Prostate Cancer

The American Cancer Society (ACS) has issued a “National Blueprint for Action,” describing a multifaceted set of proposals aimed at overcoming the disproportionate incidence of prostate cancer in African-American men.

CHICAGO-At California’s Loma Linda University, physicians have treated 1,800 patients with early-stage or locally advanced prostate cancer with proton beam radiation therapy using a synchrotron accelerator.

The review article by Forman and Velasco represents a concise, up-to-date summary of current knowledge on the use of therapeutic radiation in patients with a rising post-prostatectomy prostate-specific antigen (PSA). The conclusions reached by the authors are reasonable but conservative. In my opinion, a bit too conservative.

Drs. Forman and Velasco provide a timely and thorough review of the maturing concept of applying radiation therapy to the prostatic fossa after radical prostatectomy. The guidelines for therapy continue to evolve because of the increasing reliance on blood prostate-specific antigen (PSA) level for both detecting a recurrence of disease and evaluating response to radiotherapy.

I agree with Drs. Forman and Velasco that the optimal management of patients with an elevated prostate-specific antigen (PSA) level after prostatectomy remains to be determined. The broader issue, however, is optimizing the management of post-prostatectomy patients who are at risk for recurrence. Hence, the dilemma: Should we wait for a chemically apparent recurrence before instituting treatment? Or, should we, on the basis of available information, quantify the risk of recurrence and the possible side effects of therapy and determine whether or not adjuvant radiotherapy is warranted based on the risk/benefit ratio?

The optimal management of patients with an elevated post-prostatectomy prostate-specific antigen (PSA) level remains to be determined. In the pre-PSA era, many patients received immediate adjuvant radiation therapy on

New treatments announced at the 1997 Endocrine Society Annual Meeting could help slow the rate of prostate cancer growth and improve the quality of life of those who have the disease.

The value of screening for prostate cancer, the second most common cancer in men, has been fiercely debated in recent years, but Professor Bolla from the Department of Radiotherapy, Centre Hospitalier de Grenoble, France, has no doubt that early detection is of prime importance in the treatment of prostate cancer.

Researchers have found preliminary evidence suggesting that a man’s lifetime risk of prostate cancer may be linked to the amount of testosterone circulating in his body as early as puberty or even in utero, although direct evidence of this link

ORLANDO-Permanent trans-peritoneal ultrasound-guided radioactive implants (brachytherapy) get high marks for quality of life (QOL) in men with clinically localized prostate cancer, V. Elayne Arterbery, MD, reported in a poster session at the annual meeting of the American Society of Therapeutic Radiology and Oncology (ASTRO).

NEEDHAM, Mass-UroMed Corporation has received FDA clearance for marketing of its nerve-locating product, the CaverMap Surgical Aid. The device is intended to guide surgeons during radical prostatectomy in mapping and ultimately sparing the cavernous nerves responsible for potency.

Professor Michel Bolla of the Department of Radiotherapy, Centre Hospitalier de Grenoble, France, commented on new

HAMBURG-Patients with poor-prognosis M1 prostate cancer who undergo orchidectomy have little to gain and much to lose from adjuvant mitomycin (Mutamycin) therapy, according to the findings of a phase III study from the EORTC’s Genitourinary Tract Cancer Cooperative Group.

In Session I of the First Sonoma Conference on Prostate Cancer, a critical concern in prostate cancer management was addressed: improving the pretreatment prediction of patients’ outcomes in localized prostate cancer.

Using a series of 421 patients with localized prostate cancer who were treated with radiation, six predictive models were analyzed to determine which model correlates most closely to actual clinical outcome data in regard to biochemical freedom from failure. Multivariate analysis was performed using the following covariates: prostate specific antigen; Gleason score; stage; dose; PSA density; and perineural invasion. Initially, the Pisansky model appeared to be the most predictive.

A Scandinavian study challenges the efficacy of endocrine treatment alone, compared to endocrine treatment plus radiotherapy for the treatment of locally advanced prostate cancer. All patients in the study receive neoadjuvant total androgen blockade for 3 months and then continue with antiandrogens alone. After 3 months, radiotherapy will be started in one arm of the study. The primary end point of the study is survival, with secondary end points of prostate-specific antigen (PSA) progression, clinical progression, and quality of life. [Oncol News Int 6(Suppl 3):18-19, 1997]

To investigate the potential use of adjuvant hormonal therapy, a randomized, prospective trial was conducted among patients with locally advanced prostate cancer, comparing irradiation alone, with irradiation plus hormonal treatment with goserelin, an agonist anologue of gonadotropin-releasing hormone that reduces testosterone secretion. A total of 415 men under 80 years old with locally advanced disease and no previous treatment for prostate cancer were initially recruited, with data available for analysis on 401 of these patients. Preliminary results at 33-months’ follow-up suggested that goserelin started at the onset of external irradiation improved both local control and 5-year survival. Updated results at 45 months confirm these data. The overall 5-year survival rate for those treated with goserelin in addition to radiotherapy was 79%, compared to 62% in the radiotherapy only group. The localized control rate was 97% in the combined treatment group compared to 77% in the radiotherapy only group. [Oncol News Int 6(Suppl 3):21-22, 1997]

