Cynthia T. Soloway

Careful Selection and Close Monitoring of Low-Risk Prostate Cancer Patients on Active Surveillance Minimizes the Need for Treatment

BACKGROUND With the advent of prostate-specific antigen (PSA) screening and the increase in the number of transrectal ultrasound-guided biopsy cores, there has been a dramatic rise in the incidence of low-risk prostate cancer (LRPC). Because > 97% of men with LRPC are likely to die of something other than prostate cancer, it is critical that patients give thought to whether early curative treatment is the only option at diagnosis. OBJECTIVE To identify a group of men with LRPC who may not require initial treatment and monitor them on our active surveillance (AS) protocol, to determine the percentage treated and the outcome and to analyze the quality-of-life data. DESIGN, SETTING, AND PARTICIPANTS We defined patients eligible for AS as Gleason ≤ 6, PSA ≤ 10, and two or fewer biopsy cores with ≤ 20% tumor in each core. MEASUREMENTS Kaplan Meier analysis was used to predict the 5-year treatment free survival. Logistic regression determined the predictors of treatment. Data on sexual function, continence, and outcome were obtained and analyzed. RESULTS AND LIMITATIONS The AS cohort consisted of 230 patients with a mean age of 63.4 yr; 86% remained on AS for a mean follow-up of 44 mo. Thirty-two of the 230 patients (14%) were treated for a mean follow-up of 33 mo. Twelve had a total prostatectomy (TP). The pathologic stage of these patients was similar to initially treated TP patients with LRPC. Fourteen underwent radiation therapy, and six underwent androgen-deprivation therapy. Fifty percent of patients had no tumor on the first rebiopsy, and only 5% of these patients were subsequently treated. PSA doubling time and clinical stage were not predictors of treatment. No patient progressed after treatment. Among the AS patients, 30% had incontinence, yet < 15% were bothered by it. As measured by the Sexual Health Inventory for Men, 49% of patients had, at a minimum, moderate (≤ 16) erectile dysfunction. CONCLUSIONS If guidelines for AS are narrowly defined to include only patients with Gleason 6, tumor volume ≤ 20% in one or two biopsy cores, and PSA levels ≤ 10, few patients are likely to require treatment. Progression-free survival of those treated is likely to be equivalent to patients with similar clinical findings treated at diagnosis.

Active surveillance; a reasonable management alternative for patients with prostate cancer: the Miami experience

To examine the outcome of patients diagnosed with ‘low‐risk’ prostate cancer managed by active surveillance (AS).

Sexual, psychological and dyadic qualities of the prostate cancer 'couple'.

To examine the levels of sexual, psychological and dyadic functioning of the prostate cancer ‘couple’ (as studies have shown that spouses/partners play an integral role in the patients adjustment to prostate cancer treatment), to encourage the creation of innovative psychosexual interventions to be used in the outpatient setting, and to offer insights into a novel area of prostate cancer research.

Trends in Gleason Score: Concordance Between Biopsy and Prostatectomy over 15 Years

OBJECTIVES To assess the changes in the concordance rate of prostate biopsy and radical prostatectomy (RP) Gleason score (GS) over 15 years. METHODS We reviewed 1670 consecutive patients who underwent RP between 1992 and 2006. We excluded patients who underwent neoadjuvant hormone therapy or salvage RP, or who had incomplete data. Patients who had RP during 1992 through 1996, 1997 through 2001, and 2002 through 2006 were assigned to groups 1, 2, and 3, respectively. All clinical and pathological data were collected retrospectively. We defined overgrading as a biopsy GS higher than the RP Gleason score. Undergrading was a biopsy GS less than the RP Gleason score. The GS concordance between biopsy and RP was evaluated by kappa coefficient. RESULTS A total of 1363 patients satisfied the inclusion criteria. Biopsy and RP Gleason score categories correlated exactly in 937 (69%) men. Gleason undergrading occurred in 361 (26%) men and overgrading in 65 (5%). The exact correlation of GS between biopsy and RP was 58%, 66%, and 75% in groups 1, 2, and 3, respectively. The most common discordant finding was undergrading of the biopsy specimen. The number of cases with exact correlation was highest in GS 7 (78%). Undergrading was more in GS 6 or less (35%) and overgrading was more in the GS 8 through 10 (35%) category. CONCLUSIONS This large, single institutional study confirms increasing concordance of Gleason scores in prostate needle biopsies and surgical specimens. This is reassuring for patients assessing various treatment options for prostate cancer.

