A systematic review of the use of opioid medication for those with moderate to severe cancer pain and renal impairment: a European Palliative Care Research Collaborative opioid guidelines project.

BACKGROUND: Opioid use in patients with renal impairment can lead to increased adverse effects. Opioids differ in their effect in renal impairment in both efficacy and tolerability. This systematic literature review forms the basis of guidelines for opioid use in renal impairment and cancer pain as part of the European Palliative Care Research Collaborative's opioid guidelines project. OBJECTIVE: The objective of this study was to identify and assess the quality of evidence for the safe and effective use of opioids for the relief of cancer pain in patients with renal impairment and to produce guidelines. SEARCH STRATEGY: The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MedLine, EMBASE and CINAHL were systematically searched in addition to hand searching of relevant journals. SELECTION CRITERIA: Studies were included if they reported a clinical outcome relevant to the use of selected opioids in cancer-related pain and renal impairment. The selected opioids were morphine, diamorphine, codeine, dextropropoxyphene, dihydrocodeine, oxycodone, hydromorphone, buprenorphine, tramadol, alfentanil, fentanyl, sufentanil, remifentanil, pethidine and methadone. No direct comparator was required for inclusion. Studies assessing the long-term efficacy of opioids during dialysis were excluded. DATA COLLECTION AND ANALYSIS: This is a narrative systematic review and no meta-analysis was performed. The Grading of RECOMMENDATIONS Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of the studies and to formulate guidelines. MAIN RESULTS: Fifteen original articles were identified. Eight prospective and seven retrospective clinical studies were identified but no randomized controlled trials. No results were found for diamorphine, codeine, dihydrocodeine, buprenorphine, tramadol, dextropropoxyphene, methadone or remifentanil. CONCLUSIONS: All of the studies identified have a significant risk of bias inherent in the study methodology and there is additional significant risk of publication bias. Overall evidence is of very low quality. The direct clinical evidence in cancer-related pain and renal impairment is insufficient to allow formulation of guidelines but is suggestive of significant differences in risk between opioids. RECOMMENDATIONS: RECOMMENDATIONS regarding opioid use in renal impairment and cancer pain are made on the basis of pharmacokinetic data, extrapolation from non-cancer pain studies and from clinical experience. The risk of opioid use in renal impairment is stratified according to the activity of opioid metabolites, potential for accumulation and reports of successful or harmful use. Fentanyl, alfentanil and methadone are identified, with caveats, as the least likely to cause harm when used appropriately. Morphine may be associated with toxicity in patients with renal impairment. Unwanted side effects with morphine may be satisfactorily dealt with by either increasing the dosing interval or reducing the 24 hour dose or by switching to an alternative opioid.

Content development for EUROPEAN GUIDELINES on the use of opioids for cancer pain: a systematic review and Expert Consensus Study.

Workpackage 3.1 (WP 3.1), within the European Palliative Research Collaborative (EPCRC), was aimed at critically revising and updating the European Association for Palliative Care recommendations on cancer pain management. The aim of this paper is to report the results of the first phase in the revision process which consists of a literature review and an expert consensus about the contents to be considered relevant in the development of the new guidelines. A systematic literature search was carried out from 2001 to 2008 through various databases including Medline, Cinahl, Cochrane Database of Systematic Reviews, Embase and Google. Through this process, guideline quality was evaluated, content was compared with EAPC recommendations and a first set of key-points was developed. A modified two-round Delphi method was applied to choose the most relevant topics for future systematic literature reviews. Fourteen guidelines on cancer pain management, published or updated after 2000, were retrieved. A comparison of these guidelines with the EAPC recommendations led to the formulation of 37 key-points, which were submitted to a panel of experts through a Delphi method. Through the responses given by the experts (25 after the first round and 19 after the second) and after a revision by the WP 3.1 local and steering committees, a final list of 22 topics was generated to answer all identified key-points. Each of these topics will be the object of systematic literature reviews. The final version of the "Evidence-based guidelines for the use of opioid analgesics in the treatment of cancer pain: the EAPC recommendations" will be based on the results of the 22 systematic literature reviews.

Opioid analgesics for cancer pain: symptom control for the living or comfort for the dying? A qualitative study to investigate the factors influencing the decision to accept morphine for pain caused by cancer.

