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Article of the Month: Patient reported “ever had” and “current” long term physical symptoms following prostate cancer treatments

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Every Month the Editor-in-Chief selects the Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Month heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Anna Gavin discussing his paper. 

If you only have time to read one article this week, it should be this one.

Patient reported “ever had” and “current” long term physical symptoms following prostate cancer treatments.

Anna T. Gavin, Frances J. Drummond*, Conan Donnelly, Eamonn O’Leary*, Linda Sharp† and Heather R. Kinnear

Northern Ireland Cancer Registry, Centre for Public Health, Queen’s University Belfast, Mulhouse Building, Belfast Northern Ireland, UK, *National Cancer Registry Ireland, Building 6800, Airport Business Park Cork, Ireland, and †Institute of Health and Society, Newcastle University, Richardson Road, Newcastle upon Tyne, NE2 4AX, England, UK

 

Read the full article
OBJECTIVE

To investigate the prevalence of physical symptoms that were ‘ever’ and ‘currently’ experienced by survivors of prostate cancer at a population level, to assess burden and thus inform policy to support survivors.

PATIENTS AND METHODS

The study included 3 348 men surviving prostate cancer for 2–18 years after diagnosis. A cross-sectional, postal survey of 6 559 survivors diagnosed 2–18 years ago with primary, invasive prostate cancer (ICD10-C61) identified via national, population-based cancer registries in Northern Ireland and Republic of Ireland. Questions included symptoms at diagnosis, primary treatments and physical symptoms (erectile dysfunction [ED]/urinary incontinence [UI]/bowel problems/breast changes/loss of libido/hot flashes/fatigue) experienced ‘ever’ and at questionnaire completion (‘current’). Symptom proportions were weighted by age, country and time since diagnosis. Bonferroni corrections were applied for multiple comparisons.

RESULTS

Adjusted response rate 54%; 75% reported at least one ‘current’ physical symptom (‘ever’ 90%), with 29% reporting at least three. Prevalence varied by treatment. Overall, 57% reported current ED and this was highest after radical prostatectomy (RP, 76%) followed by external beam radiotherapy with concurrent hormone therapy (HT, 64%). UI (overall ‘current’ 16%) was highest after RP (‘current’ 28%; ‘ever’ 70%). While 42% of brachytherapy patients reported no ‘current’ symptoms, 43% reported ‘current’ ED and 8% ‘current’ UI. ‘Current’ hot flashes (41%), breast changes (18%) and fatigue (28%) were reported more often by patients on HT.

CONCLUSION

Symptoms after prostate cancer treatment are common, often multiple, persist long-term and vary by treatment method. They represent a significant health burden. An estimated 1.6% of men aged >45 years are survivors of prostate cancer and currently experiencing an adverse physical symptom. Recognition and treatment of physical symptoms should be prioritised in patient follow-up. This information should facilitate men and clinicians when deciding about treatment as differences in survival between radical treatments is minimal.

Read more articles of the week

Editorial: Hot topic of cancer survivorship and the ‘seven deadly sins’

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Cancer survivorship has become a hot topic as overall mortality for most cancer patients continues to decrease, the worldwide population continues to age and as patients become more information savvy [1-3]. Gavin et al. [4] provide a data-rich population-based patient survey of seven of the most common physical symptoms after prostate cancer treatment. While we, as urologists and prostate cancer providers, may not be able to recount the seven deadly sins or the seven dwarfs, we do know these seven symptoms: impotence; incontinence; bowel problems; fatigue; hot flushes; loss of libido; and breast symptoms. Urological surgeons and radiation oncologists talk to patients every day about the ‘big three’ of these: impotence, incontinence and bowel problems. Gavin et al. provide the striking statistic that ~1.6% of the male population over the age of 45 years is a prostate cancer survivor currently living with one of the seven.

The paper describes mailed survey results from a population-based cohort of 3 348 prostate cancer survivors 2–15 years after diagnosis with a response rate of 54%. The average age of respondents was 64.9 years, 64% had localized disease at presentation, 65% had Gleason 5–7 disease, and 48, 32 and 20% were surveyed 2–4.9, 5–9.9 and >10 years after diagnosis, respectively. The paper is chock full of descriptive statistics about rates of past and ongoing side effects of the various treatments and essentially has ‘something for everyone’. For example, at baseline before treatment, 51.2% of respondents reported urinary frequency, 18.8% reported impotence and 14.7% reported loss of libido. These data may be useful for estimating population-based general men’s health disease. After treatment, radical prostatectomy (RP) had the highest rates of impotence (76% current) and incontinence (current 28%; ever 70%); however, the authors examined radiation plus hormonal therapy and found impotence rates of 64% and rates of hot flushes, breast changes and bowel problems in the 20–27% range. Table 3 and Figs 3 and 4 in the paper are particularly useful to further examine the seven side effects with treatment.

On the one hand, these data could be useful in educating patients about treatment options for prostate cancer and what they might expect should they choose one treatment over another. Ideally, this education would occur in the multidisciplinary clinic setting [5]. On the other hand, these data could also be used in the wrong way. For example, an aggressive surgeon could selectively present the ‘deadly downsides’ of radiation while downplaying the ‘surgical sins’, whereas a radiation oncologist could do just the opposite to try to influence his or her patients. This highlights the limitations of the present study. While the authors are to be congratulated for a wonderful population-based survey, no control group was surveyed and, more importantly, the authors do not address satisfaction and regret. In other words, the seven side effects must be placed into the patient’s overall satisfaction regarding cancer control and the patient’s ‘trade-offs individualized internal assessment’. For example, our group examined satisfaction and regret after open and robot-assisted RP, finding an ~80–85% satisfaction rate despite levels of impotence and incontinence slightly lower but similar to those in the present population-based survey [6]. While patients who underwent open RP enjoyed more satisfaction and less regret, we attributed much of this to the ‘used car salesman’ approach to ‘selling’ robot-assisted RP in the last decade [7]. In other words, we hypothesized that patients undergoing robot-assisted RP were misled into believing the robot would lessen or eliminate the surgical sins while those undergoing open RP were counselled more realistically. Also, we found that in multivariable analysis, African-American patients exhibited more regret [6]. These data point to the fact that the present study from Ireland may not be applicable to other populations, particularly those with a mixed or different ethnic make-up. Another limitation to population-based data is the impact of centres of excellence and highly experienced treatment providers. The impact of high-volume surgeons/providers on treatment outcomes is now being recognized as a critical variable that is rarely accounted for in case series, multicentre studies or population data as seen here.

