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Thread: (F) Treatment Decisions – Comparisons – Trends

  1. #101
    Robot or radiation? A qualitative study of the decision support needs of men with localised prostate cancer choosing between robotic prostatectomy and radiotherapy treatment


    • Treatment choice is primarily influenced by clinicians’ (mainly urologists’) advice.
    • Most patients preferred robotic prostatectomy before seeing a radiation oncologist.
    • Patients valued seeing both a urologist and radiation oncologist.
    • Patients need information about all treatments earlier in treatment decision-making.


    To understand how best to support men diagnosed with localised prostate cancer to decide which treatment option best suits their needs, when robotic prostatectomy and radiotherapy are equally appropriate to offer them.

    Twenty-five men recently diagnosed with localised prostate cancer completed semi-structured interviews asking about information/decision-making needs before and/or after attending a combined clinic in which they consulted a urologist and a radiation oncologist regarding treatment options. Data was transcribed verbatim and thematically analysed.

    Most men preferred robotic prostatectomy pre-combined clinic and chose it afterwards. The thematic analysis revealed four themes: 1) trust in clinicians and the information they provide is critical for treatment choice, 2) perceived fit between treatment characteristics and personal circumstances, 3) additional considerations: specific side effects, socio-emotional and financial factors, and 4) need for tailored information delivery. Robotic prostatectomy was mistakenly believed to provide a more definitive cure than radiotherapy, which was seen as having a lesser lifestyle impact.

    Treatment choice is largely dependent on clinicians’ (mainly urologists’) recommendations.

    Practice implications
    Patients need more balanced information about alternatives to robotic prostatectomy earlier in the treatment decision-making process. Referral to a radiation oncologist or combined clinic shortly after diagnosis is recommended.

  2. #102
    The European Prostate Cancer Centres of Excellence: A Novel Proposal from the European Association of Urology Prostate Cancer Centre Consensus Meeting


    (For our European brothers.)


    High-quality management of prostate cancer is needed in the fields of clinics, research, and education.

    The objective of this project was to develop the concept of “European Prostate Cancer Centres of Excellence” (EPCCE), with the specific aim of identifying European centres characterised by high-quality cancer care, research, and education.

    Design, setting, and participants
    A task force of experts aimed at identifying the general criteria to define the EPCCE. Discussion took place in conference calls and by e-mail from March 2017 to November 2017, and the final consensus meeting named “European Association of Urology (EAU) Prostate Cancer Centre Consensus Meeting” was held in Barcelona on November 16, 2017.

    Outcome measurements and statistical analysis
    The required criteria were grouped into three main steps: (1) clinics, (2) research, and (3) education. A quality control approach for the three steps was defined.

    Results and limitations
    The definition of EPCCE consisted of the following steps: (1) clinical step—five items were identified and classified as core team, associated services, multidisciplinary approach, diagnostic pathway, and therapeutic pathway; (2) research step—internal monitoring of outcomes was required; clinical data had to be collected through a prespecified database, clinical outcomes had to be periodically assessed, and prospective trials had to be conducted; (3) educational step—it consists of structured fellowship programmes of 1 yr, including 6 mo of research and 6 mo of clinics; and (4) quality assurance and quality control procedures, related to the quality assessment of the previous three steps. A limitation of this project was that the definition of standards and items was mainly based on a consensus among experts rather than being an evidence-based process.

    The EAU Prostate Cancer Centre Consensus Meeting defined the criteria for the identification of the EPCCE in the fields of clinics, research, and education. The inclusion of a quality control approach represents the novelty that supports the excellence of these centres.

    Patient summary
    A task force of experts defined the criteria for the identification of European Prostate Cancer Centres of Excellence, in order to certify the high-quality centres for prostate cancer management.

  3. #103
    What Patients and Partners Want in Interventions That Support Sexual Recovery After Prostate Cancer Treatment: An Exploratory Convergent Mixed Methods Study
    [2019, Full Text]



    Men treated for prostate cancer suffer from treatment-related sexual side effects that adversely affect their relationships and quality of life.

    To investigate what prostate cancer survivors and their partners want from a sexual recovery intervention, and whether they consider an online tool acceptable for use in promoting sexual recovery.

    This mixed-methods study included focus groups and interviews with both heterosexual and gay cancer survivors, as well as their partners. Focus groups and interviews probed experiences with treatment, side effects, and support received/needed for sexual recovery. Participants responded to proposed web-based intervention content. Interviews were analyzed with thematic content analysis. Their sexual function was assessed with validated measures.

    Main Outcome Measures
    Acceptability of online tools for promoting sexual recovery was evaluated.

