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Valentine’s Day PSA

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A few years ago Barrack Obama, the President of the USA, is supposed to have said on Valentine’s Day – “Gentlemen – do not forget!”

He was apparently speaking “from experience”. Not remembering that important day can have catastrophic consequences for many men. On that occasion, PSA stood for public service announcement.

The headline, however, could easily have been mistaken for Prostate Specific Antigen. One could argue whether the PSA test is as important to men as Valentine’s Day. Most men probably do not bother, especially if they are less than 40 years old. The PSA debate swings around like a sine wave. Despite the best possible randomised controlled trials for and against PSA screening, there seem to be no clear answers with deep divisions amongst men and their urologists.

This February, the BJUI adds to the PSA debate by publishing the Melbourne Consensus Statement [1]. It was an attempt to bring some sense to a thorny subject. When published as a blog on www.bjui.org, most of our readers liked it, but certainly not all. The usual heated debate was inevitable. Earlier last summer Bal Carter, one of our BJUI Executive Members, chaired the AUA panel that recommended shared decision making for asymptomatic men between 55–69 years as far as PSA screening was concerned. They carefully analysed over 300 studies to make these recommendations [2]. I congratulated Bal on this milestone on the very morning this made headline news. However, such was the controversy that he had to present the findings twice – one appearance on the AUA podium was just not enough.

In a well-informed man, over diagnosis is not necessarily a problem as long as it does not lead to over treatment. I find myself treating a number of men in their 40s with strong family histories of prostate cancer. It is very difficult to deny them a PSA test when they seek it. This discussion is likely to become redundant in years to come when better risk stratification with genomic tools and improved imaging will complement the PSA test, rather than relying on it alone. In the meantime I leave it to our knowledgeable readers to make up their own minds.

Not everyone is interested in the PSA test in the month of February. If you belong to this category, perhaps we could grab your attention with a multi-institutional collaborative study showing disease free and overall survival rates of over 90% following LESS partial nephrectomy, a challenging procedure, even for technically accomplished surgeons [3]. Khurshid Guru’s group also present data to show that urinary and bowel domains take about 6 months to recover after robotic cystectomy; sexual domains even longer [4].

I have no illusions that none of the above may be of the slightest importance to some readers. In which case you may wish to head to the best florist in town. Forget that at your peril …

Prokar Dasgupta, Editor in Chief, BJUI
Guy’s Hospital, King’s College London

 

References

  1. Murphy DG, Ahlering T, Catalona WJ et al. The Melbourne Consensus Statement on the Early Detection of Prostate Cancer. BJU Int 2014; 113: 186–188
  2. Carter HB. American Urological Association (AUA) Guideline on prostate cancer detection: process and rationale. BJU Int 2013;112: 543–547
  3. Springer C, Greco F, Autorino R et al. Analysis of oncological outcomes and renal function after laparoendoscopic single site partial nephrectomy: a multi-institutional outcome analysis. BJU Int 2014; 113: 266–274
  4. Poch MA, Stegemann AP, Rehman S et al. Short-term patient reported health-related quality of life (HRQL) outcomes after robot-assisted radical cystectomy (RARC). BJU Int 2014; 113: 260–265
 

February #urojc summary: complications arising from radical treatment of prostate cancer

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February 2014 twitter-based international urology journal club #urojc continued with the theme of prostate cancer. This time the discussion was based around the complications arising from radical treatment, and the paper was available open access courtesy of Lancet Oncology. Nam et al [1]
reported on a population based retrospective cohort study of men who underwent surgery or radiotherapy alone for prostate cancer in Ontario, Canada between 2002 to 2009. Instead of the traditional outcomes that usually include urinary incontinence and erectile dysfunction, they evaluated five other treatment related complications, hospital admissions; urological, rectal or anal procedures, open surgical procedures and secondary malignancies.

First author of the manuscript Rob Nam joined the discussion using the urojcguest twitter account. The journal club kicked off on Sunday 2nd February at 8pm GMT time, quick off the mark was the ‘Queen of uro-twitter’.

There was quick agreement.

Patients who underwent surgery were more likely to undergo minimally invasive urological procedures, most commonly diagnostic cystoscopy, was this due to easy access to it for urologists?

However, there was comment from Canada where the study was performed that this may not necessarily be the case.

One of the limitations of the study was noted,

Stacy Loeb commented

and the lead author Robert Nam explained

The question was posed how much emphasis was placed on non ED, non urinary incontinence adverse events when counseling patients regarding prostate cancer treatment.

Ben Davies (the self-proclaimed King of uro-twitter) commented that bladder neck contracture was rare in the robotic prostatectomy era, which was the experience of others.