Overall, Gavin et al. are to be commended for a very rich source of side effect data for a large population-based cohort of prostate cancer survivors. The ‘seven deadly sins’ of possible side effects/complications of prostate cancer treatment should be shared openly and honestly with our patients. Furthermore, physicians and healthcare systems must be encouraged to collect provider and system-specific data to better fine-tune our pre-treatment counselling that will ultimately improve the satisfaction of our cancer survivors.

Read the full article

Judd W. Moul
Duke Cancer Institute, Durham, NC, USA

 

References

1 Resnick MJ, Lacchetti C, Bergman J et al. Prostate cancer survivorship care guideline: American society of clinical oncology clinical practice guideline endorsement. J Clin Oncol 2015; 33: 1078–85

2 Skolarus TA, Wolf AM, Erb NL et al. American Cancer Society prostate cancer survivorship care guidelines. CA Cancer J Clin 2014; 64: 225–49; Erratum in: CA Cancer J Clin. 2014; 64: 445

3 Gupta S, Peterson AC. Stress urinary incontinence in the prostate cancer survivor. Curr Opin Urol 2014; 24: 395–400

4 Gavin A, Drummond F, Donnelly C, O’Leary E, Sharp L, Kinnear H. Patient reported ‘ever had’ and ‘current’ long-term physical symptoms following prostate cancer treatments. BJU Int 2015.

5 Stewart SB, Ba~nez LL, Robertson CN et al. Utilization trends at a multidisciplinary prostate cancer clinic: initial 5-year experience from the Duke Prostate Center. J Urol 2012; 187: 103–8

6 Schroeck FR, Krupski TL, Sun L et al. Satisfaction and regret after open retropubic or robot-assisted laparoscopic radical prostatectomy. Eur Urol 2008; 54: 785–93

7 Schroeck FR, Krupski TL, Stewart SB et al. Pretreatment expectations of patients undergoing robotic assisted laparoscopic or open retropubic radical prostatectomy. J Urol 2012; 187: 894–8

 

Video: Patient-reported long-term physical symptoms after prostate cancer treatments

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Patient reported “ever had” and “current” long term physical symptoms following prostate cancer treatments.

To investigate the prevalence of physical symptoms that were ‘ever’ and ‘currently’ experienced by survivors of prostate cancer at a population level, to assess burden and thus inform policy to support survivors. The study included 3 348 men surviving prostate cancer for 2-18 years after diagnosis. A cross-sectional, postal survey of 6 559 survivors diagnosed 2-18 years ago with primary, invasive prostate cancer (ICD10-C61) identified via national, population-based cancer registries in Northern Ireland and Republic of Ireland. Questions included symptoms at diagnosis, primary treatments and physical symptoms (erectile dysfunction [ED]/urinary incontinence [UI]/bowel problems/breast changes/loss of libido/hot flashes/fatigue) experienced ‘ever’ and at questionnaire completion (‘current’). Symptom proportions were weighted by age, country and time since diagnosis. Bonferroni corrections were applied for multiple comparisons.

Adjusted response rate 54%; 75% reported at least one ‘current’ physical symptom (‘ever’ 90%), with 29% reporting at least three. Prevalence varied by the diverse treatments found at https://www.ukmeds.co.uk/finasteride. Overall, 57% reported current ED and this was highest after radical prostatectomy (RP, 76%) followed by external beam radiotherapy with concurrent hormone therapy (HT, 64%). UI (overall ‘current’ 16%) was highest after RP (‘current’ 28%; ‘ever’ 70%). While 42% of brachytherapy patients reported no ‘current’ symptoms, 43% reported ‘current’ ED and 8% ‘current’ UI. ‘Current’ hot flashes (41%), breast changes (18%) and fatigue (28%) were reported more often by patients on HT.

Anna T. Gavin, Frances J. Drummond*, Conan Donnelly, Eamonn O’Leary*, Linda Sharp† and Heather R. Kinnear

Northern Ireland Cancer Registry, Centre for Public Health, Queen’s University Belfast, Mulhouse Building, Belfast Northern Ireland, UK, *National Cancer Registry Ireland, Building 6800, Airport Business Park Cork, Ireland, and †Institute of Health and Society, Newcastle University, Richardson Road, Newcastle upon Tyne, NE2 4AX, England, UK

 

Read the full article
OBJECTIVE

To investigate the prevalence of physical symptoms that were ‘ever’ and ‘currently’ experienced by survivors of prostate cancer at a population level, to assess burden and thus inform policy to support survivors.

PATIENTS AND METHODS

The study included 3 348 men surviving prostate cancer for 2–18 years after diagnosis. A cross-sectional, postal survey of 6 559 survivors diagnosed 2–18 years ago with primary, invasive prostate cancer (ICD10-C61) identified via national, population-based cancer registries in Northern Ireland and Republic of Ireland. Questions included symptoms at diagnosis, primary treatments and physical symptoms (erectile dysfunction [ED]/urinary incontinence [UI]/bowel problems/breast changes/loss of libido/hot flashes/fatigue) experienced ‘ever’ and at questionnaire completion (‘current’). Symptom proportions were weighted by age, country and time since diagnosis. Bonferroni corrections were applied for multiple comparisons.

