Category: Prostate cancer

Which is better for prostate cancer – surgery or radiation therapy?

Resources: Prostate cancer institute | Targeting Cancer |

 

NEED TO BUY THIS ARTICLE: Patient-Reported Outcomes Following Treatment for Localized Prostate Cancer: Helping Decision Making for Patients and Their Physicians

 

see: http://www.jstor.org.ezp.lib.unimelb.edu.au/stable/pdf/27736511.pdf?refreqid=search%3A453d76b3a293d97e6e920d13f26280ad

using a time horizon of 10 to 15 years, less than 3% of men diagnosed with Gleason score 6 and classified as low risk will die as a result of prostate cancer whether treated or not [Source]

Many former Gleason score 6 tumors are now reclassified as Gleason score 7 in the modified system. [Source]

Gleason score 4 + 3 = 7 demonstrates worse pathological stage and biochemical recurrence rates than 3 + 4 = 7 [Source]

Most cancers detected as a result of PSA screening are Gleason 6 (3 + 3) or 7 (3 + 4). [Source]

ACTIVE SURVEILLANCE

While surveillance may be stressful for some
men, the reality is that most patients with prostate
cancer, whether treated or not, are concerned
about the risk of progression. Anxiety about PSA
recurrence is common among both treated and
untreated patients. Patients who are educated to
appreciate the indolent natural history of most
good risk prostate cancers may avoid much of
this anxiety. [Management of Prostate Cancer – Eric A. Klein J. Stephen Jones
Editors]

patients should consider that if they wait
to treat the cancer until the tumor grows, the bigger tumor may mean either an
increased risk of side eff ects (because it requires more extensive surgery) or it may
mean a shift from curable to incurable disease.

Men under 60, for example, are better candidates if
they fulfill the Epstein criteria for insignificant
prostate cancer  – In my case this criteria is not fulfilled. Hence I am not suitable for active surveillance.

Further, “untreated, the… likelihood of disease progression is about three times greater than those without Gleason 4 pattern”  [Management of Prostate Cancer – Eric A. Klein J. Stephen Jones Editors]

In my case there are two small sections with Gleason 4 pattern. Therefore, again, active surveillance is ruled out.

To be a candidate for active surveillance, the
patient must meet certain criteria (as in a study from the Royal Marsden Hospital
in London): 2
• Ages between 50 and 80 years
• Gleason’s score less than or equal to 7
• Clinical stage T1 or T2 disease
• Total PSA less than 15
• PSA score doubling time less than 2 years
• 50 % or less of the biopsy samples positive for cancer
• A reasonable state of health with no other major medical problems [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

 

RADICAL SURGERY

About 40 % of the men who are diagnosed with prostate cancer undergo either
radiation or have radiation combined with surgery.    [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

Victoria has a Prostate Cancer Registry and the most accurate data available about which treatment patients are choosing. Victorian data from 2014 showed that 48 per cent of men in the state with prostate cancer chose surgery compared with just 18 per cent who chose radiation therapy. [Source]

The 5-year biochemical risk-free survivals for the 5 Grade Groups based on radical prostatectomy were – Grade Group 1 – 96.6% –

Grade Group 2 – 88.1%

Grade Group 3 – 69.7% –

Grade Group 4 – 63.7% –

Grade Group 5 – 34.5 % • (p < 0.001)

 

There is a real (albeit small) risk of prolonged illness or death would occur with surgery  [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

Removal of the prostate gland — a procedure called a prostatectomy — can offer patients the best chance to permanently cure their cancer. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

One of the principles of any cancer surgery is that all tissue within a half an inch of the cancer should be cut out to ensure all the cancer cells are removed. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

after removal of the prostate, when a man has sex, he will still have orgasm and all the good feelings that happen with sex, but he will not have the emission of any fluid. Th at means that during post-prostatectomy
sex, he will “shoot blanks” or have dry orgasms. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

I often recommend perineal surgery for all my patients because it can be done
rapidly (within 70 to 90 minutes) and with little bleeding. In general, you want
your surgery to be over quickly, because the longer you are under general anesthesia,
the higher the chance of complications. Also, a quicker surgery can mean a
shorter recovery time. From a surgeon’s point of view, the perineal approach
also provides a better angle to view the bladder and urethral area after the removal
of the prostate gland.   [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

  1. radical retropubic prostatectomy. – through abdomen
  2. radical perineal prostatectomy, – near anus – Th is is a more direct route yet is currently less common —
    only 4 % of prostatectomies are done through the perineum — because most urological surgeons have not been trained in the approach.