It was noted that the risk of secondary malignancy is probably underplayed due to the relatively short follow up in the study,

and secondary malignancies may sway the decision-making balance towards surgery

Stacy Loeb changed her avatar and commented that the study may not be generalizable to patients treated in the active surveillance era

The timing and severity of complications post treatment was discussed

It was commented that this is likely ‘real world’ data.

The side effects and their likely effects on quality of life were commented on, (from a surgical perspective).

In the same way that surgeons get different results for the same procedure, do radiation oncologists results differ.

A radiation oncologist joined in the discussion.

There was discussion regarding the mode of radiotherapy and variability in outcomes.

We were reminded that not all prostate cancer requires radical treatment.

Final thoughts in the last few minutes of the journal club came from Stacy Loeb.

Thanks to all who participated, looking forward to next months #urojc. Best tweet prize was won by @VMisrai and is complimentary registration to #WCE14 courtesy of @EndourolSoc. His tweet provided a particularly useful link alerted us to an article published on line ahead of print in the ESTRO Green Journal within hours of his tweet. Special acknowledgement again to Rob Nam who contributed as an author and also to brave attendance by Matt Katz whose insightful tweets gave us urologists much to think about.

 

Kate. D. Linton is a consultant urological surgeon at Sheffield Teaching Hospitals/Barnsley Hospital, UK. Twitter @linton_kate

 

Reference

  1. Nam RK, Cheung P, Herschorn S, et al. Incidence of complications other than urinary incontinence or erectile dysfunction after radical prostatectomy or radiotherapy for prostate cancer: a population-based cohort study. Lancet Oncol 2014; 15: 223-31

 

Editorial: The age old question: who benefits from prostate cancer treatment?

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Widespread PSA-based screening has dramatically altered the profile of newly diagnosed prostate cancer in many countries. Although screening effectively decreases the rates of metastatic disease and prostate cancer death [1], the increasing proportion of low-risk disease necessitates a critical assessment of the need for aggressive therapy.

Active surveillance and watchful waiting are potential alternatives to delay or avoid the need for treatment in carefully selected patients. The key issue is determining which patients are appropriate for conservative management. Although these approaches are often targeted toward elderly men, such men are more likely to be diagnosed with high-risk disease. A recent study by Scosyrev et al. [2] raised concern about excess prostate cancer mortality attributable to under-treatment in the elderly.

Overall, there is very little Level 1 evidence to guide prostate cancer treatment selection. One such trial, the Swedish Prostate Cancer Group 4 (SPCG-4), showed that radical prostatectomy significantly improved survival compared with watchful waiting [3]; however, that study examined a primarily clinically detected population from the 1990s. Subsequently, the Prostate Cancer Intervention versus Observation Trial (PIVOT) randomized US male veterans diagnosed with prostate cancer from 1994 to 2002 to radical prostatectomy vs observation [4]. At 10 years, they reported no significant difference in overall survival between the two arms in the intent-to-treat analysis (hazard ratio 0.88; 95% CI 0.71–1.08, P = 0.22). However, that study was smaller than anticipated owing to difficulty with recruitment and there was a high rate of crossovers between the intervention and observation arms. Per-protocol analysis was not reported for PIVOT and the prostate cancer landscape has continued to change in the past decade, raising unanswered questions over what the results would be if we compared contemporary men who were actually treated to those who were not.

This is the knowledge gap addressed by Aizer et al. [5] who used Surveillance, Epidemiology and End Results (SEER) data for 27 969 US men diagnosed with low-risk prostate cancer from 2004 to 2007. Overall, 67.1% of these men received radical prostatectomy or radiation therapy, while >30% underwent active surveillance or watchful waiting. Using competing risks regression, they showed that both age and non-curative treatment were associated with a significantly higher short-term prostate cancer-specific mortality. These results should be interpreted with caution, however, since they comprise observational data with great potential for confounding. Interestingly, at a short median follow-up of only 2.75 years, 5.4% of these men with presumed low-risk disease died from prostate cancer. Recently, there has been debate over whether Gleason 6 disease should really be considered a cancer [6], but these data highlight the limitations of current clinical staging, such that even presumed low-risk disease may be understaged. The authors suggest that use of a more extended biopsy scheme before active surveillance might reduce the risk of early progression due to undersampling. MRI represents another potential non-invasive treatment method to improve clinical staging and patient selection for active surveillance in the future [7].