RESULTS

Adjusted response rate 54%; 75% reported at least one ‘current’ physical symptom (‘ever’ 90%), with 29% reporting at least three. Prevalence varied by treatment. Overall, 57% reported current ED and this was highest after radical prostatectomy (RP, 76%) followed by external beam radiotherapy with concurrent hormone therapy (HT, 64%). UI (overall ‘current’ 16%) was highest after RP (‘current’ 28%; ‘ever’ 70%). While 42% of brachytherapy patients reported no ‘current’ symptoms, 43% reported ‘current’ ED and 8% ‘current’ UI. ‘Current’ hot flashes (41%), breast changes (18%) and fatigue (28%) were reported more often by patients on HT.

CONCLUSION

Symptoms after prostate cancer treatment are common, often multiple, persist long-term and vary by treatment method. They represent a significant health burden. An estimated 1.6% of men aged >45 years are survivors of prostate cancer and currently experiencing an adverse physical symptom. Recognition and treatment of physical symptoms should be prioritised in patient follow-up. This information should facilitate men and clinicians when deciding about treatment as differences in survival between radical treatments is minimal.

Read more articles of the week

Clever surgeons and challenging study endpoints

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CaptureIntraoperative in vivo tracking of a periprostatic nerve with multiphoton microscopy in rat model.

In the last 6 months, the BJUI editorial team has evaluated an average of 59 urological oncology papers per month with an average acceptance rate of 16%. We receive additional papers for our ‘Translational Science’ section. Studies with high-quality methods are given the highest priority. Other papers compete well if they are highly applicable to clinical practice (i.e. comparative, multicentre, multi-surgeon design) and/or show us new ideas in surgical technique, re-designed study endpoints, or explore new sources of data. For translational science, the best candidates are studies that look at new diagnostic tests in humans and beyond simple immunostaining techniques. We want to evaluate biomarkers likely to be validated and translated into a clinical test. Clinical impact will be even higher if a biomarker is linked to a therapy outcome rather than just a risk estimate. We want our papers to guide us to better outcomes for our patients, hopefully control healthcare costs, and, yes, be well-cited in the literature.

Our review process is tough but fair, and we congratulate and highlight three authorship groups for acceptance into this month’s issue of BJUI. The theme of ‘clever surgeons and challenging study endpoints’ is well illustrated by all three groups. Zargar et al. [1] report on an exclusive database of high-volume minimally invasive surgeons who have tackled the partial nephrectomy option for small renal masses. The comparison is simple in concept and retrospective in design, but what they have done is to significantly increase the outcome measures into a ‘trifecta’ concept in perioperative outcomes (previously reported) with an even more stringent ‘optimal outcome’ endpoint that includes renal function preservation. With a database of 1185 robotic and 646 laparoscopic cases, the robotic procedures showed superior trifecta results (70% vs 33%), complication rates (14.8% vs 20.9%), positive surgical margin rates (3.2% vs 9.7%), and warm ischaemia time (18 vs 26 min). The optimal outcome endpoint included a minimum 90% estimated GFR (eGFR) preservation and no chronic kidney disease upstaging. Only the robotic cohort had sufficient data available and the rate was 38.5%. The latter figure is an interesting challenge, as defining such a high threshold for success challenges surgical technique and allows more room to identify incremental advancement. This may be the largest study of its kind, but non-randomised and with limitations discussed in peer review such as the learning curve influence, use of eGFR as an endpoint with two kidneys, and incomplete data. The definitions used are of interest and the field could use some uniformity moving forward in measuring perioperative and long-term benchmarks of quality.

Durand et al. [2] give us a glimpse into the future of surgery, a science fiction world of prostate surgery where nerves and prostatic glands can be colour coded and seen at a microscopic level in real time. The pictures stand for themselves, especially Fig. 1. If such imaging can be integrated into technique decisions, and perhaps future instrument designs, then perhaps we will have a whole new wave of studies possible on linking surgical technique to improved functional and oncological outcomes after radical prostatectomy. The paper has a nice depth in detail, methods, results, as well as narratives in solving technical problems with novel technology.

This issue’s ‘Article of the Month’ by Gavin et al. [3] is a different look at the question of morbidity after localised prostate cancer treatments, specific to long-term care at >2 years from treatment. The database is from a cancer registry and they have an impressive 54% response rate from a population that is 2–18 years from diagnosis. Rather than Likert-like scales of symptom severity, they simply look at ‘current’ vs ‘ever had’ symptoms and look at the total burden including multiple/overlapping symptoms. Although this may not be as robust and validated as the Expanded Prostate Cancer Index Composite (EPIC) instrument, the simple phrasing of ‘current’ vs ‘ever had’ is probably capturing a very high proportion of symptoms rather than dismissing them if minor or in the past. Again, we see more erectile dysfunction after radical prostatectomy and radiation with hormonal therapy, and more bowel symptoms after radiation therapy. Hormone therapy patients have hot flashes and fatigue, and watchful-waiting patients have some advantages but are certainly not free of symptoms. The burden of symptoms is interesting, nine of 10 reported at least one of seven key symptoms at some point and three of four are current. Therefore, as the authors indicate, ≈75% of prostate cancer survivors will have ongoing symptoms needing follow-up care. This is a significant database resource adding to our understanding of long-term outcomes of patients with prostate cancer and supporting the significance of the Durand et al. [2] study that may show the way forward towards reducing such burdens of disease treatment.