    Participants included 14 patients and 10 partners (2 male). Patient and partner median age was 62 and 62.5 years, respectively. Treatment ranged from surgery alone to combined radiation and hormonal therapy. Qualitative data analysis yielded 5 main intervention needs: (i) pretreatment discussion of sexual side effects, rehabilitation, emotional impact and realistic expectations, (ii) improved sexual communication within couples, (iii) strategies for promoting sexual intimacy beyond penetrative intercourse, (iv) attentiveness to partners' needs, and (v) access to peer support. Gay men specifically expressed the need for improved provider understanding of their sexuality and experiences. Most considered a web-based approach to be acceptable.

    Patients and partners value both pretreatment preparation for sexual recovery and support for sexual recovery for both after treatment. A web-based approach may help mitigate barriers to access to these support services.

  4. #104
    Oncological control in high-risk prostate cancer after radical prostatectomy and salvage radiotherapy compared to radiotherapy plus primary hormone therapy

    [Paper is in Spanish]



    In patients with high-risk localized prostate cancer (HRPCa), multimodal treatment plays a fundamental role.

    To compare relapse-free survival (RFS) in patients with HRPCa, treated primarily with radiotherapy (RT)+hormone therapy (HT) versus radical prostatectomy (RP) and salvage RT (sRT)±HT when biochemical recurrence (BCR) appears.

    Retrospective analysis of 226 patients with HRPCa (1996-2008 ), treated primarily with RT+HT (n=137) or RP (n=89). The Kaplan-Meier method has been used to evaluate survival and the log-rank test has been used to evaluate the contrast between the different categories of the variables. Multivariate analysis has been performed using Cox regression to determine variables with an impact on RFS with statistical significance (P<0.05).

    The median follow-up of the series was 111 (IQR 85-137.5) months. After RT+HT, 32 (23.4%) patients relapsed, and after RP (P=0.0001), 41 (46.1%) cases. When comparing the primary treatments, the RFS at 5 and 10 years was higher after RT+HT versus RP in monotherapy (P=0.001). The primary treatment with RT+HT reduced the risk of BCR when compared to the RP (HR=0.41, P=0.002). The estimation of the RFS at 5 and 10 years after RP+sRT±HT was 89.7 and 87.1%, while after primary RT+HT was 91.6 and 71.1%, respectively (P=0.01). The only factor that behaved as an independent predictor of RFS was the multimodal treatment with RP+sRT±HT when BCR showed up (HR=2.39, P=0.01).

    In HRPCa, multimodal treatment with RP+sRT±HT if BCR, significantly improves RFS with respect to treatment with RT+HT.

  5. #105
    Is external beam radiotherapy for prostate cancer a risk factor for bladder or rectal cancer?


    Introduction & Objectives: Local prostate cancer is often treated by external beam radiotherapy (ERBT). In this study we intended to find whether this therapy is associated with an increased risk of bladder or rectal cancer in comparison to operated patients.
    Materials & Methods: 2537 patients with prostate cancer were treated by either radical prostatectomy (372) or ERBT (2165) in our institute from 1992-2016. All cases of bladder and rectal cancer developing after treatment of prostate cancer in these patients were extracted from the national cancer registry.
    Results: During follow up 36 patients (1.4%) were diagnosed with bladder cancer and 7 (0.3%) with rectal cancer. Mean time from prostate cancer therapy to diagnosis of the secondary malignancy was 40.1 months (S.D. 57.8 ). After EBRT 36 patients (1.7%) developed cancer; 30 in the bladder and 6 in the rectum (6 patients). After surgery 7 (1.9%) developed cancer in the bladder (six patients) and one patient in the rectum. NIH SEER stage was non-invasive in 17 patients (15 post ERBT, 2 post RP) and 26 were invasive (21 post ERBT 5 post RP). Data regarding tumor grade was available in 36 patients including: 16 high-grade tumors (13 post ERBT, 3 post RP) and 20 low-grade. There was no significant difference in tumor incidence, grade or stage between operated and irradiated patients. Secondary cancer incidence was also compared excluding the first 5 years after initial treatment (to exclude a presumed latency period of 5 years). Again, no significant difference between groups. Additionally, Kaplan-Meier survival curves for secondary cancers failed to exhibit a difference between the groups (Long Rank >0.843).
    Conclusions: The incidence of secondary bladder and rectal tumors following ERBT or radical surgery for prostate cancer is similar. Therefore, secondary tumors weight should not be a factor when choosing treatment option.

