What makes The Prostate Clinic different?
'Probably the leader in the field of keyhole radical prostatectomy'.
- according to a poll of 40 British Urologists recently published in the The Daily Mail.
Latest published results for radical prostatectomy
- Overall potency in 500 men having nerve-sparing laparoscopic radical prostatectomy (2006-2008) was 86.9%.
- Overall continence was 97.4%.
- Complication and recurrence rates were 4.2% & 1.2% (Eden
et al., J Endourol 2011;25:815-819).
Salvage radical prostatectomy
- Recurrent prostate cancer following radiotherapy is now the 4th commonest cancer in men in the USA (Jones JS. Eur Urol 2011;60:411-412).
- In a recent study comparing surgery with cryotherapy following failed radiotherapy the authors concluded that 'Young, healthy patients with recurrent prostate cancer after radiation therapy should consider salvage radical prostatectomy as it offers superior biochemical disease-free survival and may potentially offer the best chance of cure' (Pisters et al. J Urol. 2009;182:517-525).
- Laparoscopic salvage prostatectomy is an option after non-surgical treatment (usually radiotherapy) has failed and staging investigations (MRI or CT and a bone scan) demonstrate no evidence of distant spread.
- Salvage surgery is always more difficult to perform technically because of the scarring caused by radiotherapy and should only be performed by very experienced surgeons.
Surgery for high-risk prostate cancer
- Patients with a PSA ≥20, Gleason grade ≥8 or stage ≥T3 prostate cancer have historically been treated with radiotherapy and hormones.
- There is now an increasing recognition that 'a multimodal approach seems the best way to achieve acceptable outcomes for high-risk prostate cancer patients' (Bastian et al. Eur Urol 2012;61:1096-1106) and that when this approach is used surgery must come first.
- Extended pelvic lymph node dissection is an integral part of this surgery and has been shown to improve cancer survival in men with involved nodes by 23% and in men with no lymph node involvement by 15% (Heidenreich et al., Eur Urol 2007; 52: 29-37).
- Our results presented at the European Assocation of Urology annual meeting in 2010 showed tumour down-grading in 46.4% of patients, continence in 96% and, at 30 months follow-up, a recurrence rate of only 4%.
Extended pelvic lymph node removal (ePLND) for intermediate- and high-risk prostate cancer
- This encompasses men with a PSA ≥10, Gleason grade ≥7 or stage ≥T3 prostate cancer.
- Current American Urological Association & European Association of Urologists guidelines recommend ePLND for more aggressive and higher stage prostate cancers.
- Worryingly, the rate of surgeons performing any form of lymph node removal during prostate (especially keyhole) surgery appears to be declining worldwide, probably due to its difficulty and time-consuming nature (Bolenz et al., Eur
Urol 2010; 57: 453-458).
- Our results (submitted for publication) showed an overall incidence of lymph node involvement in 500 such operated patients of 12.4%.
- Extended pelvic lymph node dissection has been shown to improve cancer survival in men with involved nodes by 23% and in men with no lymph node involvement by 15% (Heidenreich et al., Eur Urol 2007;52:29-37).
Our work in this area was Highly Commended and awarded Runner-Up in the prestigious 2012 UK national Quality in Care oncology awards.
Genes and prostate cancer
In order to develop prostate cancer it is necessary to have both a genetic susceptibility and an environmental promoter. We believe that the most important environmental promoter is diet, specifically one that is rich in saturated fat (red meat and dairy products) and lacking in fruit and vegetables, which contain a variety of powerful anti-cancer compounds. Being overweight is also associated with an increased risk of developing prostate cancer. Evidence of genetic susceptibility can usually be found in family histories and the more members of that family that are affected by prostate cancer the greater is the risk that other members (including children) will be affected in the future.
We can now test for several genetic markers of prostate cancer. Although not all are specific for prostate cancer, all are correlated with the risk of developing it. Knowledge of this risk can help to inform patients, their relatives and their doctors about the relative importance of screening for prostate cancer for any individual and of modifying their lifestyle in the form of taking regular exercise, weight loss and change of diet.