BACKGROUND: Morphine and other opioids are the mainstay of cancer pain management, yet considerable fears surrounding them present barriers to pain control. Research in groups already using opioids has examined their concerns, but there is little evidence about how patients react when first offered opioids. We explored the factors influencing the decision to accept or reject morphine when first offered to patients with cancer. PATIENTS AND METHODS: A qualitative in-depth interview study nested within a cancer pain management trial. Interviews were conducted with 18 patients (nine females), aged 42-88 years. RESULTS: The categories that surrounded decisions about commencement of opioids were: anticipation of death; morphine as a last resort; the role of the professional; and 'no choice' but to commence. Participants rejected morphine as a medical intervention to control pain and promote quality of life because they saw it only as a comfort measure for the dying. However, opioids were more acceptable if health care providers had confidence in opioids and side-effects were well managed. CONCLUSION: Among cancer patients the idea that opioids represent a comfort measure for the dying and not legitimate analgesics may represent a greater barrier to their uptake than concerns about tolerance or addiction.

Oral transmucosal fentanyl citrate in the management of breakthrough pain in cancer: an open, multicentre, dose-titration and long-term use study.

Sixty-six patients with cancer-related pain entered an open multicentre study to examine the safety and efficacy of oral transmucosal fentanyl citrate (OTFC) in the treatment of breakthrough pain. Patients were eligible for the study if they were stabilized on a long-acting opioid but were experiencing up to four episodes of breakthrough pain a day and achieving at least partial relief from breakthrough pain using conventional medication (normal release oral morphine in the majority of patients). The efficacy of the conventional medication was documented in a run-in phase and patients then changed to OTFC. All patients were treated initially with a 200 mcg unit of OTFC and the dose was increased if necessary to a level that produced relief of breakthrough pain without troublesome adverse effects. Fifty-eight patients completed the run-in phase using their usual medication and entered the dose titration phase with OTFC and 57 patients received at least one dose of OTFC. Forty-two patients (72%) found a successful dose of OTFC. The primary outcome measures were the Summed Pain Intensity Differences (SPID) and Total Pain Relief (TOTPAR) scores at 60 min. There was a significant difference in both measures in favour of OTFC compared with conventional medication in these patients. Twenty-eight of the 42 patients (67%) preferred OTFC to their usual medication. The most common adverse effects attributed to OTFC were nausea, stomatitis, vomiting and dizziness but there were no unpredicted or severe problems. Thirty-seven patients continued into the long-term study and 12 of these completed six months treatment. Most drop-outs in this phase were associated with progression of the underlying disease. No patient stopped using OTFC because of dissatisfaction with the drug. OTFC appears to be a safe and effective treatment for breakthrough pain in cancer patients and may have advantages over currently available opioid formulations.

Ki-67 staining is a strong predictor of distant metastasis and mortality for men with prostate cancer treated with radiotherapy plus androgen deprivation: Radiation Therapy Oncology Group Trial 92-02.

PURPOSE: The Ki-67 staining index (Ki67-SI) has been associated with prostate cancer patient outcome; however, few studies have involved radiotherapy (RT) -treated patients. The association of Ki67-SI to local failure (LF), biochemical failure (BF), distant metastasis (DM), cause-specific death (CSD) and overall death (OD) was determined in men randomly assigned to short term androgen deprivation (STAD) + RT or long-term androgen deprivation (LTAD) + RT. PATIENTS AND METHODS: There were 537 patients (35.5%) on Radiation Therapy Oncology Group (RTOG) 92-02 who had sufficient tissue for Ki67-SI analysis. Median follow-up was 96.3 months. Ki67-SI cut points of 3.5% and 7.1% were previously found to be related to patient outcome and were examined here in a Cox proportional hazards multivariate analysis (MVA). Ki67-SI was also tested as a continuous variable. Covariates were dichotomized in accordance with stratification and randomization criteria. RESULTS: Median Ki67-SI was 6.5% (range, 0% to 58.2%). There was no difference in the distribution of patients in the Ki-67 analysis cohort (n = 537) and the other patients in RTOG 92-02 (n = 977) by any of the covariates or end points tested. In MVAs, Ki67-SI (continuous) was associated with LF (P =.08), BF (P =.0445), DM (P <.0001), CSD (P <.0001), and OD (P =.0094). When categoric variables were used in MVAs, the 3.5% Ki67-SI cut point was not significant. The 7.1% cut point was related to BF (P =.09), DM (P =.0008), and CSD (P =.017). Ki67-SI was the most significant correlate of DM and CSD. A detailed analysis of the hazard rates for DM in all possible covariate combinations revealed subgroups of patients treated with STAD + RT that did not require LTAD. CONCLUSION: Ki67-SI was the most significant determinant of DM and CSD and was also associated with OD. The Ki67-SI should be considered for the stratification of patients in future trials.