Factors That Influence Patient Enrollment in Active Surveillance for Low-risk Prostate Cancer

OBJECTIVES To learn from patients their rationale for enrollment in active surveillance (AS) for low-risk prostate cancer as an alternative to primary treatment. METHODS A rank-order survey was designed to assess the relative influence of factors that contributed to the decision to elect AS. The survey was mailed to 185 patients enrolled in AS at our university-based urologic oncology practice. Participants were also asked whether they had been offered AS as an alternative to primary treatment by the urologist who had initially diagnosed their cancer. RESULTS The survey was returned by 105 (57%) of 185 patients. AS was offered to 38 (36%) of 105 patients by the physician who had made the initial diagnosis. Patients most frequently reported physician influence as the greatest contributor to their decision to elect AS (73%). Patients also cited concerns regarding the potential side effects of incontinence (48%) and erectile dysfunction (44%) associated with therapy as reasons for choosing AS. CONCLUSIONS The results of the present study have shown that patients are heavily influenced by physicians in their decision to elect AS. Notably, the majority of our sampled patients were not offered AS at diagnosis. Evidence has indicated that AS is an appropriate approach for low-risk prostate cancer and should be discussed with patients in this risk category.

Complete transurethral resection of bladder tumor: are the guidelines being followed?

OBJECTIVES To determine how often complete eradication of all visible tumors during transurethral resection of bladder tumor (TURBT) is accomplished in a referral setting. The American Urological Association guidelines recommend complete eradication whenever possible. METHODS We retrospectively reviewed the records of patients who underwent a second TURBT within 4 weeks of being referred to us. Relevant data such as residual tumor location, number, stage, and grade were collected and analyzed. Patients with muscle invasive tumor or known incomplete resection were excluded. RESULTS Forty-seven patients met the inclusion criteria. Mean age was 75 years. In the initial TURBT, 35 (75%) had a high grade tumor and 12 (25%) had low grade tumors. Twenty-four (52%) were Ta and 23 (48%) were T1 tumors. Of the 47 patients who satisfied the criteria, 33 (70%) had an initial incomplete resection. Of these, 10 (30%) had macroscopic residual tumor at the resection site. Twenty-three (70%) had at least 1 unresected tumor away from the previous resection site. There were 39 unresected or partially resected tumors. Thirteen (33%) tumors were located in the anterior wall, 12 (31%) in the posterior wall and trigone, 10 (26%) in the lateral wall, 3 (7.5%) in the dome, and 1 (2.5%) in the prostatic urethra. CONCLUSIONS Although TURBT is a commonly performed operation, in this selected series, the incidence of unresected and gross residual tumor after initial TURBT is high. This indicates a need to emphasize the guidelines for a complete resection and to emphasize the use of a proper technique in this commonly performed urological procedure.

Prospective randomized comparison of the safety, efficacy, and cosmetic outcome associated with mini-transverse and mini-longitudinal radical prostatectomy incisions

Aims: Open radical retropubic prostatectomy (ORP) has traditionally been performed through a lower midline incision. Prior efforts to reduce pain and expedite recovery include a variety of alterations in length and the orientation of the incision. The aim of our study is to compare the safety, efficacy, and cosmetic outcomes associated with transverse and longitudinal mini-radical prostatectomy incisions. Materials and Methods: Consecutive patients undergoing ORP at a single institution were studied. Patients were randomized to receive either a modified transverse or longitudinal incision. In all patients, the length of the incision was 7cm. The following parameters were compared between the two groups: Perioperative blood loss, duration of surgery, technical factors, pain and analgesic requirements, length of hospital stay (LOS), and pathological stage. The Patient and Observer Scar Assessment Scale (POSAS) was used to compare the cosmetic aspects associated with the incisions. Results: Fifty-six patients underwent a transverse (n=27) and longitudinal (n=29) mini- incision ORP. No significant differences were noted in the perioperative parameters that were compared (P>0.116). None of the patients required blood transfusion, there were no wound complications. Perioperative pain and analgesic requirements were not significantly different among the two study arms (P>0.433). The POSAS indicated no significant difference in cosmesis scores with both incisions (P>0.09). Conclusions: Seven-centimeter transverse and longitudinal mini-incisions offer alternatives to the standard ORP incision, and to minimally invasive approaches. Both incisions are safe, associated with little postoperative pain, and a short postoperative LOS. Both incisions provide highly satisfactory cosmesis for the patient.