Robotic surgery can be more likely to be nerve sparing given the higher magnification and ability to see. robotic-assisted radical prostatectomy has virtually supplanted the laparoscopic
prostatectomy. Men who have the laparoscopic, robotic,
or perineal surgery can return to work and daily living faster — usually within
2 weeks — because there is less pain with the smaller incisions. With a traditional
radical retropubic procedure, it might take the full 6 weeks.

 

urinary incontinence persists in up to 15 % of men 2 years after surgery.
Th e incidence of the incontinence is higher among older men who have surgery.

Your unique anatomy
also plays a role as the nerves can be in slightly diff erent positions in diff erent
people, and on some people more than others, it may be harder for the surgeon to
avoid touching them or possibly nicking them when removing the cancerous tissue.
Because nerves don’t show up on scans, this is one of the factors that the surgeon
faces in the operating room, and thus cannot predict with absolute certainty
whether there will be any nerve damage in your case. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

For those particularly concerned
about urinary continence after surgery, I might steer them toward robotic or
perineal surgeries as these aff ord the best possible view of the urethral-bladder area
so the surgeon can have the best possible chance of joining the urethra and bladder
tightly and smoothly.  [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

PREPARATION:

In the weeks or months leading up to the operation,
I usually suggest increasing the amount of exercise, such as walking or swimming,
to be as strong as possible going into surgery. Th e physical training will help
with breathing and muscle tone and perhaps will help you to lose a few unnecessary
pounds of weight — all of which will help your recovery. Th ere are other exercises
that may prove even more important to your recovery: pelvic fl oor exercises.
When started in the weeks before surgery, these exercises can help your body
regain urinary continence faster after the prostate is removed ( see page 98).

 

The two muscles that affect the control of urine are the bladder neck, which
is not under your voluntary control, and the external urinary sphincter. Th e latter
muscle can shut off the urinary fl ow while you are urinating. To help with control
of the starting and stopping of urination, the muscle needs to be strengthened as
if you were weight-lifting. Th e more lifting, the stronger the muscle. Of course
there are no tiny weights to lift, but muscle strength can be increased with repetitive
exercise like a Kegel exercise. Th e best program is starting and stopping the
urinary stream. Th is can be started long before surgery. Each time you urinate,
stop the stream several times. Th at action will increase the strength and size of the
sphincter muscle and help with control after the surgery.

When the prostate gland is
completely removed, as happens with radical prostatectomy, that buff er is also
removed and control of urine leakage becomes dependent on the muscles of the
pelvic fl oor, known as the external urinary sphincter. By strengthening this muscle,
you can lower your chances of post-operative incontinence, or if you strengthen
post-surgery, you will increase your chances of returning to full continence.

Generally the best case for urinary control is THREE MONTHS after surgery

OPTION TO USE RADIATION

For men who experience a recurrence of their cancer after surgery (meaning that
some cancer cells remained in the body after surgery and reproduced), then radiation
known as salvage radiation is the best course.

GOOD TO UNDERTAKE RADIATION JUST AFTER SURGERY

http://www.medscape.com/viewarticle/842346

 

Costs

There is a debate between the benefits of robotic tools vs traditional surgery. Costs are quite different.

