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Thread: (F) Treatment Decisions Comparisons Trends

  1. #131
    Three Discipline Collaborative Radiation Therapy (3DCRT) Special Debate: I would treat prostate cancer with proton therapy
    [2019, Full Text]


    Three Discipline Collaborative Radiation Therapy (3DCRT) Debate Series

    Radiation Oncology is a highly multidisciplinary medical specialty, drawing significantly from three scientific disciplines — medicine, physics, and biology. As a result, discussion of controversies or changes in practice within radiation oncology involves input from all three disciplines. For this reason, significant effort has been expended recently to foster collaborative, multidisciplinary research in radiation oncology, with substantial demonstrated benefit.1, 2 In light of these results, we endeavor here to adopt this “team‐science” approach to the traditional debates featured in this journal. This article represents the fourth in a series of special debates entitled “Three Discipline Collaborative Radiation Therapy (3DCRT)” in which each debate team will include a radiation oncologist, medical physicist, and radiobiologist. We hope that this format will not only be engaging for the readership but will also foster further collaboration in the science and clinical practice of radiation oncology.

  2. #132
    The increase of stage, grading, and metastases in patients undergoing radical prostatectomy during the last decade
    [2019, Full Text]

    [A German study]



    To investigate changes in clinical data and pathological features of prostatectomy specimens of prostate cancer (PCa) patients in a large tertiary care center over the last 12 years as potential consequence of reduced acceptance of prostate-specific antigen (PSA)-based screening and implementation of active surveillance as a therapeutic option in PCa.

    We retrospectively identified all patients with PCa who underwent radical prostatectomy at our institution between 2004 and 2016 from our clinical database. We reviewed clinical and pathological data including patient age, PSA level, number of positive cores and Gleason score in prostate biopsy, and pathologic N- and T-stage, and Gleason score in radical prostatectomy specimen.

    Data of 5497 consecutive patients were analyzed. Median PSA increased from 7 (IQR 4.8–10.5) to 9 ng/ml (IQR 5.8–16.1; p < 0.001), and median number of positive biopsy cores increased from 3 (IQR 2–5) to 5 (IQR 3–7; p < 0.001). The proportion of patients with Gleason score ≥ 7 in biopsy and prostatectomy specimens increased from 40 to 78% and 49 to 89% (p < 0.001), respectively. The rate of locally advanced (≥ pT3a) and lymph node-positive tumors increased from 28 to 43% and 5 to 16% (p < 0.001), respectively.

    We observed a significant change in clinical and pathological findings in our prostatectomy series with a significantly higher proportion of aggressive and locally advanced PCa in recent years. These findings may be related to a reduced acceptance of PSA-based screening and the use of active surveillance as management strategy and have significant impact on daily patient care.
    [Emphasis mine]

  3. #133
    Radiotherapy with or without androgen deprivation therapy in intermediate risk prostate cancer?
    [2019, Full Text]



    Androgen deprivation therapy (ADT) is beneficial for unfavorable intermediate-risk (IR) prostate cancer patients receiving curative radiotherapy (RT). However, for favorable IR patients the latest NCCN guidelines recommends RT alone. We retrospectively studied treatment patterns and outcomes of patients with IR prostate cancer in our institution over the past two decades.

    Materials and methods
    Three hundred seventy-three IR prostate cancer patients treated with definitive RT between 5/2002–5/2016 were identified in an institutional review board approved database. All patients received conformal RT to the prostate while the vast majority did not receive nodal radiation. ADT was commenced 2 months prior to RT and was continued for 4 months after RT.

    Compared to RT alone, patients receiving combined RT+ ADT had more positive biopsy cores, higher pre-radiation PSA, more IR factors, and were more likely to receive pelvic lymph node radiation. However, there were no differences in failure either biochemical, local or distal, nor on survival between the favorable RT alone and the unfavorable RT+ ADT cohorts, suggesting a beneficial role for ADT. On multivariate analysis, patients 70 years or younger receiving RT alone were at increased risk for biochemical failure during a 6-year follow-up (HR 3.06, P = 0.025). Biochemical relapse free survival in patients ≤70 years who received RT alone was 82.1% vs 94.0% for RT + ADT (P = 0.030). There was no difference for combined treatment modality in patients > 70 years (P = 0.87).