The outcome of 500 patients treated solely with irradiation for clinical stages T1-T4, N0, M0 prostatic carcinoma was used to develop an enhanced prognostic system for patients with clinically localized prostatic cancer. Clinical tumor stage, Gleason score, and pretherapy prostate-specific antigen (PSA) were independently associated with clinical or biochemical relapse and included in a risk score equation that defined patient groups with distinctly different outcomes. [Oncol News Int 6(Suppl 3):8-9, 1997]

Outcomes beyond tumor response and patient survival have increasingly gained in importance over the past two decades. Quality of life (QOL) and cost-effectiveness of therapy have emerged as additional end points of interest. Conflicting results can and have been reported, however, depending on the measures used to report QOL and cost-effectiveness. Examples of QOL and cost-effectiveness issues and measures related to androgen deprivation therapy (ADT) for prostate cancer follow. [Oncol News Int 6(Suppl 3):22-24, 1997]

The single most significant predictor of the inability of radiotherapy to prevent biochemical failure is the pretreatment PSA level. Palpable stage and Gleason score are also important pretreatment prognostic factors and have been combined with PSA to construct a model to predict treatment outcome.

Three equations have been formulated to estimate the risk that men treated for clinically localized prostate cancer have extracapsular extension, lymph node involvement, and non-organ confined disease. The equation for extracapsular extension risk is based on pretreatment prostate-specific antigen (PSA) and Gleason scores.

Reverse-transcriptase polymerase chain reaction (PCR) technology can detect small numbers of cells expressing prostate-specific antigen (PSA), even when these cells are extensively diluted in a population of non-PSA expressing cells. The assay was applied to a cohort of more than 200 patients who were candidates for radical prostatectomy based on diagnostic tests that predicted that the prostate cancer was localized to the prostate gland. In this group, a positive RT-PCR test correlated significantly with early metastatic spread of prostate cancer. [Oncol News Int 6(Suppl 3):11-12, 1997]

A total of 186 randomly selected needle biopsies were evaluated and radical prostatectomy samples were matched with preoperative PSA concentration and patient demographics. Gleason score and optimized microvessel density were determined from the needle biopsy samples; pathologic stage was verified by independent review of the prostatectomy samples. An automated digital image analysis system measured microvessel morphology and calculated the optimized microvessel density in biopsies. Using this system in combination with the Gleason score and serum PSA significantly increases the ability to predict extraprostatic extension of cancer preoperatively. [Oncol News Int 6(Suppl 3):13-14, 1997]

Information from pathologic stage and pretreatment clinical parameters-prostate-specific antigen (PSA), Gleason score, and clinical stage-can be incorporated into a single construct-calculated prostate cancer volume. It is represented by the quotient of the cancer-specific PSA and the PSA measured in serum per cm3 of prostate cancer of a given Gleason score, where cancer-specific PSA is defined as PSA corrected for the PSA contributed by benign prostatic epithelial cells.

Data from three academic institutions were used to develop a model to predict pathologic stage in a group of men with clinically localized prostate cancer. The model combined serum prostate-specific antigen (PSA) level, clinical stage, and Gleason score. The data were used to generate nomograms that present the probability of a patient having organ-confined cancer, isolated capsular penetration, seminal vesicle involvement, or pelvic lymph node involvement. [Oncol News Int 6(Suppl 3):14-15, 1997]

As health-care costs escalate, health-care planners must determine how the allocation of health-care dollars should be prioritized. One approach is to assess the cost of achieving a quality-adjusted year of life and then allocating the dollars in descending order, from least to most expensive, until all available money has been expended. Of course, calculating the cost per life-year is the real challenge because it is usually determined from mathematical decision models, which include many assumptions that may be subject to criticism.

BOSTON-Between 1984 and 1990, the age-adjusted rate of radical prostatectomy to treat early prostate cancer increased almost sixfold. One reason may be that physicians and patients believed, based on published reports, that newer nerve-sparing procedures gave patients a much greater chance of retaining sexual potency after surgery.

HAMBURG-The Federation of European Cancer Societies released information on prostate cancer in Europe at its biennial European Cancer Conference (ECCO 9).

In October 1996, the FDA approved ProstaScint (capromab pendetide), a new diagnostic imaging agent for prostate cancer, manufactured by Cytogen Corporation, Princeton, NJ.[1-5]

Waselenko and Dawson provide a summary of the extensive experience in the management of metastatic prostate cancer. Their article follows a traditional descriptive format and is quite informative. The part that is missing is a general discussion of the various biological aspects involved in the complex process of prostate cancer progression, which has been the focus of major research over the past few years.[1] Undoubtedly, this emerging body of knowledge will provide the background for the design and development of new treatments. There are a few issues, however, that deserve more emphasis.