Prostate cancer news reports: Thursday, February 18, 2010

Today’s news reports include commentary on studies dealing with:

  • Whether RALP outcomes are really comparable to those from RRP
  • Surgical expertise, surgical caseload, and pelvic lymphadenectomy in treatment of intermediate- and high-risk prostate cancer
  • Sexual function after first-line treatment with SBRT (CyberKnife)
  • Distinguishing true biochemical recurrence from a PSA “bounce” after 125I-based prostate brachytherapy

Kang et al. have carried out a systematic review of published literature on robot-assisted laparoscopic prostatectomy (RALP) compared to radical retropubic prostatectomy (RRP). They identified 75 original research publications which met eligibility criteria. Most of these studies  (55/75, 73.3 percent) were published between 2005 and 2008; 20/75 studies (26.7 percent) were published between 2001 and 2004. Nearly 75 percent of the studies were simple case series and only two randomized, controlled trials were identified. Perhaps of greatest import, just 12 authors co-wrote 54/75 (72 percent) of all the published studies. Kang  et al. conclude that, “The published RALP literature is limited to observational studies of mostly low methodologic quality. Our findings draw into question to what extent valid conclusions about the relative superiority or equivalence of RALP to other surgical approaches can be drawn and whether published outcomes can be generalized to the broader community.” (See also the article in last Saturday’s New York Times by Gina Kolata.)

Eden et al. have published data from their series of 1,269 patients treated with non-robot-assisted laparoscopic radical prostatectomy (LRP) over a period of just over 9 years (starting in 2000). Specifically, this study addresses the roles for extended and standard pelvic lymphadenectomy (ePLND and sPLND) during LRP for patients with intermediate- and high-risk prostate cancer. Based on their experience and data, Eden et al. offer three recommendations: (a) all patients should undergo ePLND if they are being treated with curative intent for intermediate- and high-risk prostate cancer; (b) ePLND should replace sPLND for all such patients; and (c) surgeons performing < 35 cases of RP a year should stop performing RP. There is no evident data in the abstract of their paper to support their final recommendation, but as far as we are aware, this is the first time a leading prostate cancer surgeon has published a report in which (s)he states categorically that surgeons with limited caseloads should no longer try to carry out what is acknowledged to be a complex and difficult procedure.

Wiegner and King have published an early report on sexual function after first-line treatment of localized prostate cancer with stereotactic body radiotherapy (SBRT; aka CyberKnife  radiotherapy). Their study involved just 32 consecutive patients with a median age of 67.5 years whose sexual function was assessed at baseline and then at median times of 4, 12, 20, and 50 months after treatment. No  patient received androgen deprivation therapy, and the use of erectile dysfunction (ED) medications was monitored. The authors acknowledge that this is a small study. Their core findings are that the patients had a baseline ED rate of 38 percent which increased to 71 percent after treatment. Use of ED medications was 3 percent at baseline and progressed to 25 percent . For patients aged < 70 years at follow-up, 60 percent maintained satisfactory erectile function after treatment compared with only 12 percent for the patients aged 70 years or more. They conclude that the rates of ED after SBRT are similar to those reported for other forms of radiation treatment, but that further research is needed to expand on this initial study.

Thompson et al. have analyzed data from their series of 1,006 consecutive low-risk and “low tier” intermediate-risk patients treated with 125I-based prostate brachytherapy and followed for a minimum of 4 years. Their goal was to assess differences between patients who had actual PSA failure (PSAf) as opposed to a PSA bounce (PSAb) after permanent 125I seed implantation. According to their analysis, 57/1,006 patients triggered the Phoenix definition of PSA failure, of whom 32/57 (56 percent) had a true PSAf and 25/57 (44 percent) had only a PSAb. The PSAb patients were significantly younger, had significantly shorter times to reach their PSA nadir, and had shorter PSA doubling times than the men who had true PSAf. The authors also state that, “Men younger than age 70 who trigger nadir + 2 PSA failure within 38 months of implant have an 80% likelihood of having PSAb and 20% chance of PSAf.” Their data certainly appear to suggest that over-reaction to initial, apparent PSA recurrence after prostate brachytherapy may place about 40-50 percent of these patients at risk for unnecessary second-line treatment if they are not carefully followed for an appropriate time period before the application of second-line therapy.

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