The imPaCT study: a randomised controlled trial to evaluate a hospital palliative care team.

A randomised controlled trial was undertaken to assess the effectiveness of a hospital Palliative Care Team (PCT) on physical symptoms and health-related quality of life (HRQoL); patient, family carer and primary care professional reported satisfaction with care; and health service resource use. The full package of advice and support provided by a multidisciplinary specialist PCT ('full-PCT') was compared with limited telephone advice ('telephone-PCT', the control group) in the setting of a teaching hospital trust in the SW of England. The trial recruited 261 out of 684 new inpatient referrals; 175 were allocated to 'full-PCT', 86 to 'telephone-PCT' (2 : 1 randomisation); with 191 (73%) being assessed at 1 week. There were highly significant improvements in symptoms, HRQoL, mood and 'emotional bother' in 'full-PCT' at 1 week, maintained over the 4-week follow-up. A smaller effect was seen in 'telephone-PCT'; there were no significant differences between the groups. Satisfaction with care in both groups was high and there was no significant difference between them. These data reflect a high standard of care of patients dying of cancer and other chronic diseases in an acute hospital environment, but do not demonstrate a difference between the two models of service delivery of specialist palliative care.

Use of opioid analgesics in a patient with chronic abdominal pain.

Pethidine is the most commonly used opioid in hospitals in the UK, but it lacks potency, has a short duration of action and a narrow therapeutic index. These points are illustrated by a case history of a patient prescribed pethidine for chronic abdominal pain. Misplaced fears of the side-effects of morphine result in its underuse in the management of chronic pain with consequential restriction of patients' functional ability.

Changing face and different countenances of prostate cancer: racial and geographic differences in prostate-specific antigen (PSA), stage, and grade trends in the PSA era.

The purpose of this investigation was to examine changes in pretreatment prostate-specific antigen (PSA), stage, and grade over the past decade as a function of race and geographic region. A multiinstitutional database representing 6,790 patients (1,417 African-American, 5,373 white) diagnosed with nonmetastatic prostate cancer between 1988 and 1997 was constructed. PSA, stage, and grade data were tabulated by calendar year and region, and time trend analyses based on race and region were performed. There was an overall decline of PSA of 0.8%/year, which was significant (P = 0.0001), with a faster rate of decline in African-Americans (1.9%/year) than for whites (0.6%/year). The odds ratio (OR) for a stage shift was 1.09, which was significant (P < 0.0001), and this shift was greater in whites. The OR for an overall grade shift was 1.15, which was significant (P < 0.0001). Although grade and PSA trends were similar for the different regions, there were significant regional differences in stage trends. The implications are that the face of prostate cancer has changed over the past decade; i.e., the distributions of stage, grade, and PSA (the most important prognosticators) have changed. In addition, the countenances of that face are different for whites and African-Americans. For African-Americans, this is good news: the stage, grade, and PSA distributions are more favorable now than before. For whites, the trends are more complex and more dependent on region. These findings should be used for future clinical and health-policy decisions in the screening and treatment of prostate cancer.

Plasma levels of IGF-1, IGF-2, and IGFBP-3 in white and African-American men at increased risk of prostate cancer.

OBJECTIVES: To further investigate the relationship between the plasma levels of insulin-like growth factor-1 (IGF-1), insulin-like growth factor-2 (IGF-2), insulin-like growth factor binding protein-3 (IGFBP-3), growth hormone, testosterone, and demographic factors, particularly race, within a group of men at increased risk of prostate cancer development. METHODS: Enzyme-linked immunosorbent assays or an immunosorbent assay was used to quantitate the plasma levels of IGF-1, IGF-2, IGFBP-3, growth hormone, and testosterone. The study group consisted of 169 men (85 African-American, 84 white) aged 35 to 69 years, with no personal history of prostate cancer, but having at least one first-degree relative diagnosed with the disease, unless they were African-American. The relationships between the plasma levels and the categorical covariates were assessed using the nonparametric Wilcoxon test and between the continuous variables using Spearman's correlation coefficient. RESULTS: The mean plasma levels of IGFBP-3 were significantly lower in African-American (2657 ng/mL) than in white (2965 ng/mL) men (P = 0.0062). The plasma levels of IGF-2 were also lower in the African-American (503.5 ng/mL) than in the white (549.1 ng/mL) men (P = 0.0084). Overall, the IGF-1 plasma levels correlated positively with the IGF-2, IGFBP-3, and growth hormone levels and the IGF-2 plasma levels correlated negatively with the testosterone levels. CONCLUSIONS: Our results demonstrate that lower plasma levels of IGFBP-3 and IGF-2 are associated with race in a population of men at increased risk of developing prostate cancer. The ability of these markers to predict earlier disease onset is currently under investigation.

