J. Trachtenberg

A Negative Confirmatory Biopsy Among Men on Active Surveillance for Prostate Cancer Does Not Protect Them from Histologic Grade Progression

BACKGROUNDnMany men (21-52%) are reported to have no cancer on the second, also known as the confirmatory, biopsy (B2) for prostate cancer active surveillance (AS). If these men had a reduced risk of pathologic progression, particularly grade related, the intensity of their follow-up could be decreased.nnnOBJECTIVEnTo investigate if men with no cancer on B2 are less likely to undergo subsequent pathologic progression.nnnDESIGN, SETTING, AND PARTICIPANTSnMen were identified from our tertiary care center AS prostate cancer database (1995-2012). Eligibility criteria were prostate-specific antigen (PSA) ≤ 10, cT2 or lower, no Gleason grade 4 or 5, three or fewer positive cores, and no core >50% involved. Only patients with three or more biopsies were selected and then dichotomized on cancer status (yes or no) at B2.nnnINTERVENTION AS OUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnPathologic progression was defined as grade (advancement in Gleason score) and/or volume (more than three positive cores, >50% core involved). Progression-free survival was compared. Predictors of progression were investigated using a Cox proportional hazards model.nnnRESULTS AND LIMITATIONSnOf the 286 patients remaining on AS after B2, 149 (52%) had no cancer and 137 (48%) had cancer. The median follow-up after B2 was 41 mo (interquartile range [IQR]: 26.5-61.9). Progression-free survival at 5 yr was 85.2% versus 67.3% for negative B2 versus cancer on B2, respectively (p = 0.002). Men with no cancer at B2 had a 53% reduction in risk of subsequent progression (hazard ratio [HR]: 0.47; 95% confidence interval [CI], 0.29-0.77; p = 0.003). Subanalysis showed prognostic indicators of volume-related progression were absence of cancer (HR: 0.36; 95% CI, 0.20-0.62; p = 0.0006) and PSA density (HR: 1.79; 95% CI, 1.12-2.89; p = 0.01). The only predictor of grade-related progression was age (HR: 1.05; 95% CI, 1.00-1.10; p = 0.04). Retrospective analysis was the major limitation of the study.nnnCONCLUSIONSnAbsence of cancer on B2 is associated with a significantly decreased risk of volume-related but not grade-related progression. This must be considered when counseling men on AS.

Exploring Gay Couples’ Experience With Sexual Dysfunction After Radical Prostatectomy: A Qualitative Study

This exploratory study examines the experience of three gay couples managing sexual dysfunction as a result of undergoing a radical prostatectomy. Semi-structured interviews were conducted as part of a larger study at an urban hospital in Toronto, Ontario, Canada. Interview transcripts were transcribed verbatim, and analyzed using interpretative phenomenological analysis. The authors clustered 18 subordinate themes under 3 superordinate themes: (a) acknowledging change in sexual experience (libido, erectile function, sexual activity, orgasmic function); (b) accommodating change in sexual experience (strategies: emphasizing intimacy, embracing plan B, focus on the other; barriers: side-effect concerns, loss of naturalness, communication breakdown, failure to initiate, trial and failure, partner confounds); and (c) accepting change in sexual experience (indicators: emphasizing health, age attributions, finding a new normal; barriers: uncertain outcomes, treatment regrets). Although gay couples and heterosexual couples share many similar challenges, we discovered that gay men have particular sexual roles and can engage in novel accommodation practices, such as open relationships, that have not been noted in heterosexual couples. All couples, regardless of their level of sexual functioning, highlighted the need for more extensive programming related to sexual rehabilitation. Equitable rehabilitative support is critical to assist homosexual couples manage distress associated with prostatectomy-related sexual dysfunction.

In-Bore Transperineal Magnetic Resonance Imaging-Guided Laser Ablation

Localization of clinically significant prostate cancer with multiparametric magnetic resonance imaging (mpMRI) theoretically allows for a more precise and targeted prostate cancer ablation. With in-bore therapy, real-time visualization of the lesion during fiber insertion ensures accurate targeting. In comparison to ultrasound-guided focal therapy, in-bore treatment provides the advantage of real-time thermal monitoring during treatment and assessment of treatment coverage by a contrast-enhanced scan immediately post treatment. Preliminary results of ongoing phase I and II in-bore focal prostate cancer treatment trials via transperineal route have shown promising early results.

1092 5-alpha reductase inhibitors diminish the rate of progression in men with low risk prostate cancer on active surveillance

INTRODUCTION AND OBJECTIVES: 5-alpha reductase inhibitors (5ARIs) have been shown to prevent prostate cancer in two large randomized controlled trials. No prior work has shown the effect of 5ARIs on those already diagnosed with low risk prostate cancer. Our goal was to determine the effect of 5ARIs on pathologic progression in men on active surveillance for prostate cancer. METHODS: This was a single institution retrospective cohort study comparing men taking a 5ARI versus no 5ARI while on active surveillance for prostate cancer. All men had at least two biopsies. Inclusion criteria for active surveillance were PSA 10 ng/ml, clinical stage T1c/T2a, Gleason score 6, and 3 cores positive with no more than 50% of a core involved at initial diagnostic biopsy. Pathologic progression was evaluated and defined as Gleason score 6, or maximum core involvement 50% or 3 cores positive on a follow-up prostate biopsy. Univariate, multivariate and Kaplan-Meir analyses were conducted. RESULTS: A total of 288 men on active surveillance met the inclusion criteria. The median follow-up was 38.5 months (IQR 23.6– 59.4) with 93 men (32%) experiencing pathologic progression and 96 men (33%) abandoning active surveillance. Men taking a 5ARI experienced a lower rate of pathologic progression (18.6% vs 36.7%, p 0.004) and were less likely to abandon active surveillance (20% vs 37.6%, p 0.006). The median time to progression was longer in the 5ARI group (42.5 months) compared to the non-5ARI group (31.5 months; p 0.026). On multivariate analysis, lack of 5ARI use was most strongly associated with pathologic progression (OR 2.98, 95% CI 1.5–5.9) followed by age and baseline maximum percentage involvement of any biopsy core. CONCLUSIONS: 5ARIs were associated with a significantly lower rate of pathologic progression and abandonment of active surveillance.