    High detection rate of colorectal cancer in scheduled serial total colonoscopy screening after radiation therapy for prostate cancer [2019]


    Introduction & Objectives: Radiation therapy (RT), including external beam radiation therapy (EBRT) and brachytherapy (BT), reportedly have survival outcomes similar to surgery for men with localized prostate cancer. However, some studies suggest that pelvic RT produces a significant risk of secondary colorectal cancer (CRC). Stool-based screening for CRC, however, is difficult owing to rectal bleeding after RT to the prostate. For early and efficient detection of secondary CRC, scheduled serial total colonoscopy (TCS) has been introduced with the help of regional hospitals and clinics since 2013. We report incidence and characteristics of secondary CRCs detected by scheduled serial TCS.
    Materials & Methods: From February 2013 to January 2018. 279 men who underwent EBRT or low-dose BT were advised to receive scheduled TCS screening annually or biannually. Results of their TCS screening were collected from medical records. We evaluated incidence and characteristics of CRC, and radiation proctitis, which was graded according to the RTOG/EORTC radiation morbidity scoring scheme.
    Results: Their median follow-up was 44 months. Of the 279 men, 65 received three-dimensional conformal RT, 205 received intensity-modulated RT, and 9 had BT; 21 patients (7.5%) underwent EBRT as a salvage RT for recurrent prostate cancer after radical prostatectomy. Of the 279 patients, 249 (89%), 136 (49%), and 46 (16%) received first, second, and third screening TCS at a median of 14.1, 30.9, and 42.9 months after RT, respectively. Asymptomatic and symptomatic (grade 1 and over) radiation proctitis was found in 64 (23%) and 61 (22%) patients, respectively. Thirteen patients (4.7%) needed endoscopic hemostasis. Thirteen patients (4.7%) were diagnosed with CRC, including three submucosal invasive cancers, during the follow-up period and incident rate was 1.22% (95% CI: 0.56–1.89), which was higher than the standardized incident rate for 60–85-year-old Japanese men (0.45%).
    Conclusions: Scheduled serial TCS showed a high incidence of CRC, most of which was intramucosal early-stage disease. The results suggest an association between pelvic RT and secondary CRC, and the utility of scheduled serial TCS to screen for early-stage CRC after RT for prostate cancer.
    Note that the first study looked at EBRT alone, not with BT.

  6. #106
    Multidisciplinary Care in High-Risk Prostate Cancer Is the New Standard of Care
    [2019, Editorial]


    Approximately 10% to 15% of patients with newly diagnosed prostate cancer have high-risk disease, and up to 50% of this population treated with current standard of care, that is, either radiation therapy (RT) with androgen deprivation therapy (ADT) or radical prostatectomy (RP) with or without planned adjuvant therapy, are at risk for death as a result of the disease.1,2 Poorer outcomes are reflected in the failure of these therapeutic approaches to control both local and systemic disease.

  7. #107
    Proton versus photon-based radiation therapy for prostate cancer: emerging evidence and considerations in the era of value-based cancer care



    Advances in radiation technology have transformed treatment options for patients with localized prostate cancer. The evolution of three-dimensional conformal radiation therapy and intensity-modulated radiation therapy (IMRT) have allowed physicians to spare surrounding normal organs and reduce adverse effects. The introduction of proton beam technology and its physical advantage of depositing its energy in tissue at the end-of-range maximum may potentially spare critical organs such as the bladder and rectum in prostate cancer patients. Data thus far are limited to large, observational studies that have not yet demonstrated a definite benefit of protons over conventional treatment with IMRT. The cost of proton beam treatment adds to the controversy within the field.

    We performed an extensive literature review for all proton treatment-related prostate cancer studies. We discuss the history of proton beam technology, as well as its role in the treatment of prostate cancer, associated controversies, novel technology trends, a discussion of cost-effectiveness, and an overview of the ongoing modern large prospective studies that aim to resolve the debate between protons and photons for prostate cancer.

    Present data have demonstrated that proton beam therapy is safe and effective compared with the standard treatment options for prostate cancer. While dosimetric studies suggest lower whole-body radiation dose and a theoretically higher relative biological effectiveness in prostate cancer compared with photons, no studies have demonstrated a clear benefit with protons.

    Evolving trends in proton treatment delivery and proton center business models are helping to reduce costs. Introduction of existing technology into proton delivery allows further control of organ motion and addressing organs-at-risk. Finally, the much-awaited contemporary studies comparing photon with proton-based treatments, with primary endpoints of patient-reported quality-of-life, will help us understand the differences between proton and photon-based treatments for prostate cancer in the modern era.

  8. #108
    Triple treatment of high-risk prostate cancer. A matched cohort study with up to 19 years follow-up comparing survival outcomes after triple treatment and treatment with hormones and radiotherap
    y [2019]



    To evaluate the efficacy of a triple treatment strategy, including surgery, on high risk prostate cancer comparing long-term survival outcome with a cohort receiving standard radiotherapy with endocrine therapy.