 

References

1 Zargar H, Al laf ME, Bhayani S et al. Trifecta and optimal perioperative outcomes of robotic and laparoscopic partial nephrectomy in surgical treatment of small renal masses: a multi-institutional study. BJU Int 2015; 407–14

 

2 Durand M, Jain M, Aggarwal A et al. Real-time in vivo periprostatic nerve tracking using multiphoton microscopy in a rat survival surgery model: a promising pre-clinical study for enhanced nerve-sparing surgery. BJU Int 2015; 478–86

 

3 Gavin AT, Drummond FJ, Donnelly C, O’Leary E, Sharp L, Kinnear HR. Patient-reported ‘ever had’ and ‘current’ long-term physical symptoms after prostate cancer treatments. BJU Int 2015; 397–406

John W. Davis, MD
Associate Editor, BJUI

#pass4prostate gears up for Rugby World Cup

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Declan_theatre2Here is a fun campaign which should appeal to anyone interested in rugby or prostate cancer for that matter. The 2015 Rugby World Cup kicks off in England and Wales next month and as part of their warm up schedule, Australia are playing USA Rugby in a friendly match at Soldier Field in Chicago on the 5th of September. As part of their sponsorship of this fixture, Astellas are supporting a social media campaign called #pass4prostate which will directly raise funds for prostate cancer research in both the USA and Australia.

As part of their support, Astellas will donate $5 to prostate cancer research and advocacy organizations for every qualifying #pass4prostate submission posted to Twitter, Facebook, or Instagram, up to a maximum contribution of $125,000 in the USA and a further $40,000 in Australia. At socialboost you will get the best review of the instagram traffic boosting tools.  Therefore to make sure we maximize this commitment, we need to drive lots of traffic using the #pass4prostate hashtag! You can see examples of Australian and US rugby players supporting the campaign below by throwing around special blue rugby balls, but the campaign is encouraging people to make videos supporting the campaign and throwing anything blue around (in a rugby style of course!).

pass4prostate 1

The campaign will run up to the match on 5th September, and there be lots of activity at the 2nd Prostate Cancer World Congress which takes place in sunny Far North Queensland, Australia, from 17-21st August 2015. Follow #pcwc15 or #pass4prostate to get involved!


For full details, please visit the pass4prostate website.

 

Declan Murphy

Melbourne, Australia

@declangmurphy

 

Sailing into “UnCHAARTED” waters

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Chemotherapy comes alive for prostate cancer!

staff-chowdhury1Systemic therapy for metastatic prostate cancer has radically changed in the last 10 years with the introduction of several novel agents that have shown significant improvements in progression free and overall survival. These have all been studied in metastatic castrate refractory prostate cancer (mCRPC) and have improved overall survival but in each case by less than 6 months. (The latest major breakthrough is the introduction of a relatively old drug, docetaxel chemotherapy, earlier in the disease for hormone sensitive patients).

In this week’s New England Journal of Medicine we see the eagerly awaited results from the CHAARTED study from Christopher Sweeney and colleagues. This novel study aimed to improve treatment for men with newly diagnosed hormone sensitive metastatic prostate cancer by adding docetaxel chemotherapy to androgen deprivation therapy (ADT).

790 men with newly diagnosed metastatic prostate cancer were randomised to ADT plus docetaxel (6 cycles at 75mg/m2) or ADT alone. The addition of docetaxel to ADT was shown to significantly improve overall survival by 13.6 months (57.6 months vs. 44.0 months; p<0.001). The clinical benefit was greatest in the subgroup with high volume disease where the improvement in overall survival was 17 months (49.2 months versus 32.2 months). High volume disease was defined as the presence of visceral metastases and/or 4 or more bone metastases with at least one beyond the vertebral bodies or pelvis. The combination was well tolerated with approximately 6% of patients having neutropenic fever and one death possibly related to docetaxel.

The results from this study are truly practice changing. Supporting evidence from the UK STAMPEDE study (Systemic Therapy in Advancing or Metastatic Prostate Cancer: Evaluation of Drug Efficacy) was presented at this year’s American Society of Clinical Oncology (ASCO) meeting. STAMPEDE showed that for men with metastatic hormone sensitive prostate cancer 6 cycles of docetaxel in addition to ADT improved median overall survival by 22 months (43 versus 65 months).

Chemotherapy for metastatic prostate cancer has had a checkered past with a lack of enthusiasm and nihilism from clinicians and patients. The results from CHAARTED and STAMPEDE are already changing those views. The prostate cancer community needs to react to these results and look to make this treatment available to all suitable men. There are issues with regards to costs of chemotherapy (although docetaxel is now generic), workload, sequence, patient selection, toxicity management, etc. The CHAARTED and STAMPEDE investigators must also use this opportunity to interrogate the tumour samples from these studies to see if they can identify biomarkers that predict docetaxel activity. We will not get this opportunity again as docetaxel + ADT will be be standard of care for future studies.

The clinical benefit from the addition of docetaxel to ADT is one of the largest seen in any oncology study. All men presenting with newly diagnosed metastatic prostate cancer should be considered for 6 cycles of docetaxel in addition to ADT.

 

Simon Chowdhury is a Consultant Medical Oncologist at Guy’s, King’s and St Thomas’ Hospitals, London. He is actively involved in clinical trial research into urological cancers.

 

 

Highlights from #BAUS15

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#BAUS15 started to gain momentum from as early as the 26th June 2014 and by the time we entered the Manchester Central Convention Complex well over 100 tweets had been made. Of course it wasn’t just Twitter that started early with a group of keen urologists cycling 210 miles to conference in order to raise money for The Urology Foundation.

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Monday 15th June 2015

By the time the cyclists arrived conference was well under way with the andrology, FNUU and academic section meetings taking place on Monday morning:

  • The BJU International Prize for the Best Academic Paper was awarded to Richard Bryant from the University of Oxford for his work on epithelial-to-mesenchymal transition changes found within the extraprostatic extension component of locally invasive prostate cancers.
  • Donna Daly from the University of Sheffield received the BJUI John Blandy prize for her work on Botox, demonstrating reductions in afferent bladder signaling and urothelial ATP release.