For a high-end operation in a top private hospital in Sydney men can expect to pay $7,000 to $30,000. In a public hospital the same operation can cost just $200. The out-of-pocket expenses of an open operation in a private hospital ranges from $3000 to $5000. [Source]

those with private health insurance tended to have double the out-of-pocket expenses than their public patient peers. [Source]

At Epworth, where most of Victoria’s private robotic surgery is performed, they’ve taken steps in past year to reduce its costs.” Moon says notes that paying for treatment for an early cancer can be far cheaper than paying for an advanced one. In Victoria, the average out of pocket cost for early treatment is $5000 compared to $14000 for advanced cancer. [Source]

There are major cost differences between the two main treatments, with surgery costing more than $20,000 in private hospitals, while radiation therapy is free in public hospitals. [Source]

it was not until after he told the surgeon he could not afford the operation that he was informed he could receive free radiotherapy in a public hospital.[Source]

After analysing claims data for the 12 months to last November, Bupa found 17 per cent of radical prostatectomies were fully covered but 28 per cent carried gap fees of $5001-$10,000 and 35 per cent gap fees of $2001-$5000. [Source]

CHOOSING THE PUBLIC HOSPITAL

The gender gap for Victoria was biggest at Geelong Hospital a comparison of wait times provided on the government’s MyHospital website shows. Prostatectomies, used in the treatment of prostate cancer in Geelong had a median wait time of 94 days compared to 7 days or breast cancer surgery — a difference of 87 days. [Source]

 

RADIATION

Because prostate cancer cells can be relatively resistant to radiation, high doses of energy are often used to kill the prostate cancer. Unfortunately these dosages can also cause damage to normal cells in the rectum and bladder. [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

A recent study of more than 2,000 Australian prostate cancer patients, published in the Journal of Medical Imaging and Radiation Oncology, found no major difference in cure rates between each treatment. [Source]

UNDERSTANDING BRACHYTHERAPY FOR PROSTATE CANCER

risk of cancer recurrence in the robotic and laparoscopic prostatectomy patients was 3 times higher than in standard open radical prostatectomy patients. [Source]

brachytherapy, external beam radiation therapy and open radical prostatectomy were successful in the majority of patients. This was true for all risk groups, but higher dose radiation (EBRT + Brachytherapy) appeared to have better relapse-free survival outcomes in the higher risk and higher grade cancers.

patients in the surgical (radical prostatectomy) arms are typically younger and healthier before treatment than those in the EBRT or brachytherapy arms

the average age and health of the surgically treated patient (before surgery) is more favorable than the average age and health EBRT or brachytherapy patient. Multiple studies prove that younger, healthier patients recover from virtually any type of treatment better than older, sicker patients. So, all these studies have a built-in bias favoring the surgically treated patients.

patients treated with surgery suffer higher rates of incontinence and impotency than those treated with either seed implantation or IMRT radiation.

Those treated with radiation have higher rates of (usually temporary) increased urinary frequency and bowel frequency.

 

 

 

 

troubling is the higher rate of side effects associated with the radioactive seeds. Investigators from the Pacific Northwest Cancer Foundation reported that following interstitial brachytherapy, 5.1 percent of patients were incontinent, and in 1.7 percent, the incontinence was so severe that the men required a urinary diversion– attachment of a bag, worn under the clothes, to collect urine. Three other patients also required the urinary diversion procedure because of severe strictures or urinary retention. [Source]

Continue Reading

About prostate cancer – general, and up to the biopsy stage

GENERAL INFO

STAGING THE CANCER

A source: https://en.wikibooks.org/wiki/Radiation_Oncology/Prostate/Localized_Prostate_Cancer#Active_Surveillance_vs_Radical_Intervention

Prostate cancer has a 95 per cent survival rate, but it was still the second biggest cancer killer among Australian men. “You only have a small window for cure. When it’s closed, it’s closed for good,” Professor Loeb said. [Source]

MRI can reduce the number of men over-diagnosed with prostate cancer and improve the precision of biopsy to detect aggressive cancers, recent research suggests. [Source]

Get Vitamin D: There are well over 800 scientific studies confirming the link between vitamin D deficiency and multiple types of cancers, including prostate cancer. For example, according to a 2005 study, men with higher levels of vitamin D in their blood were half as likely to develop aggressive forms of prostate cancer as those with lower amounts. Another study published two years ago found that men with higher levels of vitamin D in their blood were seven times less likely to die from prostate cancer than those with lower amounts. [source]

Know that there is over-treatment: Watch this video. [55 per cent of prostate cancers should not be treated]