Stacy Loeb
Department of Urology, New York University, New York, NY, USA

Read the full article

References

  1. Schroder FH, Hugosson J, Roobol MJ et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med 2012; 366: 981–990
  2. Scosyrev E, Messing EM, Mohile S et al. Prostate cancer in the elderly: frequency of advanced disease at presentation and disease-specific mortality. Cancer 2012; 118: 3062–3070
  3. Bill-Axelson A, Holmberg L, Ruutu M et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 2011; 364: 1708–1717
  4. Wilt TJ, Brawer MK, Jones KM et al. Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med 2012;367: 203–212
  5. Aizer AA, Chen MH, Hattangadi J, D’Amico AV. Initial management of prostate-specific-antigen-detected, low-risk prostate cancer and the risk of death from prostate cancer. BJU Int 2014; 113: 43–50
  6. Carter HB, Partin AW, Walsh PC et al. Gleason score 6 adenocarcinoma: should it be labeled as cancer? J Clin Oncol 2012; 30:4294–4296
  7. Vargas HA, Akin O, Afaq A et al. Magnetic Resonance Imaging for Predicting Prostate Biopsy Findings in Patients Considered for Active Surveillance of Clinically Low Risk Prostate Cancer. J Urol 2012; 188: 1732–1738

 

Another new year, but evidently no new overall survivability for patients presenting with metastatic prostate cancer

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The first International Journal Club of 2014 pulled momentum from December’s discussion on treatment of metastatic prostate cancer. The study reported retrospective review of the California Cancer Registry (CCR) from 1988 to 2009 and found no significant improvement in overall or disease-specific survival in men presenting with metastatic prostate cancer. [1] Senior author Marc Dall’Era (@mdallera) led the Twitter #urojc chat.

 

 

 

 

Fresh into a new year, the crowd was giddy.

… and turned toward more important current events, like the U.S. Preventative Services Task Force’s prostate cancer screening recommendations from 2012.

Ultimately, Dall’Era reigned in the masses. His study sought to investigate whether improvement in patients with metastatic prostate cancer have contributed to the overall decline in prostate cancer mortality since the introduction prostate-specific antigen (PSA). The authors identified 19,336 men through the CCR who presented with de novo metastatic prostate cancer between 1988 and 2009. Over the entire study time period, median age of diagnosis decreased significantly from 73 years to 71 years.

The authors separated the men into chronologic cohorts:  1988-1992, 1993-1997, 1998-2003, and 2004-2009. Men in the recent era showed no significant overall survival (OS) or disease-specific survival (DSS) improvements versus earlier cohorts after 1988. Interestingly, on multivariate analysis controlling for baseline patient characteristics, OS was better for men in the 1988, 1993, and 1998 cohorts versus the 2004 cohort. DSS did improve with time when comparing the 2004 cohort with patients presenting in all earlier years.

If there have been no changes in overall survival in patients with de novo metastatic prostate cancer, might this support the effect of PSA screening?

Tweeters discussed prostate cancer screening selecting out a more biologically aggressive metastatic disease. Dall’Era explained the theory.

The overwhelming question chat participants asked is whether the lack of survival benefit over time is truly accurate, a false reflection of treatment advancements made in recent years, or an artifact created from limitations of the study.

Future studies should attempt to control for the different metastatic disease profiles, namely those patients diagnosed after clinical symptom workup versus those who are asymptomatic on presentation. Examining and comparing tumor biology is another future step.

Ultimately, it’s important not to lose sight of the two dramatic trends over the past decade: the decline in prostate cancer-specific mortality and incidence of metastatic disease. The next steps are solidifying which low-risk patients to treat and developing advanced methods to treat the most aggressive diseases.

The Best Tweet prize for January goes to Parth Modi from New Brunswick, NJ, which goes to show that even Urology residents are in with a chance to win.  The January prize has been kindly been donated by European Urology.

Thank you, Marc Dall’Era, for joining the chat. Your interaction made the January chat particularly lively and insightful. Thank you, European Urology for generously providing the Best Tweet prize.

Finally, here are the Symplur.com analytics for the chat.

[1] Wu JN, Fish KM, Evans CP, deVere White RW, Dall’Era MA. No improvement noted in overall or cause-specific survival for men presenting with metastatic prostate cancer over a 20-year period. Cancer 2013. In Press. doi: 10.1002/cncr.28485

Christopher Bayne is a PGY-3 urology resident at The George Washington University Hospital in Washington, DC and tweets @cbaynemd.

 

Avoiding treatment in prostate cancer: time and money, please?

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It seems impossible to say anything regarding prostate cancer without inciting emotionally charged controversy, even when based on high-level evidence. The updated prostate cancer guidelines from the National Institute of Clinical Health and Excellence (NICE) this week sparked media attention that focused on the role of active surveillance for low and intermediate risk groups.