Hypoxia in human prostate carcinoma: an Eppendorf PO2 study.

The purpose of this study was to characterize the extent of hypoxia in human prostate carcinoma using the Eppendorf PO2 microelectrode. Custom-made Eppendorf PO2 microelectrodes were used to obtain PO2 measurements from the pathologically involved region of the prostate (as determined by the pretreatment sextant biopsies), as well as from a region of normal muscle for comparison. Fifty-nine patients with localized prostate cancer were studied, all of whom received brachytherapy implants under spinal anesthesia. A multivariate mixed effects analysis for prediction of tumor oxygenation was performed including the following covariates: type of tissue (prostate versus muscle), prostatic-specific antigen, disease stage, patient age and race, tumor grade, volume, perineural invasion, and hormonal therapy. Because of differences in patient characteristics, control measurements were obtained from normal muscle in all patients. This internal comparison showed that the oxygen measurements from the pathologically involved portion of the prostate were significantly lower (average median PO2 = 2.4 mm Hg) compared with the measurements from normal muscle (average median PO2 = 30.0 mm Hg), p < 0.0001. A multivariate, linear, mixed analysis demonstrated that the only significant predictor of oxygenation was the type of tissue (prostate versus muscle). This study, using in vivo electrode oxygen measurements, suggests that hypoxia exists in human prostate carcinoma. More patients will be accrued to this study to ultimately correlate the oxygenation status in prostate carcinoma tumors with treatment outcome.

Defining the optimal radiation dose with three-dimensional conformal radiation therapy for patients with nonmetastatic prostate carcinoma by using recursive partitioning techniques.

BACKGROUND: The objective of this study was to determine the effect of dose and its interaction with known prognostic variables, including pretreatment prostate specific antigen (PSA), Gleason score (GS), and T classification, on patients with nonmetastatic prostate carcinoma treated with three-dimensional conformal radiation therapy (3DCRT) alone using recursive partitioning analysis. METHODS: Between November 1987 and November 1997, 939 patients with nonmetastatic prostate carcinoma were treated with 3DCRT alone at Fox Chase Cancer Center. Biochemical no evidence of disease (bNED) control was defined using the American Society of Therapeutic Radiology and Oncology Consensus definition. Recursive partitioning analysis was used to identify subgroups with similar risks of bNED failure. Prognostic factors used in the model included pretreatment PSA, GS, T classification, and radiation dose. The median follow-up was 47 months (range, 2-133 months). RESULTS: Twelve terminal nodes of the decision tree were merged to form four prognostic groups with similar bNED control rates. The 5-year actuarial rates of bNED control rates for Groups I, II, III, and IV were 84%, 41%, 16%, and 67%, respectively (P < 0.0001). Increasing the dose to greater than 7235 centigray (cGy) improved bNED control rates for patients with PSA levels of 10-19.9 ng/mL and T1/2a classification disease. Increasing the dose to greater than 7629 cGy improved bNED control rates for patients with T2b/3 classification disease with PSA levels less than 20 ng/mL. Patients with PSA levels greater than or equal to 20 ng/mL need high-dose 3DCRT. For those patients with GS 2-6 and T1/2a classification disease, treatment with greater than 7400 cGy resulted in 67% bNED control rate versus 16% at 5 years for treatment with less than 7400 cGy. High radiation dose (> 7700 cGy) improved bNED control rate from 16% to 41% for patients with high-risk disease (PSA > or = 20 ng/mL and GS 7-10) at 5 years. CONCLUSIONS: The authors showed that with recursive partitioning techniques radiation dose continues to be an important predictor of bNED control rate and that a radiation dose response for patients with clinically localized prostate carcinoma exists. Patients with one or more prognostic feature (PSA > 10 ng/mL, classification T2b/T3, GS 7-10, or the presence of perineural invasion) achieve similar rates of bNED control compared with those patients with lower volume disease when radiation dose is increased.