Ben Stiller reveals his battle with ‘aggressive’ prostate cancer

Fact sheet (US govt)

Very slow growing cancer, generally: Prostate cancer may follow an aggressive course, similar to that of other cancers. However, many prostate cancers are indolent, and will have no impact on health, even without treatment. The natural history of prostate cancer diagnosed in the 1970s and 1980s has been welldescribed. For example, Albertsen et al. (2005), reporting the long-term outcome of watchful
waiting, found that the 15-year prostate cancer mortality for men with a Gleason score of 6 was
18–30%, while their 15-year risk of death from other causes was 25–59%. [Prostate cancer: diagnosis and treatment – by National Collaborating Centre for Cancer]

Evidence comes from a randomised trial comparing radical prostatectomy and watchful waiting
(Bill-Axelson et al. 2005; Steineck et al. 2002), in men with localised, well to moderately well
differentiated prostate cancer (i.e. Gleason 6 or 7). Overall mortality, within 10 years of follow-up, was lower in men treated with prostatectomy than in those managed with watchful waiting: 27.0% versus
32.0% respectively (Bill-Axelson et al. 2005). Similarly, the rate of death from prostate cancer
within 10 years of follow-up was lower in the prostatectomy group than in the watchful waiting
group (9.6% vs. 14.9% respectively). Erectile dysfunction and urinary incontinence, however,
were significantly more likely in the prostatectomy group (Steineck et al. 2002). [Prostate cancer: diagnosis and treatment – by National Collaborating Centre for Cancer]

Over-detection: In comparison with those with clinically detected disease, men with PSA-detected cancers will have longer to endure any adverse effects of curative treatment, and longer to wait for any
beneficial effect on survival to emerge. [Prostate cancer: diagnosis and treatment – by National Collaborating Centre for Cancer]

“My advice to my patients is to be as aggressive in treatment as possible to cure a potentially curable cancer.” [After Prostate Cancer A WHAT-COMES-NEXT GUIDE TO A SAFE AND INFORMED RECOVERY –  Arnold Melman, M.D. and Rosemary E. Newnham]

TREATMENT RECOMMENDATION FOR LOCALISED CANCER

Healthcare professionals should offer radical prostatectomy or radical radiotherapy (conformal) to men with intermediate-risk localised prostate cancer. here is no strong evidence for the benefit of one treatment
over another.[Prostate cancer: diagnosis and treatment – by National Collaborating Centre for Cancer]

prostate cancer starts with tiny alterations in the shape and size of the prostate gland cells – Prostatic intraepithelial neoplasia (PIN). Any patient who was found to have high-grade PIN after a prostate biopsy is at a significantly greater risk of having cancer cells in his prostate

he diagnosis of high-grade PIN, which is based on a pathologist’s reading of a given tissue sample, is subjective. Partly for that reason, it is unclear how many men can expect to be diagnosed with high-grade PIN in any given year. Studies of men who have undergone prostate biopsies have found that anywhere from less than 1% to more than 20% had high-grade PIN. A respectable ballpark estimate is that 4% to 8% of men who undergo prostate biopsies will be diagnosed with high-grade PIN.

HOW AGGRESSIVE IS YOUR CANCER?

Caution: “Gleason grade from biopsy is frequently upgraded at prostatectomy, resulting in a reluctance to assign a low GS at diagnosis” [Source] – i.e. there is a small probability that my cancer is worse than the score. However, since locations to be assessed were guided by the MRI, there is a good chance that this is a genuine score.

“For prostatectomy specimens, 4 + 3 cancers were associated with a three-fold increase in lethal PCa compared with 3 + 4 cancers” [Source]

Gleason score 7 is made up of two grades (3+4=7 and 4+3=7), with the latter having a much worse prognosis. Cancers with a Gleason score of 7 can either be Gleason score 3+4=7 or Gleason score 4+3=7:

  • Gleason score 3+4=7 tumors still have a good prognosis (outlook), although not as good as a Gleason score 6 tumor.
  • A Gleason score 4+3=7 tumor is more likely to grow and spread than a 3+4=7 tumor, yet not as likely as a Gleason score 8 tumor.