 

The newspaper headlines state that patients with prostate cancer have been told to avoid immediate treatment. Whether patients are to go against advice given by their doctor or whether this is an attempt by the government to save money is unclear if the online comments are anything to go by. On a local level, patients who are awaiting treatment are questioning their choices.

The sensational implication is that active surveillance is a novel management strategy that was previously not considered. In fact, the equally controversial guidelines from 2008 promoted this alternative: the phrase “suitable for all options including active surveillance” is expressed frequently throughout the country when discussing individual cases at multidisciplinary team meetings.

There is no doubt that a proportion of men who undergo radical treatments may not benefit. The challenges arise in determining who these men are within the constraints of NHS pathways. A standard pathway for a UK man is to request a PSA blood test from his GP, commonly sparked by concerned relatives or friends and endorsed by high-profile survivors and campaigners. A raised result then triggers a “two-week” urgent suspected cancer referral and a clock ticks with diagnosis, staging and treatment to be completed within a 62-day target.

Inevitably, the urgency of referral will influence patient beliefs regarding the seriousness of their condition. A quick online search of comments on recent mainstream articles will throw up anecdotes from men who have sadly failed “wait and see” policies by progressing and finding themselves with incurable disease. A well informed patient will know that a standard transrectal biopsy will have under-estimated his risk in a third of cases. In this emotional state and limited time-frame, our patients are expected to make a rational decision regarding complex management choices – definitive treatment with associated side effects but the knowledge that every effort has been made to “cure” the disease, or what may be a lifetime of repeated, potentially dangerous, biopsies, blood tests and prostate examinations with risk of failure and “living with cancer”. Active surveillance is hardly an attractive option when considered in these terms.

What’s the answer? Detailed evaluation of prostate disease can be achieved with improved imaging with multiparametric MRI in conjunction with a modern transperineal biopsy technique that evaluates the prostate more thoroughly. Suitable patients for active surveillance (and radical treatment) can then be potentially better selected and counseled with higher confidence. Of course, resources are required for this, but shouldn’t this be what we should be campaigning for? And time to deliver this.

Benjamin Disraeli said, “He who gains time gains everything” and perhaps this is the greatest gift we can give to our patients. The lack of time pressure in terms of clinical urgency in low risk prostate cancer gives ample opportunity to get it right in these patients.

I can’t agree that the NICE guidelines are designed to cut NHS costs (active surveillance may cost the same as surgery) but I do fear that without better resources and the reduction in target pressures for low risk prostate cancer, active surveillance will remain an under-utilized management option for many who would benefit from it.

Peter Acher

Prostate cancer survivorship: a new way forward

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Over 2 million people in England have a diagnosis of cancer. This is such a large problem, the Department of Health is spending £750 million on improving earlier diagnosis and prevention of cancer, yet at the same time, £20 billion of efficiency savings must be made. One arm of post-cancer care is survivorship. Survivorship care was initially developed in the USA 20 years ago, starting with breast cancer patients. Prostate cancer survivorship care has been lagging far behind.

Survivorship care involves risk profiling of patients, supported by community based teams and developing shared care/decision making. More often than not, they are fit and well, requiring PSA follow-up only. Yet no guidance relates to survivorship management.  

 

Cancer survivorship encompasses the “physical, psychosocial, and economic issues of cancer from diagnosis until the end of life.” There are significant concerns that current follow-up methods are unsuitable. Concerns regarding permanent physical, psychosocial, and economic effects of cancer treatment have been highlighted and give us good landmarks for survivorship care. These include monitoring for recurrence, metastases, side effects and coordination between secondary and primary care and impact on quality of life. If we examine what patients expect, this includes a full assessment of needs, discussion on side effects of treatment and a personalised care plan post-treatment. Patients also report not knowing who to contact for their care out of hours. Five key phases to survivorship care were identified: care via primary treatment from diagnosis, enable as rapid and full a recovery as possible, ensure recovery is sustained, manage side effects of treatment and monitor for recurrence or disease progression. As part of a National Cancer Survivorship Initiative, a recovery package was developed. This includes a holistic needs assessment and care planning at key points of the care pathway, a treatment summary, a cancer care review, a patient education and support event.

Based on these facts, we have developed a new survivorship model – this was set up as a National Cancer Survivorship Initiative. This programme was initially devised when it was identified specific areas of care were lacking in this cohort, when followed up on a clinic basis. It aims to address the holistic need of the survivorship cohort, and at the same time, allow monitoring for acute recurrence and follow-up care as well as community based follow-up and patient support.

