THE "NEW" PROSTATE CANCER INFOLINK

This weekend’s news includes items on:

• The ongoing major prostate cancer screening trials
• The changing landscape of first-line management for early stage, low risk prostate cancer
• Outcomes of RALP procedures in which surgical fellows participate
• Hypofractionation procedures in radiotherapeutic treatment
• The current state of sexual rehabilitation post-prostatectomy

The other day, Dubben suggested that attempting to develop trials that will prove (or disprove) the value of screening for prostate cancer in terms of its impact on mortality is simply an impossible task. Now Concato has  suggested that, with two major, ongoing, randomized trials evaluating the association of screening for prostate cancer and mortality, the results from these trials are anticipated as if an “emperor” was about to make a pronouncement. Concato notes, however, that the expectation of a definitive answer from these trials may overlook methodological problems and underestimate the uncertainty inherent in scientific investigations. He also points out that the tendency for personal beliefs (among investigators) to influence the interpretation of data introduces further complexity. Concato believes that, currently, the need to counsel patients regarding the possible benefits and harms that can result from screening for (and treating) prostate cancer remains justified. The “New” Prostate Cancer InfoLink entirely agrees with this belief and also suspects that the results on ongoing screening trials are unlikely to resolve this issue.

In a review of the continuing evolution of the characteristics of newly diagnosed prostate cancer among the US population, Moul et al. present a rationale for the use of  new, noninvasive or minimally invasive management options. They argue that the current prostate cancer patient landscape is an increasingly low risk population who may require reconsideration of treatment options. They propose that — at least for select cohorts of patients with low-risk features, based on the D’Amico definition — active surveillance or focal ablative therapy may be a rational alternative to surgical prostatectomy or whole-gland radiation therapy. They further propose that organ-sparing focal therapy might ideally fill the gap between a surveillance strategy and whole-gland treatment, providing a reasonable balance between cancer control and quality of life. [Note: Dr. Moul is the Chairman of the Scientific Advisory Board of The “New” Prostate Cancer InfoLink.]

Link et al. have published data suggesting that — at least at their institution — they noted no adverse impact of the involvement of surgical fellows in training on surgical outcomes following robot-assisted laparoscopic prostatectomy (RALP). They base this conclusion on a review of the charts of 1,833 patients who underwent RALP at the City of Hope from January 2004 to September 2007. During any one academic year, each fellow in training participated in 300 or more RALPs, with a systematic stepwise approach to learning the operation. No differences were found across quartiles of the academic year for intraoperative or perioperative complications, length of hospital stay, continence rates at 1 year, time to continence, and PSA-free recurrence rates. In the first and third quarters of the academic year, from July to September and from January to March, there were slightly longer operative times — with a mean of 2.9 hours compared with the second and fourth quarter mean of 2.8 hours. The third quarter demonstrated slightly higher estimated blood loss of 280 ml compared with the overall mean of 262 ml.

Ritter et al. have reviewed available data on the use of hypofractionation as a strategic approach to prostate cancer radiotherapy. (Hypofractionation is a process in which the radiotherapist increases the daily dose of radiation and therefore fewer fractions to gtreat the patient.) This procedure was initially carried out in hope of efficiency and convenience but has attracted renewed interest based upon a hypothesis that prostate cancers have a higher sensitivity to total dose fraction size than do late responding organs at risk such as the rectum or the bladder. Ritter et al. argue that the studies completed to date lack sufficient patient numbers and follow-up, are clouded by dose inhomogeneity issues in the case of brachytherapy, or delivered effective doses that were too low by contemporary standards. Based on this argument, they conclude that the clinical efficacy of hypofractionation has yet to be fully validated. However, newer prospective trials, some randomized, are under way or have reached accrual but await sufficient follow-up for analysis. These studies should ultimately be capable of validating the utility of prostate hypofractionation and the models that predict its effects. They note that the future management of localized prostate cancer could be profoundly altered in the process.

Latini et al., in reviewing currently available data on sexual rehabilitation after treatment for localized prostate cancer note that, while many articles have documented the impact of prostate cancer treatment on sexual functioning in men treated for localized disease, the literature on interventions to rehabilitate men’s sexual functioning is much more limited. They review currently used sexual rehabilitation interventions for prostate cancer patients and identify common themes across interventions. They also identify areas where further research is needed and propose a conceptual model based on psychologic and nursing theories and informed by the published research.

Filed under: Living with Prostate Cancer, Management, Risk, Treatment | Tagged: active surveillance, focal therapy, hypofractionation, outcomes, RALP, screening, sexual rehabilitation, training, trials |