Psychological and screening profiles of first-degree relatives of prostate cancer patients.

The purpose of the present study was to systematically compare the psychological and screening profiles of first-degree relatives (FDRs) of prostate cancer patients versus non-FDRs. FDRs (n = 56) and non-FDRs (n = 100), recruited through prostate cancer index cases and newspaper advertisements, completed questionnaires via mail. FDRs reported feeling at greater risk for prostate cancer, estimated that they were at higher average lifetime risk for the disease, agreed more strongly that prostate cancer is inherited, and that less can be done to prevent the development of the disease. Increased age, but not FDR status, was associated with more frequent screening behavior. Taken together, the results indicate that FDRs are characterized by greater perceived vulnerability to prostate cancer and lower expectations about disease prevention. Yet, they are no more likely to be screened than non-FDRs. These findings underscore the importance of developing, and evaluating, evidence-based health communication protocols to promote screening adherence among at-risk patients.

Clinical staging of prostate cancer: reproducibility and clarification of issues.

The American Joint Committee on Cancer (AJCC) staging system for prostate cancer adopted in 1992 is based on tumor-node-metastasis (TNM) designations. It has been widely accepted for use in local and advanced disease. The purpose of this study was to assess reproducibility of staging among observers and to help clarify staging issues. Twelve prostate cancer cases were sent to 20 physicians with special expertise in prostate cancer including eight urologists, eight radiation oncologists, and four medical oncologists. Physicians were asked to assign a stage based on the 1992 AJCC clinical staging. The most frequently reported stage assigned to each case was taken to be the consensus. Agreement was the percentage of physicians who reported that particular stage. Seventy-five percent of the physicians responded. The overall agreement for assignment of T stage was 63.9%. Differences were found by specialty for inclusion of available information in designating a T stage. The overall agreement for N stage was 73.8%. The most common designation was Nx regardless of availability of a computed tomography scan. The overall agreement for M stage was 76.6%. Without a bone scan the most common designation was Mx regardless of Gleason grade or prostate-specific antigen (PSA). A frequent comment was that PSA was more indicative of disease extent than current clinical staging. The reproducibility of the 1992 clinical AJCC staging is poor even among experts in the field. This problem arises primarily from disagreement regarding which studies are included in assigning a stage. Some of these difficulties are addressed in the 1997 revision. However, the clinical staging does not address the true biological significance of disease in many instances.

Patterns and fate of PSA bouncing following 3D-CRT.

PURPOSE: The goals of this study were to quantify the frequency of post-treatment prostate-specific antigen (PSA)-level bouncing following three-dimensional conformal radiation therapy (3D-CRT) for prostate cancer and to identify any relationships that may exist between bouncing activity and biochemical control (bNED). METHODS: Between May 1989 and July 1995, 306 patients were treated with 3D-CRT alone. All patients had 6 or more post-treatment PSA levels and at least 5 years of PSA follow-up. The median total follow-up and total dose to the center of prostate was 79 months and 74 Gy, respectively. A bounce was defined by a minimum rise in PSA of 0.4 ng/mL over a 6-month period, followed by a drop in PSA of any magnitude. Estimates of bNED control rates were made using Kaplan-Meier methodology and comparisons were made using the log-rank test. Multivariate analysis of bNED control predictors was accomplished using a stepwise Cox proportional hazards model. RESULTS: Nearly one third of the patients experienced at least one bounce. Bouncers were found to present with higher pretreatment PSA levels and were treated with lower dose levels to the center of prostate. Five-year bNED control estimates for nonbouncers vs. bouncers were 69% and 52%, respectively (p = 0.0024). After controlling for dose and pretreatment PSA level, total number of bounces emerged as a significant predictor of bNED control (p = 0.02). CONCLUSIONS: Bouncing PSA levels occur in approximately one third of the patients treated with 3D-CRT alone, with bouncing occurring at a constant rate from 2 to 5 years post-treatment. Bouncing is associated with lower radiation dose levels, higher pretreatment PSA levels, and decreased bNED control. Nearly half of the bouncers are bNED controlled; thus, clinicians should not use bouncing as a sole indicator of relapse.