Our Survivorship programme is for patients post-curative therapy for organ confined disease (surgery, external beam radiotherapy or brachytherapy). Patients are offered the option of entering into the survivorship programme and discharged from clinic (Figure 1). Inclusion criteria specify patients must be two years post-radical prostatectomy with an unrecordable PSA, or three years post-radiotherapy or brachytherapy with a stable PSA. We currently have over five hundred patients on this programme. The patients’ demographic, disease and treatment details are entered onto a password protected web based database. The IT programme allows patients to be monitored for recurrence via automatic extraction of PSA results from the hospital database. It is a bespoke database. Alerts are automatically generated if the PSA is above a previously set range. The clinical nurse specialist (CNS) running the programme will contact the responsible consultant once an alert is generated with the patient reviewed in clinic, if required. The CNS will also go through a ‘Distress Thermometer’ with patients on admission to the programme, to identify areas where the patient needs support, psychological, social etc. The specialist nurse would act as the patients’ keyworker, should they develop any side effects of treatment, or any recurrence.

At its initial inception, a focus group of patients was conducted, as part of participatory action research, to find out what they wanted as part of this programme – a user led system. Specifically, they mentioned a conference where they have access to health care professionals and specific topics covered including diet and exercise, nutrition, psychosexual counselling. This conference is held annually, with a range of healthcare professionals advising on identified patient issues e.g. psychological care, health promotion, research, and welfare. The conference allows patients to draw on their strengths and share experiences with each other. Topics such as identification of recurrence, long-term complications, rehabilitation services, quality-of-life issues, pain and symptom management and treatment of recurrent cancer are examples of areas covered. 

There are over 600 patients currently on the programme, a mixture of post-surgery, radiotherapy and brachytherapy. Of these patients, 29 have been referred back to clinic. When asked at the pilot conference if it was worth attending, 100% said yes. As a result of the initial focus group, comments have been made in support this programme.

Whilst this programme is currently only for patients post curative treatment, the next steps forward are to see if patients undergoing active surveillance or hormone therapy can be followed-up using this programme.

Further information:

National Cancer Survivorship Initiative

Worcestershire Prostate Cancer Survivorship Conference

Worcestershire Prostate Cancer Survivorship Programme

 

Goonewardene SS*, Persad R†,Nanton V‡, Young A‡, Makar A
*Homerton University Hospital, London, †North Bristol NHS Trust, ‡Warwick University, Worcestershire Acute Hospitals

Editorial: Too many men still undergo needless prostate biopsy

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Multiple studies have shown that only one in three or four men with a raised PSA level prove to have prostate cancer and many men suffer potentially life-threatening complications from transrectal prostate biopsy. There is an urgent need for better risk stratification of men with elevated PSA levels. Any such test should have a high negative predicative value (NPV; small number of significant cancers missed) but also a high positive predictive value (PPV; i.e. the yield would be high and there would be very few false positives) to diminish the number of unnecessary biopsies. Multiparametric MRI (mpMRI) of the prostate, especially with a stronger 3 T magnet, has been advocated for this purpose. The parameters refer to the separate MRI sequences used, typically at least three. Sequences can not only study the anatomy of the gland (standard T2-weighted MRI), but there is also a measure of the tissue cellularity (diffusion-weighted MRI), vascularity (dynamic contrast-enhanced MRI) or biochemistry (magnetic resonance spectroscopy). Initial data have shown promise but the changes seen on these various sequences can be subtle and interpretation is subjective. Naturally observer experience plays a large part but a standardised scoring system, the so called Prostate Imaging Reporting and Data System (PIRADS) system, has been proposed to improve reporting performance [1]. Each parameter is scored on a scale of 1–5 according to the likelihood of cancer. Scoring systems are always a compromise between the NPV and PPV, and so far there is no agreement where the threshold for each parameter should be set. In the original document, the authors proposed that a score of 4 or 5 signifies a high likelihood or almost certainty of cancer, whilst scores of 1 or 2 denote a high likelihood of benign tissue. A score of 3 is evens. The paper by Kuru et al. [2] shows a high NPV only when the threshold was set at the low level of 2 for each parameter. Predictably, at this threshold the PPV was extremely low, and therefore many men would still undergo unnecessary biopsy. Another similar paper advocated a mean threshold of 3, but even then the PPV was 38% with a NPV of 95% [3]. Both these papers are retrospective studies, in particular the MRI readings were done retrospectively. Nevertheless, the low PPV is disappointing. The results of prospective studies with multiple readers are keenly awaited and I hope that that these will find a higher PPV for mpMRI, and we can to move to an era when fewer men undergo needless prostate biopsy.