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  • Professor Reisman’s talk on ‘Porn, Paint and Piercing’ as expected drew in the crowds and due to a staggering 44% complication rate with genital piercings it is important for us to try to manage these without necessarily removing the offending article as this will only serve to prevent those in need from seeking medical attention.
  • With the worsening worldwide catastrophe of antibiotic resistance, the cycling of antibiotics for prevention of recurrent UTIs is no longer recommended. Instead, Tharani Nitkunan provided convincing evidence for the use of probiotics and D-Mannose.

The afternoon was dominated by the joint oncology and academic session with Professor Noel Clarke presenting the current data from the STAMPEDE trial. Zolendronic acid conferred no survival benefit over hormones alone and consequently has been removed from the trial (stampede 1). However, Docetaxal plus hormones has shown benefit, demonstrated significantly in M1 patients with disease-free survival of 65 months vs. 43 months on hormones alone (Hazard ratio 0.73) (stampede 2). This means that the control arm of M1 patients who are fit for chemotherapy will now need to be started on this treatment as the trial continues to recruit in enzalutamide, abiraterone and metformin arms.

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The evening was rounded off with the annual BAUS football tournament won this year by team Manchester (obviously a rigged competition!), whilst some donned the

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lycra and set out for a competition at the National Cycle Centre. For those of us not quite so energetic, it was fantastic to catch up with old friends at the welcome drinks reception.

 

Tuesday 16th June 2015

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Tuesday kicked off bright and early with Professor John Kelly presenting results from the BOXIT clinical trial, which has shown some benefit over standard treatment of non-muscle invasive bladder cancer, but with significant cardiovascular toxicity.

The new NICE bladder cancer guidelines were presented with concerns voiced by Professor Marek Babjuk over discharging low-risk bladder cancer at 12 months given a quoted 30-50% five-year recurrence risk. Accurate risk stratification, it would seem, is going to be key.

The President’s address followed along with the presentation of the St. Peter’s medal for notable contribution to the advancement of urology, which was presented to Pat Malone from Southampton General Hospital. Other medal winners included Adrian Joyce who received the BAUS Gold Medal, and the St. Paul’s medal went to Mark Soloway.

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A plethora of other sessions ensued but with the help of the new ‘native’ BAUS app my programme was already conveniently arranged in advance:

  •     ‘Heartsink Conditions’ included pelvic and testicular pain and a fascinating talk by Dr Gareth Greenslade highlighted the importance of early and motivational referral to pain management services once no cause has been established and our treatments have been exhausted. The patient’s recovery will only start once we have said no to further tests: ‘Fix the thinking’
  • Poster sessions are now presented as ‘e-posters’, abolishing the need to fiddle with those little pieces of Velcro and allowing for an interactive review of the posters.

 

Photo 22-06-2015 22 36 07Pravisha Ravindra from Nottingham demonstrated that compliance with periodic imaging of patients with asymptomatic small renal calculi (n=147) in primary care is poor, and indeed, these patients may be better managed with symptomatic imaging and re-referral as no patients required intervention based on radiograph changes alone.

Archana Fernando from Guy’s presented a prospective study demonstrating the value of CTPET in the diagnosis of malignancy in  patients with retroperitoneal fibrosis (n=35), as well as demonstrating that those with positive PET are twice as likely to respond to steroids.

 

Wednesday 17th June 2015

Another new addition to the programme this year was the Section of Endourology ‘as live surgery’ sessions. This was extremely well received and allowed delegates to benefit from observing operating sessions from experts in the field whilst removing the stressful environment and potential for risk to patient associated with live surgery. This also meant that the surgeon was present in the room to answer questions and talk through various steps of the operation allowing for a truly interactive session.
Wednesday saw multiple international speakers dominating the Exchange Auditorium:

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  • The BJU International guest lecture was given by Professor Hendrik Van Poppel: a heartfelt presentation describing what he believes to be the superiority of surgery over radiotherapy for high-risk localised prostate cancer.
  • The Urology Foundation presented the Research Scholar Medal to Ashwin Sachdeva from Freeman Hospital, Newcastle for his work on the ‘Role of mitochondrial DNA mutations in prostate carcinogenesis’. This was followed by an inspiring guest lecture by Inderbir Gill on ‘Robotic Urologic Oncology: the best is yet to come’ with the tag line ‘the only thing that should be open in 2015 is our minds’
  • Robotic Surgery in UK Urology: Clinical & Commissioning Priorities was a real highlight in the programme with talks from Jim Adshead and Professor Jens-Uwe Stolzenburg focussing on the fact that only 40% of T1a tumours in the UK were treated with partial (as opposed to radical) nephrectomy, and that the robot really is the ‘game-changer’ for this procedure. Inderbir Gill again took to the stage to stress that all current randomised trials into open vs. robotic cystectomy have used extracorporeal reconstruction and so do not reflect the true benefits of the robotic procedure as the dominant driver of complications is in the open reconstruction.

These lectures were heard by James Palmer, Clinical Director of Specialised Commissioning for NHS England who then discussed difficulties in making decisions to provide new technologies, controlling roll out and removing them if they show no benefit. Clinical commissioning policies are currently being drafted for robotic surgery in kidney and bladder cancer. This led to a lively debate with Professor Alan McNeill having the last word as he pointed out that what urologists spend on the robot to potentially cure cancer is a drop in the ocean compared with what the oncologists spend to palliate!

 

Thursday 18th June 2015

The BJU International session on evidence-based urology highlighted the need for high-quality evidence, especially in convincing commissioners to spend in a cash-strapped NHS. Professor Philipp Dahm presented a recent review in the Journal of Urology indicated that the quality of systematic reviews in four major urological journals was sub-standard. Assistant Professor Alessandro Volpe then reviewed the current evidence behind partial nephrectomy and different approaches to this procedure.

