Genitourinary Cancer


Screening for Prostate Cancer, in which men diagnosed with low-risk prostate cancer were randomized to immediate RP or expectant management with delayed RP.20


The authors reported that the frequencies


Men who are of younger age, have higher PSA, and have a higher Gleason grade were more likely to receive active treatment. Other studies have reported similar results.22–25


of Gleason score >6, capsular penetration, or biochemical progression rates were similar between the two groups. Data from the CaPSURE database suggest that about 50% of men who choose active surveillance for localized prostate cancer do not need any active treatment at five years.21


Finally, a large population-based study comparing androgen deprivation therapy (ADT) and observation among elderly patients (≥66 years of age) with low-risk prostate cancer (clinical stage T1–T2) reported no overall survival benefit with ADT compared with observation (30.2 versus 30.3%, HR 1.00) for this age group.26


Thus, a significant number of prostate


cancers that are diagnosed, particularly among the elderly, are clinically insignificant and will likely not pose a significant health problem. In such cases, no treatment with active surveillance and close follow-up is appropriate.


Various statistical models and nomograms have been developed that can predict the presence of ‘clinically insignificant’ or ‘indolent cancers,’ i.e. small, organ-confined prostate cancer.27–33


It is suggested that PSA


velocity rather than absolute value of PSA might be helpful in predicting presence of aggressive prostate cancer.34,35


Case Study 2 Recent studies have also


suggested that besides age, PSA, and initial Gleason score, the results of the first repeat prostate biopsy are also an important predictor of disease progression.36–39


Another key factor that should be considered in decision-making is patient preference and beliefs. Often the fear of the word ‘cancer’ is out of proportion to the real threat of cancer. The patient may have a loved one who experienced a terrible death from cancer and consequently he is afraid he is going to have a painful death as well. Listening carefully to the patient, understanding his concerns, and addressing them in an effective and rational fashion is thus of paramount importance in decision-making.


The NCCN recommends that active surveillance is appropriate for men with very-low-risk prostate cancer and a life expectancy of less than 20 years, or those with low-risk disease and a life expectancy of less than 10 years. The recommended follow-up includes PSA checks every three to six months, DRE every six to 12 months, and prostate biopsy after 18 months if initial biopsy had greater than 10 cores, or if any abnormality is noted on PSA or DRE. Prostate cancer progression warranting treatment is to be considered if PSA doubling time is less than three years, a primary Gleason score of 4 or 5 is found on repeat biopsy, or carcinoma is detected to a greater extent or in greater number in repeat biopsies. The advantages of active surveillance include reduced time spent away from work and family due to therapy as well as avoidance of potential side effects of a therapy that was not needed.40


For example, RP can have a significant impact on urinary and sexual function, while ADT can lead to osteopenia, weight gain, and increased risk for cardiovascular events.41,42


The disadvantages of active 52


A 60-year-old pharmacist was found to have a rise in PSA on his yearly screenings from 2.9 to 6.5ng/ml in the past year. He was otherwise in good health. His physical examination, including DRE, was unremarkable. Pathologic examination of the 12-core prostate biopsy showed that eight of the 12 cores were involved on the left with Gleason 4+5, >50% of cores were positive, and peri-neural invasion was noted. CT scan of the chest/abdomen/pelvis was unremarkable, except for possible seminal vesicle invasion. He was then seen by a radiation oncologist who recommended external-beam radiation therapy (RT), and also referred him to a medical oncologist for consideration of neoadjuvant and adjuvant hormonal therapy.


Role of Androgen Deprivation Therapy in Localized Prostate Cancer After Radiation Therapy While RP or RT is performed with curative intent, about 30–40% of men with localized prostate cancer, particularly those with high-risk disease, have disease recurrence (local recurrence or metastatic disease). Thus, there has been interest in utilizing adjuvant therapies among men with high-risk prostate cancer. The most studied agent has been ADT. Seminal work by Huggins in the 1940s demonstrated that prostate cancer cells are androgen-dependent for growth and proliferation,43


and the


observation was recognized with a Nobel prize in 1966 (shared with Peyton Rous). This discovery led to great interest in the development of ADTs for prostate cancer. These therapies include surgical castration, medical castration with leuteinizing-hormone-releasing hormone (LHRH) agonists such as leuprolide (Lupron®) and goserelin (Zoladex®), and anti-androgen agents such as bicalutamide (Casodex®). More recently there has been interest in identifying other androgen-suppressing agents, including inhibitors of the androgen-regulating enzyme CYP17, such as abiraterone, and androgen receptor antagonists, such as MDV3100.44,45


ADT is the first-line therapy for metastatic prostate cancer US ONCOLOGY & HEMATOLOGY


surveillance include the potential for greater progression of disease than anticipated, the chance that the subsequent treatment may be more complex and invasive, increased patient anxiety, and the need for close follow-up, including prostate biopsies.


In summary, risk stratification of prostate cancer and the life expectancy of the individual person in consideration, along with patient preference, are crucial in clinical decision-making for low-risk localized prostate cancer. Our patient (case study 1) has very-low-risk prostate cancer and a life expectancy of about 10–15 years. Thus, the prostate cancer is most likely clinically insignificant and will not pose a significant health problem. Therefore, active surveillance with regular PSA, DRE, and prostate biopsy would be appropriate and is the recommended treatment.


Summary for Case Study 1


This was discussed with the patient. The relevant data were reviewed, including the concept that while he did have prostate cancer, the cancer was likely not to have a significant impact clinically, cause bothersome symptoms, or shorten his survival. Moreover, it was emphasized that he would be followed closely to monitor for any progression of disease and/or development of symptoms. The fears and anxiety of the patient were allayed, and he agreed to participate in active surveillance for his localized prostate cancer.


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80  |  Page 81  |  Page 82  |  Page 83  |  Page 84