    This study compared two cohorts in survival outcomes, matched on the year of diagnosis and age. In both groups there was a curative intention to treat localized high-risk prostate cancer (one or more of Gleason score 8-10, PSA 20-50 or stage T3), diagnosed between 1995-2010, follow-up at the end of 2014. Triple treatment group: 153 patients treated primarily with radical prostatectomy with neoadjuvant endocrine treatment, and a majority with adjuvant radiotherapy. Standard radiotherapy group: 702 patients with a treatment of either external radiotherapy or high dose brachytherapy combined with external beam therapy, both modalities in combination with neoadjuvant endocrine therapy.

    The prostate-cancer-specific mortality was 10% for the triple treatment group and 15% for the standard radiotherapy group during the period, HR = 2.01 (1.17-3.43), p = 0.011. The corresponding overall mortality was 26% vs 29%, HR = 1.54 (1.09-2.17), p = 0.015. High Gleason score was the dominating risk factor for early death due to the disease. Clinical T-stage was not an independent risk factor for death in this population.

    Adding surgery in a multimodal treatment model in high-risk prostate cancer showed significantly better survival outcome compared with the current standard of radiotherapy. Surgery in this group is, therefore, compelling and that also includes a clinical T3-stage of the disease. The study is limited by possible selection bias for the two treatment models.

  9. #109
    'I'm not a chance taker': A mixed methods exploration of factors affecting prostate cancer treatment decision-making



    African American prostate cancer survivors experience post-treatment decisional regret more often than European Americans, which can lead to negative long-term effects on quality of life. A prominent driver of health-related decision-making is emotion, yet little work has examined the impact emotions may have on decisional regret. The goal of this study was to explore experiences, perceptions, and emotions of prostate cancer survivors in relation to their diagnostic and treatment decision-making processes, prostate cancer treatment, and outcomes. Additionally, we sought to identify factors that might explain differences in prostate cancer outcomes between African and European Americans.

    This mixed-methods study utilized a convergent parallel design, in which quantitative and qualitative data were collected simultaneously and then integrated to more robustly explain relationships between variables. Survivors were eligible for the study if they had been previously diagnosed with localized prostate cancer and were no more than six months post-treatment. The study was guided by the Risk as Feelings Model, which predicts the relationship between emotion and cognition in high-risk decision-making.

    No men experienced decisional regret following treatment, even if they experienced side effects. While all men reported being surprised about their prostate cancer diagnosis, strong negative emotions were more common among men under 65. Family support and spirituality appeared to mitigate negative emotions. Perceived authenticity of provider communication was the most influential mediator in men's decision-making and positive perceptions of their outcomes.

    To mitigate the impact emotional responses have on decision-making and post-treatment regret, providers should explore alternate therapies (e.g. counseling for men diagnosed with prostate cancer at a young age) and include family members in prostate cancer treatment discussions. Most importantly, providers should be aware of the importance of quality communication on men's cognitive and emotional processes and their perceptions of treatment outcomes.

  10. #110
    Effects of androgen deprivation therapy duration and Gleason grade on survival outcomes of high risk prostate cancer
    [2019, Editorial, Full Text]



    Prostate cancer (PCa) is the most frequently diagnosed malignancy in men worldwide. There are various types of
    PCa treatments like as surgery, radiotherapy, and hormone therapy. Many PCa patients receive androgen deprivation therapy (ADT) based on the hormone dependence of PCa. Recently, several studies have been conducted to establish the relationship between ADT and various complications (e.g., cardiovascular disease, stroke, Alzheimer’s disease, and osteoporosis). Most of them have reported a correlation between ADT and these complications, leading to an interest in proper duration of ADT. Consequently, several trials have been conducted to confirm this.
    Kishan et al. (1) focused on identifying the difference in association of ADT duration with clinical outcomes of patients with Gleason grade group (GG) 4 (formerly Gleason score 8 ) vs. GG 5 (formerly Gleason score 9–10) disease. Meta-analysis using individual patient-level data of 6 randomized clinical trials was done to compare the different treatment methods [RT alone, lifelong ADT, short term ADT (STADT), and long-term ADT (LTADT)]. The hypothesis of the study indicated that longer durations of ADT offered significant survival chances in both groups (GG 4 and 5).
    The objective of the meta-analysis was to consolidate the results of several similar studies to verify the validity of the conclusions and to enhance evidence in actual practice or to make a substantial change in practice. Network meta-analyses combine a networks of direct and indirect comparisons of interventions which allows researchers to simultaneously evaluate the impact of two or more interventions on the same condition (2). The term “individual patient data” refers to the data recorded for each participant in a study. Meta-analysis of individual participant data has potential statistical and clinical advantages over meta-analysis of aggregate data such as: (I) more standardization of analyses across studies; (II) direct induction of desired information; (III) a longer follow-up time; and (IV) more participants and outcomes than were considered in the original study publication (3).


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