Another fantastic technology, which BAUS adopted this year, was the BOD-POD which allowed delegates to catch-up on sessions in the two main auditoria that they may have missed due to perhaps being in one of the 21 well designed teaching courses that were available this year. Many of these will soon be live on the BAUS website for members to view.

The IBUS and BAUS joint session included a lecture from Manoj Monga from The Cleveland Clinic, which led to the question being posed on Twitter: ‘Are you a duster or a basketer?’The audience was also advised to always stent a patient after using an access sheath unless the patient was pre-stented.

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The updates session is always valuable especially for those studying for the FRCS (Urol) exam with far too many headlines to completely cover:

  • Endourology: The SUSPEND trial published earlier this year was a large multi-centre RCT that showed no difference in terms of rates of spontaneous passage of ureteric stone, time to stone passage or analgesic use between placebo, tamsulosin and nifedipine. There was a hot debate on this: should we be waiting for the meta-analysis or should a trial of this size and design be enough to change practice?
  • Oncology-Prostate: The Klotz et al., paper showed active surveillance can avoid over treatment, with 98% prostate cancer survival at 10 years.
  • Oncology-Kidney: Ellimah Mensah’s team from Imperial College London (presented at BAUS earlier in the week) demonstrated that over a 14-year period there were a higher number of cardiovascular-related admissions to hospital in patients who have had T1 renal tumours resected than the general population, but no difference between those who have had partial or radical nephrectomy.
  • Oncology-Bladder: Arends’s team presented at EAU in March on the favourable results of hyperthermic mitomycin C vs. BCG in the treatment of intermediate- and high-risk bladder cancer.
  • Female and BPH: The BESIDE study has demonstrated increased efficacy with combination solifenacin and mirabegron.
  • Andrology: Currently recruiting in the UK is the MASTER RCT to evaluate synthetic sling vs. artificial sphincter in men with post-prostatectomy urinary incontinence.

 

Overall BAUS yet again put on a varied and enjoyable meeting. The atmosphere was fantastic and the organisers should be proud of the new additions in terms of allowing delegates to engage with new technologies, making for a memorable week. See you all in Liverpool!

 

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Rebecca Tregunna, Urological Trainee, West Midlands Deanery @rebeccatregunna

 

Dominic Hodgson, Consultant Urologist, Portsmouth @hodgson_dominic

 

Men’s Health – Driving the Message Home

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Gentlemen, Start Your Engines

Over the past couple of years, we have seen a growing number of fun and exciting ways to help raise awareness for prostate cancer and men’s health. Movember, for example, has become increasingly popular across the globe. This summer, a couple of high-octane, awareness and fund-raising events are taking place on both sides of the Atlantic. I encourage you to check out both of these events and consider participating – jump in and fasten your seat belts, we’re going for a ride!

 

The Drive for Men’s Health

 

Electron Powered

For the second straight year, American urologists Dr. Jamin Brahmbhatt and Dr. Sijo Parekattil have organized the Drive for Men’s Health. Last year, the team drove an all-electric powered TESLA from Clermont, Florida, to Manhattan, New York.

This year, on Thursday, June 11th, the Drive for Men’s Health will again start in Clermont, Florida. However, once they arrive in Manhattan, they’ll take a sharp left turn and head West to Los Angeles, California. The 6,000 mile journey is expected to take nine days to complete. Along the way, the team will need to stop over 60 times to plug in and recharge.

 

Putting a Plug In for Men’s Health

Over the course of the drive, the urology duo will host live webcasts, on a variety of men’s health topics, including the topic of home health care provided by our partners at www.oxford-healthcare.com/tulsa-home-care-services/, all this with the help of over 200 speakers from around the world. The drivers hope the car, and technology used during the drive, will function as a magnet to pull men and their loved ones into further discussions about healthy living, as well as knowing when to request respite care Tinton NJ once aware of what this kind of care entails. This year’s Drive for Men’s Health coincides with National Men’s Health Week in the United States.

 

The Banger 3K Rally for Prostate Cancer

Banger 3K Car

 

 Putting the Pedal to the Metal

As summer approaches, auto racing heats up in Europe. In July, amateur hockey player Adam Clark (Clarky) and his friend Robert Lamden (Lambo) will strap themselves into a 28-year-old Toyota MR2 Mk1 for the 2015 Banger Rally Challenge. The race is similar to the Gumball 3000 Rally, but with old cars that cannot be worth more than £350. These old cars needs to be modified with Remapping stages for better performance.

In England, an old car is referred to as “an old banger”. It’s not going to be easy by any stretch of the imagination, and we hope not to break down.” – Adam Clark, “Clarky”

Over the course of ten days, the team will attempt to drive 3,000 miles across France, Switzerland, Monaco, Italy, and thru the Alps. The purpose of the event is to raise awareness and money for Prostate Cancer UK, the largest men’s health charity in the UK, dedicated to helping men survive prostate cancer, and enjoy a better quality of life.

It’s a lighthearted race, but being the first one to the finish line does not mean you have won. There are lots of challenges along the way that need to be completed – and we have no idea what they are yet as it is all secret! It’s very much a social activity, many laughs, great memories. It will be competitive, but I think everyone will be happy just to get to the finish line without breaking down! – Adam Clark, “Clarky”

 

A Shot and a Goal

Clarky and Lambo have already raised nearly £9,000 for Prostate Cancer UK by selling sponsorship spaces on the car, and from donations. When the team finally arrives back home in London, England, Clarky will wrap up the fundraising event on the ice, as assistant captain, playing for Team Prostate in an All-Stars Charity Ice Hockey Tournament at the home of British ice hockey, Sheffield Arena.

team prostate cancer UK

 

 Driving the Message Home

Every man has a unique set of interests. Some men respond to technology under the hood, while others enjoy the screeching of tires on pavement, or the excitement of a shot and a goal. When it comes to men’s health, this summer offers something for just about everyone.