- PCA3 - only expressed in human prostate tissue; the gene is highly overexpressed in prostate cancer.
- TMPRSS2-ERG fusion gene - present in 40-80% of prostate cancers.
- BRCA1 & BRCA2 – these genes have recently been in the news thanks to Angelina Jolie. Mutations in these genes produce a hereditary breast-ovarian cancer syndrome in the women of affected families but account for only 5-10% of all breast cancer cases in women. In men, mutation of the BRCA1 & BRCA2 genes increases the risk of prostate cancer by 3.5x & 8.5x, respectively.
- SNP – single nucleotide polymorphisms on a number of chromosomes have now been found to be associated with an increased risk of developing prostate cancer.
Toxicity of brachytherapy & external beam radiotherapy appears to have been underestimated
A study recently reported in European Urology by Nepple and colleagues (Eur Urol 2013; 64: 372-378) of 10,361 fit men treated for localized prostate cancer between 1995-2007 in the USA has demonstrated that patients who had radiotherapy (either external beam radiotherapy or brachytherapy) had a significantly increased overall mortality compared to patients treated by radical prostatectomy, although the prostate cancer-specific mortality in the two groups was equal. The authors postulate that the differences seen in the survival rates between the two groups might be explained either by the higher incidence of other cancers seen in previously-irradiated patients or to the co-administration of hormonal manipulation, which is commonly given prior to radiotherapy and which is associated with an increased risk of heart attack and stroke.
Latest recommendations on PSA testing
The European Association of Urologists has recently updates their guidelines for the detection of prostate cancer (Eur Urol 2013; 64: 347-354) and has made the following statements based on the best available current evidence:-
1. early detection prostate cancer reduces prostate cancer-related mortality (by 21-44%).
2. early detection of prostate cancer reduces the risk of being diagnosed and developing advanced and metastatic prostate cancer (by 30-49%).
3. a baseline PSA level should be obtained in men 40 - 45 years of age (men aged 45 years who have a PSA greater than or equal to 1, and men aged 60 years who have a PSA greater than or equal to 2, have a significantly greater risk of dying of prostate cancer).
4. intervals for early detection of prostate cancer should be adapted to the baseline PSA level (a safe screening intervals for patients with a PSA within these limits could be up to 8 years, whereas patients with a PSA outside these limits need to be screened every 2-4 years).
5. PSA screening should be offered to men with a life expectancy of 10 years or more (there is little evidence of benefit in screening elderly men).
Prostate cancer: call to test men in their 40s
- A Swedish study of 21,277 men between 1974-1984 published recently in the British Medical Journal has attracted a great deal of interest in the press as it showed that 'Screening men at the age of 45-49....spotted nearly half (44%) of the cancers that went on to be deadly'.
- It suggest that men should have 'a PSA test in their mid-to-late 40s. Those with a high result should return for frequent screening and checks (and treatment if necessary), while those with normal results could wait until their early 50s for their next PSA test.'
- To read the BBC article click here.
- To read the paper itself click here.
Pre-biopsy MRI scan adds accuracy to prostate cancer diagnosis
The evidence that multiparametric MRI scanning prior to transrectal ultrasound-guided prostate biopsy increases the rate of detection of prostate cancer over the standard practice of <em>biopsy first, MRI scan later</em> by allowing suspicious areas to be specifically targeted continues to grow. A recent study from Lille, France published in the August 2013 issue of the journal Radiology showed that targeted biopsies (TB) <em>'detected 15 percent more clinically significant cancers than SB, with those cancers going undetected had the patient not undergone prebiopsy MR imaging and TB' </em>. Most of the cancers missed on conventional prostate biopsy lie in the anterior (front) part of the prostate, which is more difficult to reach with a biopsy needle unless you know specifically to look there.
Patients with knee and hip pain have been used to MRI scanning as an integral part of their investigation for the past 10-15 years and it appears that this is what patients with suspected prostate cancer should now expect as the gold-standard management.