Uday Patel
St George’s Hospital, London, UK

Read the full article

References

  1. Barentsz JO, Richenberg J, Clements R et al. ESUR prostate MR guidelines 2012. Eur Radiol 2012; 22: 746–757
  2. Kuru T, Roethke M, Rieker P et al. Histology core-specific evaluation of the European Society of Urogenital Radiology (ESUR) standardised scoring system of multiparametric magnetic resonance imaging (mpMRI) of the prostate. BJU Int 2013; 112:1080–1087
  3. Portalez D, Mozer P, Cornud F et al. Validation of the European Society of Urogenital Radiology scoring system for prostate cancer diagnosis on multiparametric magnetic resonance imaging in a cohort of repeat biopsy patients. Eur Urol 2012; 62: 986–996

Would you really do a radical prostatectomy on a man with known metastatic prostate cancer?

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This year’s final #urojc concluded with intense discussions on the role of local treatment (LT) in metastatic prostate cancer. One study author, @mbwilliams95 joined the conversation to provide valuable insights.

 

 

 

Despite the fact only a small number of Stage IV patients had LT between 2004-2010 (post docetaxel era), this population based study revealed statistically significant differences between overall survival (OS) and disease specific survival (DSS).

Treatment Patient number 5 yr OS (%) DSS (%)
Radical prostatectomy
(RP)		 245 67.4 75.8
Brachytherapy(BT) 129 52.6 61.3
No surgery or radiation (NSR) 7811 22.5 48.7

 

So, can this be the start of a paradigm shift?

We may need to question our conventional approach.

Although some would consider performing RP in this population,

Others disagreed

Tzelepi et al (J Clin Oncol 2011 Jun 20;29(18):2574-81) suggested that potentially lethal cancers persist in the primary tumor and may contribute to progression. This is a possible explanation for this study’s findings, which echoed earlier results by Swanson et al (J Urol. 2006 Oct;176: 1292-8) and Shao et al (Eur Urol 2013 May 21. [Epub ahead of print]). However, SEER lacks information regarding the extent of bony metastasis, an entity that undoubtedly influences patient survival. Furthermore, patients treated with RP were 10 yrs younger than the NSR group (62 vs 72), and had a higher proportion of those with PSA <20.

To reduce bias produced by significant comorbidities, authors excluded those dying within a year of diagnosis and found the 5-yr OS continued to be higher in patients undergoing RP (76.5%) or BT (58.2%). However, patients with three or more of: age ≥70 yr, cT4 disease, PSA ≥20 ng/ml, high-grade disease, and pelvic lymphadenopathy had a 5-yr OS survival (38.2%) and a DSS probability (50.1%) similar to NSR patients.

Several contributors identified that Will Rogers phenomenon may be at play

Ultimately, the jury is still out on what is the most effective treatment of significant prostate cancer

Studies (in addition to the follow-on cohort study arising from this review), are underway

To conclude, it has been

In spite of the global participation, much of the banter involved our US urological colleagues.  On this basis, the Best Tweet Prize has been awarded to a provocative tweet from our UK colleague Ben Challacombe (@benchallacombe).

Thank you to European Urology (@EUPlatinum) for allow open access to the article discussed this month.  Thank you to Nature Reviews Urology for supporting the Best Tweet prize, which is a complimentary 12 months on-line subscription to the journal.

We look forward to seeing you at the January #urojc.

 

Dr Janice Cheng is an Australian Urology Trainee, currently based at Western Hospital. She has an interest in teaching, and enjoys laparoscopies, endoscopies, as well as male/female incontinence management. Twitter @JustUro

Editorial: How many cores are needed to detect nearly all prostate cancers?

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Virtual prostate biopsy and biopsy simulation: lessons to be learned

Prostate biopsies, transrectal or transperineal, still constitute the pillars of prostate cancer detection today [1]. With the lack of reliable imaging tools (new MRI techniques are promising but still investigational [2]); random biopsies offer the sole adequate cancer detection option [3]. However, random biopsies are far from efficient in detecting all tumours and even less efficient in detecting all significant cancer ‘spots’. To improve sensitivities and specificities, increasing the biopsy core numbers, targeting more lateral aspects and encouraging repeat biopsies have been recommended [4]. Recently, HistoScanning™ [5] and template biopsies [6] have been introduced to further improve biopsy quality and efficiency. The latest innovations include the fusion of MRI pictures with the TRUS image to offer optimal targeting of suspicious areas [7]. And yet, these efforts are far from solving the main problem. How can we perform a biopsy and be confident to detect most of the cancers, i.e. significant malignant areas.