Please consider giving a shout out to Jamin and Sijo on Twitter or Facebook as they drive across America, and/or consider donating to Clarky and Lambo who you can follow on Instagram and Twitter, and for updates along the Banger 3K, please “friend” on Facebook.

By donating and supporting the boys, you will not only help shift men’s health into high gear, but also help keep our patients and our friends out of the penalty box and firing on all cylinders.

 

Dr. Brian Stork is a community urologist who practices in Muskegon and Grand Haven, Michigan, USA. He is a member of the American Urological Association’s Social Media Workgroup, and is the Social Media Director at StomaCloak. You can follow Dr. Stork on Twitter @StorkBrian.

 

Article of the Month: Choline-PET/CT radical PCa treatment

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Every Month the Editor-in-Chief selects the Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Clinical utility of 18F-fluorocholine positron-emission tomography/computed tomography (PET/CT) in biochemical relapse of prostate cancer after radical treatment: results of a multicentre study

Sonia Rodado-Marina, Mónica Coronado-Poggio, Ana María García-Vicente*,
Jose Ramón García-Garzón†, Juan Carlos Alonso-Farto††, Aurora Crespo de la Jara‡, Antonio Maldonado-Suárez§ and Antonio Rodríguez-Fernández

 

Department of Nuclear Medicine, La Paz Universitary Hospital and §Quirón Universitary Hospital, Madrid, *Department of Nuclear Medicine, Universitary Hospital, Ciudad Real, †CETIR Unitat PET Esplugues, Barcelona, ††Gregorio Marañón Universitary Hospital, Madrid, ‡Department of Nuclear Medicine, Quirón Hospital, Torrevieja, and Department of Nuclear Medicine, Virgen de las Nieves Universitary Hospital, Granada, Spain

 

Read the full article
OBJECTIVE

To evaluate 18F-fluorocholine positron-emission tomography (PET)/computed tomography (CT) in restaging patients with a history of prostate adenocarcinoma who have biochemical relapse after early radical treatment, and to correlate the technique’s disease detection rate with a set of variables and clinical and pathological parameters.

PATIENTS AND METHODS

This was a retrospective multicentre study that included 374 patients referred for choline-PET/CT who had biochemical relapse. In all, 233 patients who met the following inclusion criteria were analysed: diagnosis of prostate cancer; early radical treatment; biochemical relapse; main clinical and pathological variables; and clinical, pathological and imaging data needed to validate the results. Criteria used to validate the PET/CT: findings from other imaging techniques, clinical follow-up, treatment response and histological analysis. Different statistical tests were used depending on the distribution of the data to correlate the results of the choline-PET/CT with qualitative [T stage, N stage, early radical prostatectomy (RP) vs other treatments, hormone therapy concomitant to choline-PET/CT] and quantitative [age, Gleason score, prostate-specific antigen (PSA) levels at diagnosis, PSA nadir, PSA level on the day of the choline-PET/CT (Trigger PSA) and PSA doubling time (PSADT)] variables. We analysed whether there were independent predictive factors associated with positive PET/CT results.

RESULTS

Choline-PET/CT was positive in 111 of 233 patients (detection rate 47.6%) and negative in 122 (52.4%). Disease locations: prostate or prostate bed in 26 patients (23.4%); regional and/or distant lymph nodes in 52 (46.8%); and metastatic bone disease in 33 (29.7%). Positive findings were validated by: results from other imaging techniques in 35 patients (15.0%); at least 6 months of clinical follow-up in 136 (58.4%); treatment response in 24 (10.3%); histological analysis of lesions in 17 (7.3%); and follow-up plus imaging results in 21 (9.0%). The statistical analysis of qualitative variables, corresponding to patients’ clinical characteristics, and the positive/negative final PET/CT results revealed that only whether or not early treatment with RP was done was statistically significant (P < 0.001), with the number of positive results higher in patients who did not undergo a RP. Among the quantitative variables, Gleason score, Trigger PSA and PSADT clearly differentiated the two patient groups (positive and negative choline-PET/CT: P = 0.010, P = 0.001 and P = 0.025, respectively). A Gleason score of <5 or ≥8 clearly differentiated positive from negative PET. Trigger PSA: mean of 8 ng/mL for positive PET/CT vs 2.8 ng/mL for negative PET/CT; PSADT: mean of 8 months for positive vs 12.6 months for negative. The optimal threshold values were: 3 ng/mL for Trigger PSA level and 6 months for PSADT (Youden index/receiver operating characteristic curve). Analysing these two variables together showed that PSADT was more conclusive in patients with lower Trigger PSA levels. Analysing variables by location showed that only PSADT was able to differentiate between those with disease confined to the prostate compared with the other two locations (lymph nodes and bone), with shorter PSADT in these two, which was statistically significant (P < 0.002). In the patient group with a PSA level of <1.5 ng/mL, 30.8% had the disease, 7% of whom had metastatic bone disease. In the multivariate logistic regression, the risks factors that were clearly independent for those with positive PET/CT were: PSA level of >3 ng/mL, no early RP, and Gleason score of ≥8.

CONCLUSIONS

Our results support the usefulness of 18F-fluorocholine PET/CT in biochemical relapse of prostate cancer after radical treatment, with an overall disease detection rate close to 50%, and it can be recommended as first-line treatment. As mentioned above, besides Trigger PSA levels, there are other clinical and pathological variables that need to be considered so as to screen patients properly and thus minimise the number of nodular lesions and increase the diagnostic accuracy of the examination.