Prolonged statin use lowers risk of prostate cancer
A recent study of 66,741 men aged 45-85 from Israel has shown that prolonged statin use can decrease the risk of developing prostate cancer (they found a 45% reduction between years 1-5 but 78% when taken for over 5 years) and that higher doses of statins offered the most protection. http://www.nature.com/pcan/journal/vaop/ncurrent/full/pcan201334a.html
Surgery appears to be more successful than radiotherapy or observation in managing prostate cancer in otherwise fit men aged 65 and above
A recently study of 67,087 American and Canadian men diagnosed with prostate cancer, aged 65 years or older and managed with surgery (26%), radiotherapy (49%) or observation alone (25%) has shown that in men that were otherwise healthy, i.e. those with a life expectancy of at least 10 years, surgery ‘was associated with improved survival (80% at 10 years) compared with radiotherapy (62%) and observation (54%), regardless of disease stage’.
Sun et al. British Journal of Urology International 2014; 113; 200-208.
This conclusions of this study are clearly at odds with the latest NICE guidance on the management of prostate cancer in British men, which urges men diagnosed with low- and intermediate-risk prostate to consider active surveillance as their initial treatment option http://publications.nice.org.uk/prostate-cancer-diagnosis-and-treatment-cg175/recommendations
Landmark Scandanavian prostate cancer treatment trial shows that surgery is more effective than radiotherapy
The landmark and recently published Scandinavian Prostate Cancer Group (SPCG)-4 study of 34,515 men treated for prostate cancer with surgery (n=21,533) or radiotherapy (n=12,982) and followed up for 15 years after treatment has shown that surgery leads to better survival than does radiotherapy. Younger and fitter men with more aggressive and/or advanced prostate cancers might have an even greater benefit from surgery. http://www.bmj.com/content/348/bmj.g1502
Radiotherapy for prostate cancer carries a higher risk of relevant complications than surgery
A study of 32,465 men receiving either surgery or radiotherapy for prostate cancer between 2002-09 and reported recently in European Urology Today showed that patient who had radiotherapy ‘had a higher incidence of complications requiring hospital admissions, rectal or anal procedures, open surgical procedures and secondary malignancies at five years than those who underwent surgery. However, the number of urological procedures was lower in the radiotherapy than in the surgery group. The risk of complications requiring surgical procedures was 2x higher after radiotherapy.’
Lancet Oncology 2014; 15: 223-231.
Recommendations on screening for prostate cancer by the US and Canadian Healthcare Task Forces
There is no doubt that prostate cancer kills a significant number of men in the UK (roughly 10,000 a year or one man every hour) and that screening for prostate cancer with PSA is effective in saving lives. The latest (third) analysis of the European Randomised Study of Screening for Prostate Cancer shows that the longer the interval after screening the greater the effect http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60525-0/abstract. The benefit at 13 years’ follow up in this study was a 27% reduction in prostate cancer related deaths in men who were screened.
However, this latest analysis, in addition to the opinions of the US (USPSTF) and Canadian (CTFPHC) healthcare task forces, concludes that screening is still unjustified because of the ‘harms’ of treatmenti.e. side-effects. This ignores the fact that the default option for low-risk prostate cancer is surveillance and the consequent conclusion that diagnosis and treatment should therefore be uncoupled, as suggested in the Melbourne consensus statement http://www.bjuinternational.com/bjui-blog/the-melbourne-consensus-statement-on-prostate-cancer-testing/. After all, PSA testing is entirely safe - it's the treatment that causes problems. It also ignores the fact that any man dying of prostate cancer would have liked the opportunity to decide for himself whether the ‘harm’ of bladder and/or sexual dysfunction (for example) would have been worthwhile to avoid the ‘harm’ of death. Unfortunately, when prostate cancer is diagnosed late choices are no longer available.
The recommendations made by the US and Canadian Healthcare Task Forces represent one end of the spectrum of the screening argument and in my opinion constitute an outdated, patrician approach to patients, whom it is assumed are incapable of making reasoned decisions about their health. I'm not sure either to what extent this approach is fuelled by the economic concerns surrounding screening for this condition.
Prof. Christopher Eden discusses on video....
- BPH (enlargement): click here.
- prostate cancer: click here.
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