Epstein criteria for insignificant prostate cancer (no more than one third of all cores positive, no more than half of any one core involved, and a PSA density <0.15).

  • In my case 3+1+4+2+1+2 (12) out of 4+4+4+3+3+3 (21) were positive (excluding one section that may have had 2-3 cores but no figures cited. This means at best 12/23 which is GREATER THAN ONE THIRD.
  • Further two sections had coverage of 50 and 55 per cent/
  • CONCLUSION: IT IS NOT INSIGNIFICANT

TREATMENT FOR SPREADING CANCERS

Prostate cancer tumours ‘shocked’ to death by flood of testosterone: researchers

Laetrile (amygdalin/ Vitamin B17) treatment for prostate cancer

Laetrile: How Much Proof Do They Need?

The cyanide released by amygdalin is one of the best killers of malignant cells as well. Amygdalin has a double punch. It lowers cancers resistance to treatment and it releases cyanide to kill cancer cells directly. [Source]

Laetrile contains an enzyme known as Emulsin that breaks down into cyanide when ingested. It is this chemical reaction that is responsible for Laetrile’s cancer-fighting properties. The most common form of laetrile, or vitamin B17, is derived from apricot seeds as these contain a large amount of the active ingredient that kills cancer…. Unlike conventional cancer treatments, Laetrile has the ability to destroy cancer cells without harming the body’s healthy cells.

 

There have been a number of studies performed in the US on the effectiveness of Laetrile against cancer, all of which claim that it has no effect on cancer cells. However, a study performed in China at the Bethune College of Medicine in 2013 found that the viability of human cervical cancer cells was significantly inhibited by amygdalin.  A 2006 study conducted at the College of Medicine in South Korea found that amygdalin was effective at killing human prostate cancer cells. [sOURCE]

  • Laetrile has shown little anticancer activity in animal studies and no anticancer activity in human clinical trials.
  • The side effects associated with laetrile toxicity mirror the symptoms of cyanide poisoning, including liver damage, difficulty walking (caused by damaged nerves), fever, coma, and death.
  • Laetrile is not approved for use in the United States.

BIOPSY ISSUES

Transperineal Prostate Biopsy – Normally, between 24 and 38 biopsies are taken. 

Australian Urology Association

NHS information sheet:  the results take around three weeks to come back. It can also diagnose other conditions such as benign prostatic hyperplasia (enlargement of the prostate), prostatitis (inflammation of the prostate, usually caused by a bacterial infection) or prostatic intraepithelial neoplasia (PIN), which is a change in the cell type but not cancer.

We give you antibiotics after your biopsy to reduce the risk of infection. You will need to take these for a minimum of three days.

Infections can be very serious after a biopsy so it is important that you seek medical attention if you have symptoms of infection even if it is in the middle of the night! [Source]

Blood when you pass urine: This is not uncommon and can range from peachy
coloured urine to rose or even claret coloured. It is rarely a sign of a serious problem.
Increasing your fluid intake will usually help ‘flush the system’ and clear any bleeding.
However, if there is persistent or heavy bleeding every time you pass urine you should
go to your nearest A&E department.

Difficulty passing urine: It is possible that the biopsy may cause an internal bruise that
causes you difficulty passing urine. This can happen in two in every 100 cases and is
more likely to happen in men who had difficulty passing urine before having the biopsy.
Should you have difficulty passing urine, you may require a catheter and you will need to
go to your nearest A&E department for assessment. A catheter is a hollow, flexible tube
that drains urine from your bladder.

Information sheet.  A general anaesthetic takes 24 to 48 hours to wear off, so please rest for this period of time

In the few days after your procedure: you may have mild discomfort in the biopsy area, with bruising around the skin of your testicles and an ‘aching’ sensation; you should rest and not do any heavy lifting; you may notice some blood in your urine and your semen may be discoloured (pink or brown) for up to six weeks, and occasionally longer — this is nothing to worry about. You should drink plenty of non-alcoholic fluids while you have blood in your urine.

If you display any of the following symptoms: • increased pain • a fever higher than 38 °C • eight hours without passing urine • passing large clots of blood • persistent bleeding.

 

 

Continue Reading