    Men 70 years or younger with favorable IR prostate cancer treated with RT alone to 78 Gy are at increased risk of biochemical failure. Short term ADT should be considered in this cohort of men.
    [Emphasis mine]

  4. #134
    Systemic Treatment of Prostate Cancer in Elderly Patients: Current Role and Safety Considerations of Androgen-Targeting Strategies
    [2019, Review]



    Prostate cancer commonly affects older men, with one out of five patients being diagnosed at 75 years or older. Elderly patients are more likely to have reduced performance and nutritional status, increased comorbidities, polypharmacy, and altered host-dependent pharmacokinetics and pharmacodynamics. Moreover, elderly patients are often underrepresented in clinical trials, mainly because of comorbidities and decline in performance status. The International Society of Geriatric Oncology recommends management of elderly patients according to fitness and personal preference, rather than chronological age. Since androgen signaling has a nodal role in prostate cancer progression, androgen-targeting agents remain the mainstay of systemic therapy for this disease. However, the potential benefit of these treatments may be compromised by toxicity, especially in elderly patients. Hence, management decisions require evidence-based consideration of both potential benefits and risks on an individualized basis. Furthermore, especially elderly patients should undergo geriatric screening and must be actively monitored during treatment to detect adverse events early and prevent complications. A personalized and vigilant approach could provide the elderly patient with the optimal benefits of existing and emerging prostate cancer treatments, while sparing them the risks of excessive toxicity and avoiding overtreatment.

  5. #135
    Updated recommendations of the International Society of Geriatric Oncology on prostate cancer management in older patients



    • Treatment should be based on health status evaluation and not on chronological age.
    • Patients with impairment may benefit from a comprehensive geriatric assessment.
    • Geriatric interventions are likely to facilitate a more appropriate and effective treatment plan.
    • Screening for cognitive impairment is important to make treatment decisions.
    • Introduction of palliative care should be made early in cases of metastatic disease.


    The median age of prostate cancer diagnosis is 66 years, and the median age of men who die of the disease is eighty years. The public health impact of prostate cancer is already substantial and, given the rapidly ageing world population, can only increase. In this context, the International Society of Geriatric Oncology (SIOG) Task Forces have, since 2010, been developing guidelines for the management of senior adults with prostate cancer.

    Material and methods
    Since prostate cancer and geriatric oncology are both rapidly evolving fields, a new multidisciplinary Task Force was formed in 2018 to update SIOG recommendations, principally on health status screening tools and treatment. The task force reviewed pertinent articles published between June 2016 and June 2018 and abstracts from European Association of Urology (EAU), European Society for Medical Oncology (ESMO), American Society of Clinical Oncology (ASCO) and American Society of Clinical Oncology Genito-urinary (ASCO GU) meetings over the same period, using search terms relevant to prostate cancer, the elderly, geriatric evaluation, local treatments and advanced disease. Each member of the group proposed modifications to the previous guidelines. These were collated and circulated. The final manuscript reflects the expert consensus.

    The 2019 consensus is that men aged 75 years and older with prostate cancer should be managed according to their individual health status, and not according to age. Based on available rapid health screening tools, geriatric evaluation and geriatric interventions, the Task Force recommends that patients are classified according to health status into three groups: (1) ‘healthy’ or ‘fit’ patients should have the same treatment options as younger patients; (2) ‘vulnerable’ patients are candidates for geriatric interventions which—if successful—may make it appropriate for them to receive standard treatment and (3) ‘frail’ patients with major impairments who should receive adapted or palliative treatment. The 2019 SIOG Task Force recommendations also discuss prospects and unmet needs for health status evaluation in everyday practice in older patients with prostate cancer.
    (Full Text is not free.)
    Last edited by DjinTonic; 06-14-2019 at 02:05 PM.

  6. #136
    Short-term benefit of neoadjuvant hormone therapy in patients with localized high-risk or limited progressive prostate cancer
    [2019, Full Text]


    Purpose: Radical surgery is the preferred method for local high-risk and limited progressive prostate cancer in the routine clinical setting. However, current guidelines do not recommend neoadjuvant hormone therapy (NHT). Opinions regarding NHT vary among individual clinicians. According to the experience gained at our center, we explored the benefits of NHT for patients with prostate cancer during the perioperative period in this study. Methods: In this retrospective study, we explored the perioperative benefits of NHT among 189 patients with local high-risk or limited progressive prostate cancer who underwent radical prostatectomy and divided them into two groups: the NHT group and the non-NHT group. The NHT regimens were a gonadotropin-releasing hormone (GnRH) agonist alone (3.75/11.25 mg of leuprolide or 3.6/10.8 mg of goserelin acetate), an androgen receptor antagonist (ARA) alone, or a combination of the two. The duration of treatment was <3 months, 3 to 6 months, or >6 months. Results: We found that NHT could reduce the surgery time and intraoperative hemorrhage, thus reducing the difficulty of surgery; NHT could also improve the postoperative recovery of patients. However, it did not reduce the stage of prostate cancer or positive surgical margin rate. Conclusions: Neoadjuvant therapy is optional for some patients. We believe that NHT will improve the overall prognosis of patients as progress continues in the medical field in the future.

