Robert E. Mitchell

Current controversies in the treatment of high-risk prostate cancer.

Purpose of review Despite the well documented stage migration in prostate cancer, a substantial number of men still present to urologists with locally advanced or metastatic disease. Recent findings The beneficial role of prostatectomy has been affirmed in several studies examining its therapeutic impact in locally advanced, nonmetastatic prostate cancer. Adjuvant therapy with radiation or hormones appears to increase prostate-specific antigen relapse-free survival. Whether prostate-specific antigen relapse-free survival is an appropriate surrogate for overall survival remains unverified. The timing and duration of hormonal therapy continues to be debated. Hormone therapy administered ‘too late’ in the course of metastatic disease portends a shortened survival but possible side effects of androgen ablation must be considered. Several docetaxel-based combination chemotherapies for hormone refractory prostate cancer are being studied, but their efficacy in the neoadjuvant setting thus far has been limited. Progress in the palliation of bony metastases has resulted in a decrease in symptoms and skeletal events. Summary This review identifies seminal data that focus on controversial therapeutic dilemmas in prostate cancer. The literature of the last few years universally emphasizes the importance of a multidisciplinary collaboration in prostate cancer. It is only with this type of cooperation that essential research will continue and succeed.

Preoperative Serum Prostate Specific Antigen Remains a Significant Prognostic Variable in Predicting Biochemical Failure After Radical Prostatectomy

PURPOSE Multiple investigators have argued that PSA may no longer be an accurate marker of prostate cancer biology. We determined whether the impact of PSA in predicting biochemical failure after radical prostatectomy has changed since the beginning of the PSA era. MATERIALS AND METHODS A total of 1,246 patients were identified from the Columbia University Comprehensive Urological Oncology Database who underwent radical prostatectomy by 1 of 3 surgeons between 1988 and 2003. Cox proportional hazards models were fit to the data to estimate the impact of PSA (logPSA) in predicting BCF (PSA 0.2 ng/ml or greater). To determine if the predictive impact of PSA changed over time, patients were classified based on year of surgery, and an interaction term between PSA and time was included. Finally concordance indexes were estimated to determine if the predictive ability of PSA has changed over time. RESULTS In a Cox model including PSA, year of surgery and a year/PSA interaction term, the impact of PSA appears to change over time (p = 0.002). However, when correcting for the effects of stage and grade there was no significant change in the impact of PSA. In addition, concordance analysis indicated that the predictive ability of PSA has remained constant throughout the PSA era (0.65, 0.66 and 0.64 for each period, respectively). CONCLUSIONS This study demonstrates that the predictive ability of PSA as a cancer outcomes biomarker has not changed significantly since the beginning of the PSA era. Despite suggestions to the contrary, PSA remains an important variable in predicting risk of BCF after RP.

The evaluation and staging of clinically localized prostate cancer

Accurate staging of clinically localized prostate cancer is crucial to ensure patients receive optimal management and counseling. Despite the growing number of diagnostic modalities, however, accurate staging remains a challenge. In this Viewpoint, Mitchellet al. discuss the relative merits of tried and tested and newly emerging staging techniques.

64 COMPARING UROLOGY RESIDENT AND FACULTY PERCEPTIONS OF SURGICAL SKILLS, LEARNING NEEDS, AND GENERAL SURGERY ROTATIONS FOLLOWING THE GENERAL SURGERY INTERNSHIP

INTRODUCTION AND OBJECTIVES: Urology program’s quality is in part measured by the graduating residents’ operative experience and duty hours compliance. This emphasis creates conflict between attaining the maximum operative experiences while being duty hour complaint and providing appropriate operative, clinical, and didactic education. In July, 2009, the Residency Review Committee in Urology implemented a minimum standard for operative cases that acts as a metric of resident competence. We set out to evaluate how the prior operative percentiles and national averages compare to the new minimum case volume standards. METHODS: An operative time study was developed using the Medical College of Wisconsin program figures and the ACGME 2008 09 Urology National Resident Report to calculate task time for registered surgical procedures. The urologic cases during a 6 month period (Jan. ’08 June ’08), were recorded to establish operative time logs. The operative times were used to calculate the total surgical times for the new minimum standards and the prior national averages. These results were then compared. RESULTS: Analysis of surgical time demonstrated that based on the 2008 09 National Average data, the 10th, 30th and 50th percentiles resulted in time consumption of 4,181 hours, 4,991 hours, and 6,430 hours respectively. The surgical time consumed with the new minimum standards was 4,282 hours. Thus, the minimum standards fall between the 10th and 30th percentiles. CONCLUSIONS: The new ACGME minimum standards reflect a reasonable baseline of operative experience. By not concentrating on attaining high volume case logs, an increase in available resident time may allow for diversification of other aspects resident education.