Chicago—Two landmark prostate cancer studies—one examining chemoprevention and the other investigating a novel therapy for advanced
disease—shared the spotlight at the 2009 AUA annual meeting. This year's meeting also featured the release of two key AUA
statements: a bold best practice statement on PSA testing and a guideline on localized kidney cancer that encourages more
widespread use of nephron-sparing treatments.
These were just a few of the meeting's many highlights. In this article, Urology Times recaps the meeting's take-home messages
across the spectrum of clinical and office practice topics. High-interest messages appear in bold.
Localized Prostate Cancer
Samir S. Taneja, MD
Presented by Samir S. Taneja, MD New York University
Results of the 4-year REDUCE (Reduction by Dutasteride of Prostate Cancer) trial in 8,000 men with a previous negative biopsy
who were randomized to dutasteride (Avodart), 5 mg, or placebo and then re-biopsied at 2 and 4 years indicate a 23% reduction
in relative risk of prostate cancer among the men treated with dutasteride. Researchers found no increase in the risk of high-grade
cancer in the dutasteride cohort, and noted that the diagnostic accuracy of PSA overall improved in this group.
In men over age 70 with favorable clinical parameters, active surveillance with selective delayed intervention is associated
with low prostate cancer mortality. At 10-year follow-up, 62% remained free of treatment and 35% were offered treatment for
a rise in PSA or Gleason score. Of those definitively treated, 52% developed biochemical recurrence, indicating the need for
more rigorous criteria for when to intervene.
In a study of active surveillance, there was no difference between PSA velocity and PSA doubling time among men who progressed,
suggesting that histologic criteria should be used. However, higher PSA and higher PSA at diagnosis were significantly associated
with progression, and PSA velocity was significantly associated with progression in a subset of men with PSA <4.0 ng/mL at
diagnosis.
The wisdom of using active surveillance in men with low-risk prostate cancer and a long life expectancy was called into question.
One group applied contemporary selection criteria for active surveillance in radical prostatectomy patients and found that
a number of men with Gleason score >7, pT3a disease, and more than 20% tumor involvement would have been selected.
When selecting men with low-risk prostate cancer for active surveillance, if baseline repeat biopsies are performed prior
to inclusion, disease progression rate can be more accurately estimated.
Addition of MRI to unilateral biopsy findings improved the sensitivity and negative predictive accuracy in selecting candidates
for focal therapy to 100%. This may be a way to improve selection of focal therapy candidates.
Lesions in 100 men with prostate cancer were mapped to determine appropriateness for focal therapy. The process identified
37 men with a dominant Gleason 6 T2 lesion and only small foci of clinically insignificant disease in the prostate. These
men may also be candidates for focally ablative therapies on the side of the index lesion.
A study of focal cryoablation in 800 men reported low morbidity—65% were sexually active at 1 year and only 4.5% were incontinent—but
men with high-risk disease had less promising outcomes.
A review of men with localized hormone-naïve prostate cancer treated with high-intensity focal ultrasound (HIFU) found 5-year
biochemical disease-free survival using the Phoenix definition was 87%, but 76% when the Stuttgart definition is applied.
Review of the data confirmed that the Stuttgart definition better correlated with clinical progression than PSA kinetics;
thus, a definition of nadir +1.2 is a reliable indicator of HIFU success.
Improvements in HIFU technology suggest its use as first-line therapy in men with low- and intermediate-risk disease, due
to increased biochemical disease-free survival rates and lower rates of post-treatment incontinence and erectile dysfunction.
Two thousand men who were treated in an overlapping contemporary time period with robot-assisted or open surgery found approximately
equivalent 3-year oncologic outcomes, even when stratified by pathologic stage, grade, and margin status.
A comparison of standard anastomosis and posterior rhabdosphincter reconstruction with a Rocco stitch found no difference
in urinary incontinence between the two groups. Social continence (=1 pad per day) was seen in 40% of patients at 6 weeks
and 70% of patients at 3 months.
Applying the Clavien criteria in a retrospective review of complications following robot-assisted laparoscopic surgery found
>5% of patients encountered major complications (grade I/II Clavien). The literature underestimates the number and severity
of complications associated with robotic surgery; thus, patients should be counseled carefully.
A 7-year longitudinal self-assessment of men's satisfaction with open retropubic radical prostatectomy found that of 1,600
men, 93% were satisfied with their treatment choice. Short-term satisfaction was associated with length of catheterization,
stricture formation, and continence, but over time, sexual function and biochemical failure wielded greater influence on men's
opinion of the surgery.
Men who take statins to lower cholesterol have a 30% lower risk of PSA recurrence after radical prostatectomy, suggesting
a possible treatment strategy for men undergoing RP.
Among 4,000 men undergoing brachytherapy, the presence of perineural invasion (PNI) on baseline biopsy strongly predicted
relapse in both univariate and multivariate analysis. Pre-treatment PSA, Gleason grade, and stage were associated with likelihood
of PNI, and disease-free survival was significantly lower in men with PNI.
90% of PSA relapses occur within 5 years after RP. PSA relapse occurring later than 5 years out is associated with lower pre-treatment
PSA and Gleason scores. Men with delayed PSA recurrence have a significant advantage over those with early recurrence in terms
of disease-specific, but not metastasis-free, survival.
Salvage androgen deprivation therapy adds significantly to overall survival in men with PSA doubling times <6 months, but
not in those with PSADT >6 months, suggesting that men with the greatest likelihood of metastasis would benefit from salvage
ADT.
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