  7. #137
    Active Surveillance Versus Radical Prostatectomy in Favorable-risk Localized Prostate Cancer



    Active surveillance (AS) and radical prostatectomy (RP) are both accepted treatments for men with favorable-risk localized prostate cancer (PCa) (ie, clinical tumor category 1-2b, Gleason Grade Group 1-2, and prostate-specific antigen < 20 ng/mL). However, head-to-head studies comparing oncologic outcomes and survival between these 2 treatment strategies are warranted. The objective of this study was to compare the use of prostate cancer treatments and PCa death in men managed on AS and men who underwent immediate RP.

    This was an observational study including 647 men on AS and 647 men treated with RP propensity score matched. We examined the 10-year cumulative incidence of salvage radiotherapy, hormonal therapy, castration-resistant PCa, and PCa death.

    The 10-year curative treatment-free survival for men on AS was 61% (95% confidence interval [CI], 57%-65%). No differences in use of salvage radiotherapy (AS, 2.7%; 95% CI, 1.4%-4.1% vs. RP 5.4%; 95% CI, 3.4%-7.3%), hormonal therapy (AS, 6.9%; 95% CI, 4.4%-9.4% vs. RP, 4.1%; 95% CI, 2.5%-5.6%), developing castration-resistant PCa (AS, 1.7%; 95% CI, 0.5%-2.9% vs. RP, 2.0%; 95% CI, 0.7%-3.4%), or cumulative PCa mortality (AS, 0.4%; 95% CI, 0%-1.0% vs. RP, 0.5%; 95% CI, 0%-1.5%) were observed between the treatment strategies. The main limitation was the non-random allocation to treatment strategy.

    In this observational study on men with favorable-risk localized PCa, we found similar PCa mortality at 10 years between men on AS and men who underwent immediate RP. Moreover, there were no differences in the use of PCa therapies between the groups. Our study supports active surveillance as a treatment strategy for men with favorable-risk localized PCa.

  8. #138
    Post-Treatment Survey on Prostate Cancer Patients: Comparing Brachytherapy and Robot-Assisted Radical Prostatectomy


    We have treated over 3200 patients at our institute using permanent seed implantation brachytherapy (BT) since September 2003. Although BT is often accompanied by postoperative irritative urinary symptoms such as frequent urination, its major adverse events are rare and generally a good post-treatment quality of life (QOL). Over 400 patients were treated with Robot-assisted radical prostatectomy (RARP) at our institution since its introduction in October 2013. In comparison with the conventional open surgery, RARP is distinguished by faster recovery from postoperative urinary incontinence and preserves sexual function, leading to better a postoperative QOL.

    Quality of Life after Prostate Cancer Treatment Comparison between Robot Assisted Radical Prostatectomy and Brachytherapy [2019]


    Health-related quality of life (HRQOL) after the treatment must be one of the most important factor for the prostate cancer (PCa) patients for deciding treatment options. Objective of this study is to compare HRQOL of patients who underwent mono treatment of permanent seed implant brachytherapy (BT alone) or robot assisted radical prostatectomy (RARP) as their initial curative treatment.


    This study revealed that advantages of BT are lower incidence of urinary and sexual dysfunction compared with RARP. However, urinary irritation, obstruction, and bowel symptoms of BT were worse than RARP right after the treatment, but they gradually recovered and became almost equal before 36-month.

  9. #139
    NICE guidelines on prostate cancer 2019
    [2019, Editorial]


    The much‐anticipated National Institute for Health and Care Excellence (NICE) Guidelines are finally published 1 after a period of consultation when they were in the draft phase. These are updated from the previous 2008 and 2014 versions and reflect the changes in our knowledge and practice over the last 10 years. While there are many similarities, the astute reader will find distinct differences from the AUA Guidelines, which feature in a summary booklet released at the #AUA19 meeting in Chicago this spring.