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Editorial: Choline-PET/CT in relapsing prostate cancer patients

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18F-choline positron emission tomography (PET)/C T has become a modern imaging technique in men with prostate cancer and biochemical relapse after local treatment with curative intent (radical prostatectomy, external beam/intensity-modulated radiation therapy, brachytherapy) in order to differentiate between local, locoregional and systemic relapse. Although 18F-choline PET/CT will probably be replaced by prostate-specific membrane antigen-PET/CT in the near future, the present paper by Rodada-Marina et al. [1] is important for daily routine because the authors attempt to define the current role of 18F-choline PET/CT in the diagnostic algorithm of men with relapsing PSA and to define specific patient cohorts in whom 18F-choline PET/CT might have a significant impact in the decision-making process regarding the most appropriate treatment.

Two issues are important to me when discussing the potential indication for performing new imaging studies in my patients with relapsing PSA: (1) whether the method is sensitive enough to detect a metastatic deposit at a given PSA serum concentration and (2) whether a positive finding using this imaging method would change my treatment recommendation. In this context, the current recommendation is 18F-choline PET/CT at a PSA serum concentration >1 ng/mL if a therapeutic consequence will be drawn [2]. If the patient would not be a candidate for a secondary local treatment option, such as salvage radiation therapy or salvage radical prostatectomy, but he would be treated with androgen deprivation therapy anyhow, none of the modern imaging studies would make sense.

In the present paper, a total of 233 patients from six different institutions were included in a retrospective study. One of the most important findings of this paper is that the detection rate was only 47.6%, despite relatively high mean and median trigger PSA serum levels of 5.3 and 2.8 ng/mL, respectively. The detection rates varied between 23.5 and 38.2% in men with PSA serum levels between <1 and 2–3 ng/mL and the detection only increased to 67% in men with PSA levels ≥3 ng/mL. Moreover, the authors identified that the best threshold for the trigger PSA level was 3.5 ng/mL, with a sensitivity and a specificity of 64 and 76%, respectively. With regard to PSA doubling time (PSA-DT), the best threshold was < 6 months, with a sensitivity and a specificity of 58% only. Based on these very high PSA serum levels at the time of imaging studies, which had the potential intent to select the most appropriate therapy, the majority of patients were already beyond the scope of secondary local therapy with curative intent [2, 3]. Furthermore, it was shown that patients with a Gleason score 8–10 and a PSA-DT of <6 months have a higher probability of having systemic disease – a fact which is well known already.

What do these data mean for clinical practice? There might be three clinical scenarios in which imaging studies might exert a significant impact on further treatment: (1) salvage radiation therapy in men with PSA relapse after radical prostatectomy (RP) [2, 3], (2) salvage RP after radiation therapy of the prostate [4] and (3) salvage pelvic lymphadenectomy in men with PSA relapse after RP or radiation therapy of the prostate [5]. In my view, the data underline the fact that imaging with 18F-choline PET/CT is not helpful in the first clinical scenario, early or late PSA relapse after RP. The clinician needs to start local salvage therapy, such as percutaneous radiation therapy, at a serum PSA concentration well below 0.5 ng/mL if a curative intent is the focus of treatment [2, 3]. Based on the current data, only one fifth of the patient cohort had a positive 18F-choline PET/CT finding even when considering aggressive biological features such as a high Gleason score, a rapid PSA-DT and a high PSA nadir after RP; therefore, PET/CT does not add significant additional diagnostic information in the individual patient so that it does not appear useful to perform 18F-choline PET/CT in men with low PSA levels at time of relapse. 18F-choline PET/CT might be helpful in the second clinical scenario to identify patients who will benefit from salvage RP. It has been shown that a PSA < 10 ng/mL and a PSA-DT >12 months at time of surgery are the most significant prognosticators for identifying organ-confined disease [4]. A positive detection rate for metastatic foci would be >75% in this scenario, underlining the indication for performing choline PET/CT. With regard to the third clinical scenario, it has been shown that a serum PSA <4 ng/mL and a slow PSA-DT represent prognostic markers for selecting men who most probably have locoregional relapse in the small pelvis and who will benefit the most from salvage lymphadenectomy [5]. Again, choline-PET/CT is indicated to exclude retroperitoneal or systemic disease and it should be performed before any salvage procedure.

In conclusion, the retrospective study performed by Rodado-Marina et al. [1] provides significant and clinically useful information with regard to the definition of a patient cohort that would benefit most from the performance of a choline PET/CT. This information should be considered when counselling patients with regard to the need for new imaging methods at the time of PSA relapse.

Read the full article
Axel Heidenreich,

 

Department of Urology,Uniklinik RWTH University Aachen, Aachen, Germany

 

References

 

1 Rodado-Marina S, Coronado-Poggio M, Garcia-Vicente A et al. Clinical utility of 18F-flourocholine PET-CT in biochemical relapse of prostate cancer after radical treatment. Results of a multicentre study. BJU Int 2015. [Epub ahead of print]. doi: 10.1111/bju.12953

 

2 Heidenreich A, Bastian PJ, Bellmunt J et al. EAU guidelines on Prostate Cancer. Part 2: screening, diagnosis, and local treatment with curative intent – update 2013. Eur Urol 2014; 65: 467–79

 

3Pfister D, Bolla M, Briganti A et al. Early salvage radiotherapy following radical prostatectomy. Eur Urol 2014; 65: 1034–43

 

4 Heidenreich A, Richter S, Th€uer D, Pfister D. Prognostic parameters, complications, and oncological and functional outcome of salvage radical prostatectomy for locally recurrent prostate cancer after 21rst-century radiotherapy. Eur Urol 2010; 57: 437–45

 

5 Rigatti P, Suardi N, Briganti A et al. Pelvic/retroperitoneal salvage lymph node dissection for patients treated with radical prostatectomy with biochemical recurrence and nodal recurrence detected by [11C]choline positron emission tomography/computed tomography. Eur Urol 2011; 60: 935–43

 

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