The present study [1] does, what should have been done a long time ago, namely to create a reliable and reproducible biopsy simulation model to allow the investigation of various biopsy schemes, core lengths and numbers. Based on a series of 109 radical prostatectomy specimens, a three-dimensional (3D) prostate and prostate cancer model was created using novel 3D slicer software and various prostate biopsy schemes were simulated. Using this method, the detection rate for tumours with a tumour volume (TV) of ≥0.5 mL plateaued at 77% (69 of 90) using a 12 core (3 × 4) scheme, standard 17-mm biopsy cutting length without anteriorly directed biopsy (ADBx) cores. Twenty of 21 (95%) tumours with a TV of ≥0.5 mL not detected by this scheme originated in the anterior peripheral zone or transition zone [1].

Confirming our earlier data with the Vienna nomograms [8], increasing the biopsy cutting length and depth/number of ADBx cores (14–18 cores) improved the detection rate for tumours with a TV of ≥0.5 mL in the 12-core scheme [1]. The best biopsy scheme used a 22-mm cutting length and a 12-core scheme with additional volume-adjusted ADBx cores. Using this combination, 100% of ≥0.5 mL tumours in prostates <50 mL in volume and 94.7% of ≥0.5 mL tumours in prostates >50 mL in volume were detected.

Certainly, these numbers will not be reproducible in real-time TRUS or transperineal biopsies (detections rates of 95–100% as seen in this simulation model, cannot be achieved without adequate imaging tools, which are not available yet), but they aid significantly in rethinking our biopsy strategy. So, if we summarise the present findings and combine them with published data, the future will demand a TRUS-fusion biopsy technique, involving 14–18 cores (or more if volume increases), involving the anterior zones of the prostate and using a 22-mm cutting length of the biopsy core vs a 15–17 mm core as is used currently. Obviously real-time prospective trials are needed to confirm these findings but nothing indicates that the outcome would be otherwise.

Bob Djavan
Department of Urology, New York University School of Medicine, NYU, New York, NY, USA

Read the full article

References

  1. Kanao K, Eastham JA, Scardino PT, Reuter VE, Fine SW. Can transrectal needle biopsy be optimised to detect nearly all prostate cancer with a volume of ≥0.5 mL? A three-dimensional analysis. BJU Int 2013; 112: 898–904
  2. Delongchamps NB, Peyromaure M, Schull A et al. Pre-biopsy Magnetic Resonance Imaging and prostate cancer detection: comparison of random and MRI-targeted biopsies using three different techniques of MRI-TRUS image registration. J Urol 2013;189: 493–499
  3. Djavan B, Rocco B. Optimising prostate biopsy. BMJ 2011; 344: d8201
  4. Thompson I, Thrasher JB, Aus G et al. Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol 2007; 177: 2106–2131
  5. Simmons LA, Autier P, Zát’ura F et al. Detection, localisation and characterisation of prostate cancer by prostate HistoScanning(™). BJU Int 2012; 110: 28–35
  6. Huo AS, Hossack T, Symons JL et al. Accuracy of primary systematic template guided transperineal biopsy of the prostate for locating prostate cancer: a comparison with radical prostatectomy specimens. J Urol 2012; 187: 2044–2049
  7. Sonn GA, Natarajan S, Margolis DJ et al. Targeted biopsy in the detection of prostate cancer using an office based magnetic resonance ultrasound fusion device. J Urol 2013; 189: 86–92
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Editorial: Regaining continence after radical prostatectomy: RARP vs. ORP

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Functional outcomes represent relevant criteria to evaluate the success of radical prostatectomy (RP) in the treatment of localised and locally advanced prostate cancer. Indeed, while the primary goal of RP remains the complete extirpation of the primary tumour, patients’ satisfaction can be negatively affected by urinary incontinence and/or erectile dysfunction after RP.

In this issue of BJUI, Geraerts et al. [1] evaluated urinary continence recovery and voiding symptoms in a well-conducted, single-centre, prospective non-randomised study comparing two contemporary series of patients who underwent either open retropubic RP (RRP) or robot-assisted RP (RARP) for clinically localised or locally advanced prostate cancer. Patients were assigned to each group according to their or their surgeon’s preference. High-risk prostate cancers were preferably treated with an open access to offer a more accurate extended lymphadenectomy. The study showed that the urinary continence recovery rate was significantly shorter in the RARP group than in the RRP group (16 vs 46 days; P = 0.008). Interestingly, the RA approach remained an independent predictor of time to urinary continence recovery on multivariable Cox regression analysis (P = 0.03; hazard ratio [HR] 1.52, 95% CI 1.03–2.26). Therefore, this study confirmed previously published results. In 2003, Tewari et al. [2] reported a shorter time to recovery of urinary continence in patients who underwent RARP (44 days) than those who received RRP (160 days). In 2008, Kim et al. [3] reported a median time to continence in RARP patients of 1.6 months, significantly lower than the 4.3 months in the RRP patients. Interestingly, Geraerts et al. [1] identified other independent predictors of time to continence, such as patient’s age >65 years (P = 0.02; HR 0.67, 95% CI 0.45–0.96) and the preoperative continence status (P = 0.004; HR 1.69, 95% CI 1.18–2.43). In all, 28% of patients who received RRP and 34% of those who underwent RARP were preoperatively defined as incontinent using a symptom-specific questionnaire [1]. These patients classifiable as ‘Cx’ according to the Survival, Continence and Potency (SCP) classification [4] represent a confounding population in the Geraerts et al. study who should be evaluated separately.

