Cancer

    http://www.redjournal.org/article/S0360-3016(18 )30680-1/fulltext
    Emoticon interference: remove the space after the 8


    The survival benefit of combined radiation therapy (RT) and androgen deprivation therapy (ADT) compared to ADT alone for clinically lymph node-positive prostate cancer remains controversial.

    We identified clinically node-positive, non-metastatic prostate cancer patients diagnosed between 2000-2015 and treated with ADT (n=450) or ADT/RT (n=198 ) from a national Veterans Affairs database. We compared prostate cancer-specific mortality (PCSM) and all-cause mortality (ACM) between treatment groups using multivariable competing risk and Cox regression, respectively. An interaction term between ADT/RT and PSA (dichotomized about the median) was included in the multivariable models.

    ADT/RT was associated with improved PCSM among patients with prostate-specific antigen (PSA) less than the median of 26 ng/mL (SDHR: 0.50 95% CI 0.28-0.88, p=0.02) but not greater than the median (HR: 1.15, 95% CI 0.67-1.96, p=0.62) (p for interaction = 0.038 ). ADT/RT was also associated with improved ACM among patients with PSA less than (HR 0.38, 95% CI 0.25-0.57, p < 0.001) but not greater than the median (HR 0.91, 95% CI 0.60-1.38, p=0.66) (p for interaction = 0.004).

    Definitive treatment with ADT/RT is associated with improved PCSM and ACM among patients with clinically node-positive prostate cancer and a lower baseline PSA. Patients with clinically node-positive disease appear to be a heterogeneous cohort, with a subset that may achieve long-term survival with combined radiation and androgen deprivation therapy.
    [Emphasis mine]
    69 yr at Dx, 20-yr Hx of BPH, 9 (!) negative biopsies, PCA3 -
    TURP 2014 (90→30 g) then PSA every 6 months, DRE yearly
    DRE 6-6-17 nodule R, PSA 3.6→4.3 (on finasteride)
    Biopsy #10 6-28-17, 2/14 cores: G10 (5+5) 3% RB, G9 (4+5) 50% RLM
    Bone scan & CTs negative
    Open RP 8-7-17, Duke Regional by my Uro, 8-20 RPs/month >25 yr
    SM LVI SVI EPE LNI (16 nodes): negative, PNI +, nerves spared
    pT2c pN0, b/l adenocarcinoma G9 (4+5) 5% of prostate (4.5 x 5 x 4 cm, 64 g)
    Slightest stress dribble; ED: OK with sildenafil
    RP Decipher score (11-10-17): 0.37 = Genomic Low Risk:
    5-yr metastasis risk: 2.4%; 10-yr PCa-specific mortality: 3.3%
    PSA 9-16-17 (5 weeks) <0.1; 3-month checkups; taking Pomi-T; requested uPSA
    uPSA 11-28-17 (16 weeks) 0.010
    uPSA 02-26-18 (6 months) 0.009

  2. #32
    Oncological impact of neoadjuvant hormonal therapy on permanent iodine‐125 seed brachytherapy in patients with low‐ and intermediate‐risk prostate cancer



    To determine whether neoadjuvant hormonal therapy improves oncological outcomes of patients with localized prostate cancer treated with permanent brachytherapy.

    Between January 2004 and November 2014, 564 patients underwent transperineal ultrasonography‐guided permanent iodine‐125 seed brachytherapy. We retrospectively analyzed low‐ or intermediate‐risk prostate cancer based on the National Comprehensive Cancer Network guidelines. The clinical variables were evaluated for influence on biochemical recurrence‐free survival, progression‐free survival, cancer‐specific survival and overall survival.

    A total of 484 patients with low‐risk (259 patients) or intermediate‐risk disease (225 patients) were evaluated. Of these, 188 received neoadjuvant hormonal therapy. With a median follow up of 71 months, the 5‐year actuarial biochemical recurrence‐free survival rates of patients who did and did not receive neoadjuvant hormonal therapy were 92.9% and 93.6%, respectively (P = 0.2843). When patients were stratified by risk group, neoadjuvant hormonal therapy did not improve biochemical recurrence‐free survival outcomes in low‐ (P = 0.8949) or intermediate‐risk (P = 0.1989) patients. The duration or type of hormonal therapy was not significant in predicting biochemical recurrence. In a multivariate analysis, Gleason score, pretreatment prostate‐specific antigen, clinical T stage, and prostate dosimetry, primary Gleason score and positive core rate were significant predictive factors of biochemical recurrence‐free survival, whereas neoadjuvant hormonal therapy was insignificant. Furthermore, neoadjuvant hormonal therapy did not significantly influence progression‐free survival, cancer‐specific survival or overall survival.

    In patients with low‐ or intermediate‐risk disease treated with permanent prostate brachytherapy, neoadjuvant hormonal therapy does not improve oncological outcomes. Its use should be restricted to patients who require prostate volume reduction.
    [Emphasis mine]

  3. #33
    Improved Recovery of Erectile Function in Younger Men after Radical Prostatectomy: Does it Justify Immediate Surgery in Low-risk Patients?
    [2018, Full Text]



    Although active surveillance is increasingly used for the management of low-risk prostate cancer, many eligible patients are still nonetheless subject to curative treatment. One argument for considering surgery rather than active surveillance is that the probability of postoperative recovery of erectile function is age dependent, that is, patients who delay surgery may lose the window of opportunity to recover erectile function after surgery.

    To model erectile function over a 10-yr period for immediate surgery versus active surveillance.

    Design, setting, and participants
    Data from 1103 men who underwent radical prostatectomy at a tertiary referral center were used.

    Outcome measurements and statistical analysis
    Patients completed the International Index of Erectile Function (IIEF-6) pre- and postoperatively as a routine part of clinical care. Preoperative IIEF-6 scores were plotted against age to assess the natural rate of functional decline due to aging. Reported erectile scores in the 2-yr period following surgery were used to assess post-surgical recovery.

    Results and limitations
    Each year increase in patient age resulted in a 0.27 reduction in IIEF scores. In addition to IIEF reducing with increased age, the amount of erectile function that is recovered from presurgery to 12-mo postsurgery also decreases (−0.16 IIF points/yr, 95% confidence interval −0.27, −0.05, p = 0.006). However, delayed radical prostatectomy increased the mean IIEF-6 score over a 10-yr period compared with immediate surgery (p = 0.001), even under the assumption that all men placed on active surveillance are treated within 5 yr.

    Small differences in erectile function recovery in younger men are offset by a longer period of time living with decreased postoperative function. Better erectile recovery in younger men should not be a factor used to recommend immediate surgery in patients suitable for active surveillance, even if crossover to surgery is predicted within a short period of time.

    Patient summary
    Younger men have better recovery of erectile function after surgery for prostate cancer. This has led to the suggestion that delaying surgery for low-risk disease may lead patients to miss a window of opportunity to recover erectile function postoperatively. We conducted a modeling study and found that predicted erectile recovery was far superior on delayed treatment because slightly better recovery in younger men is offset by a longer period of time living with poorer postoperative function in those choosing immediate surgery.
    [Emphasis mine]

    Erectile Function Recovery After Surgery in Young Men with Low-risk Prostate Cancer: Probably Not Just a Matter of Age, Certainly Not the Main Point of Discussion [2018, Full Text]

    Last edited by DjinTonic; Yesterday at 02:20 PM.


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