    NICE does not comment on screening for prostate cancer so many of us continue to rely on our Guideline of Guidelines 2, which make pragmatic recommendations such as smart screening in well‐informed men who are at higher risk because of their family history. For staging, bone scan has not been replaced by prostate‐specific membrane antigen (PSMA)‐positron‐emission tomography/CT, and Lu‐PSMA theranostics is yet to become an option in castrate‐resistant disease as the international trials are not mature.

    Multiparametric MRI before prostate biopsy in men suitable for radical treatment is a new addition, based on the PROMIS 3 and PRECISION trials 1. This approach is thought to be cost‐effective through reducing the number of biopsies and side effects despite the initial added cost of MRI scanning. In Grade Group 1 and some low‐volume Grade Group 2 cancers, protocol‐based active surveillance is recommended provided the patients are well counselled and it has been discussed by a multidisciplinary team.

    To reduce variations in active surveillance, Prostate Cancer UK has carefully examined eight different guidelines and published a consensus statement for the benefit of our patients 4. We have already promoted this widely on social media and hope that our readers will use this practical tool in their clinics. We often find that some patients just cannot live with a cancer inside their body and seek surgery as a result, however small their tumour. Careful discussion about management options and their risks vs benefits 1 can help patients arrive at a pragmatic decision. The effect of a cancer diagnosis on patients’ minds should therefore not be underestimated and a trained psychologist should be available for appropriate counselling.

    NICE also recommends hypofractionated intensity‐modulated radiotherapy, if appropriate, in combination with androgen deprivation therapy (ADT) for localized disease, and methods of decreasing the side effects while increasing accuracy of radiation. As in 2014, robot‐assisted radical prostatectomy remains a surgical option in centres performing at least 150 of these procedures per year 1. These numbers are similar to those published from other health services such as Canada. One such very high‐volume centre is the Martini Clinic which has reported its comparison of open and robot‐assisted radical prostatectomy in >10 000 patients. The oncological and functional outcomes are no different, open surgery is quicker and there is less blood loss and shorter time to catheter removal after robotic surgery. Just like the randomized trial of the two techniques, this large series highlights that surgeon experience rather than the technique is more important for clinical outcomes 5. Finally, based on the STAMPEDE results, docetaxel is recommended for metastasis in addition to ADT and can be considered for high‐risk patients receiving ADT and radiotherapy6. NICE has also identified a number of important research questions which we hope will be answered by ongoing studies in coming years.

    NICE Guidance – Prostate cancer: diagnosis and management [2019, Full Text]


    This guideline covers the diagnosis and management of prostate cancer in secondary care, including information on the best way to diagnose and identify different stages of the disease, and how to manage adverse effects of treatment. It also includes recommendations on follow‐up in primary care for people diagnosed with prostate cancer.

    Who is it for?
    • Healthcare professionals
    • Commissioners and providers of prostate cancer services
    • People with prostate cancer, their families and carers
    • Recommendations
    • People have the right to be involved in discussions and make informed decisions about their care, as described in your care (https://www.nice.org.uk/about/nice-c...bout-your-care).

    Making decisions using NICE guidelines (http://www.nice.org.uk/about/what-we...make-decisions) explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‐label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
    (See Full Text.)

  10. #140
    Prevalence and predictors of probable depression in prostate cancer survivors



    The early diagnosis and treatment of depression are cancer care priorities. These priorities are critical for prostate cancer survivors because men rarely seek mental health care. However, little is known about the epidemiology of depression in this patient population. The goal of this study was to describe the prevalence and predictors of probable depression in prostate cancer survivors.

    The data were from a population-based cohort of North Carolinian prostate cancer survivors who were enrolled from 2004 to 2007 in the North Carolina-Louisiana Prostate Cancer Project (n = 1031) and were prospectively followed annually from 2008 to 2011 in the Health Care Access and Prostate Cancer Treatment in North Carolina study (n = 805). Generalized estimating equations were used to evaluate an indicator of probable depression (Short Form 12 mental composite score ≤48.9; measured at enrollment and during the annual follow-up) as a function of individual-level characteristics within the longitudinal data set.

    The prevalence of probable depression fell from 38% in the year of the cancer diagnosis to 20% 6 to 7 years later. Risk factors for probable depression throughout the study were African American race, unemployment, low annual income, younger age, recency of cancer diagnosis, past depression, comorbidities, treatment decisional regret, and nonadherence to exercise recommendations.

    Depression is a major challenge for prostate cancer survivors, particularly in the first 5 years after the cancer diagnosis. To the authors' knowledge, this is the first study to demonstrate an association between treatment decisional regret and probable depression.


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