An interesting question is whether the reported difference in time to continence in favour of RARP is also significant from the clinical perspective. Urinary continence in patients who underwent RARP recovered 1 month early than those treated with traditional RRP. The King’s Health questionnaire seems to confirm a positive effect of this outcome on the patient’s quality of life (QoL). Indeed, there were better results in the RARP compared with RRP group at 1 and 3 months after RP. Moreover, at 12 months after RP, patients who underwent RRP were more physically limited (P = 0.01) and took more precautions to avoid urine loss (P = 0.01) than those who received a RARP [1]. These data seem to be in conflict with the reported overlapping 12-month urinary continence rates (96% in RRP and 97% in RARP group). Moreover, looking at the 12-month urinary continence rate, the Geraerts et al. study does not confirm the results of a recent cumulative analysis of available comparative studies showing a better 12-month urinary continence rate after RARP compared with RRP (odds ratio 1.53; P = 0.03) [1].

Interestingly, the 12-month urinary continence rate reported after RRP by Geraerts et al. is significantly higher (96%) than the values reported in the comparative studies included in the meta-analysis (88.7%) and in the most important and recent RRP non-comparative series (60–93%) [5]. This aspect appears to confirm the important role of surgeon experience. Indeed, in this Belgium series most of the open procedures were performed by an expert surgeon with experience of >3000 RRPs, and thus able to reach excellent functional outcomes for urinary continence recovery. In favour of robotic surgeons, we could consider that they were able to reach overlapping results after <200 cases.

In conclusion, the study published by Geraerts et al. [1] showed that modern RP in expert hands is able to achieve excellent results for urinary continence recovery regardless of the approach. However, pure and RA laparoscopy has pushed open surgeons to improve technical and postoperative aspects to achieve comparable outcomes. RARP can offer some advantages over traditional RRP, above all for the time to reach urinary continence. This advantage seems to have generated a better QoL profile in patients who underwent RARP at 12 months after RP.

However, the choice between the two techniques must be taken according to all the most relevant parameters including perioperative, functional (continence and potency) and oncological outcomes. Therefore, we strongly support the publication of clinical series or comparative studies reporting results according to the ‘trifecta’, ‘pentafecta’ or SCP systems [6].

Vincenzo Ficarra†°, Alessandro Iannetti* and Alexandre Mottrie†
†OLV Vattikuti Robotic Surgery Institute, Aalst, Belgium, °Department of Experimental and Clinical Medical Sciences – Urology Unit – School of Medicine, University of Udine, and *Department of Surgical, Oncologic and Gastrointestinal Sciences, Padua, Italy

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References

  1. Geraerts I, Van Poppel H, Devoogdt N, Van Cleynenbreugel B, Joniau S, Van Kampen M. Prospective evaluation of urinary incontinence, voiding symptoms and quality of life after open and robot-assisted radical prostatectomy. BJU Int 2013; 112:936–943
  2. Tewari A, Srivasatava A, Menon M, Members of the VIP Team. A prospective comparison of radical retropubic and robot-assisted prostatectomy: experience in one institution. BJU Int 2003; 92: 205–210
  3. Kim SC, Song C, Kim W et al. Factors determining functional outcomes after radical prostatectomy: robot-assisted versus retropubic. Eur Urol 2011; 60: 413–419
  4. Ficarra V, Sooriakumaran P, Novara G et al. Systematic review of methods for reporting combined outcomes after radical prostatectomy and proposal of a novel system: the survival, continence, and potency (SCP) classification. Eur Urol 2012; 61:541–548
  5. Ficarra V, Novara G, Rosen RC et al. Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol 2012; 62: 405–417
  6. Ficarra V, Borghesi M, Suardi N et al. Long-term evaluation of survival, continence and potency (SCP) outcomes after robot-assisted radical prostatectomy (RARP). BJU Int 2013; 112: 338–345
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