To move or not to move: measurements of prostate motion by urethrography using MRI.

PURPOSE: Urethrography is commonly used to aid in definition of the prostate apex during CT simulation for prostate cancer. If the position of the prostate were altered by the urethrogram itself, then systematic error could be introduced into the patient's treatment. Sagittal MRI scans were acquired immediately before and after a localization urethrogram to determine the extent of displacement. METHODS AND MATERIALS: Thirteen patients underwent sagittal T2-weighted fast spin echo MRI scans. Patients were scanned supine in an alpha cradle cast in the treatment position. The prostate was contoured by 3 different observers to determine the apex location on the central sagittal MRI section and the center of mass relative to an immobile bony landmark. Statistical multivariate analysis was performed to establish if there was a net displacement of the prostate (systematic error), and to determine the margin required to cover the random prostate position within a 95% confidence interval. RESULTS: There was no significant systematic motion of either the prostate nor its apex in either the anterior-posterior or superior-inferior directions. The average motion of the prostate center of mass was 0.04 +/- 0.40 cm (1 SD) and 0.01 +/- 0.33 cm in the anterior-posterior and superior-inferior direction, respectively. The corresponding figures for location of the apex were 0.05 +/- 0.30 cm and 0.01 +/- 0.33 cm, respectively. The statistical analysis revealed that a margin of 2 mm is sufficient to cover any random motion of the prostate that could occur as a result of the urethrogram 95% of the time. CONCLUSION: Urethrography during CT simulation for prostate cancer does not cause significant prostate displacement or systematic error in planning and delivering external-beam radiation.

Evidence for cure of 'young' men with prostate cancer.

A study was undertaken to evaluate the question of cure in "young" men with prostate cancer treated by external-beam radiation. Results in young men (< or = 65 years) were compared to older men. Biochemical freedom from failure was examined to 10 years' follow-up, and hazard functions for failure vs time were reported. Results show that prostate cancer patients are cured by external-beam radiation and that there is no difference in results for young or older men. Few failures occur after 5 years' follow-up and the percentage cured is similar to that with prostatectomy, with much less morbidity. Appropriate dose is necessary to optimize outcome.

The 1989 patterns of care study for prostate cancer: five-year outcomes.

PURPOSE: Five-year results from the 1989 patterns of care study (PCS) for prostate cancer are now ready for analysis. The PCS was initiated to determine national averages for treatments and examine outcomes prospectively; the 1989 prostate study is the first to have collected pre- and post-treatment serum PSA data. METHODS AND MATERIALS: Six hundred patients treated with radiotherapy with curative intent for prostate cancer at 71 separate institutions in the year 1989 made up the study population. Three hundred ninety-one cases were fully analyzable. Pretreatment patient and tumor characteristics were as follows: of the 391 analyzable, 255 had pretreatment PSA values obtained, and 245 had a Gleason's sum (GS) reported. Three hundred fifty-eight were Caucasian, 24 African-American, and 3 Hispanic (also 6 unknown). One hundred three patients had PSA < 10, 60 had PSA 10-19, and 92 presented with PSA >20. Ninety-seven patients were from Radiation Therapy Oncology Group (RTOG), Community Cancer Centers (CCC), or teaching institutions; 141 patients were from other hospital-based, nonteaching institutions; and 153 were from freestanding radiation oncology facilities. Seventy-one patients were T1, 203 T2, and 100 T3/4. Twenty-four out of 391 patients also received neoadjuvant hormone therapy. Survival curves were constructed using Kaplan-Meier methods, and differences between groups were tested for significance using the log-rank test. For cumulative incidence curves, Gray's test was used to investigate failure distributions between groups. The variables entering Cox model for multivariate analysis included age, race, T stage, pretreatment PSA, and GS. A patient was considered a PSA failure if the treating radiation oncologist reported it as such. RESULTS: With a median follow-up of 5.7 years, the 5-year biochemical no evidence of disease (bNED) and overall survival were 56% and 79% respectively for Stage T1, 52% and 81% for T2, and 36% and 63% for Stages T3 and T4 combined. As expected, higher pretreatment PSA, GS, and T stage were all prognostic of poorer outcome. On univariate analysis, bNED survival was adversely impacted by T stage (p = 0.009), pretreatment PSA (p = 0.0035), and by the GS (p = 0.0038). Cause-specific failure was significantly lower for higher T stage (p = 0.014), GS (p = 0.001), and also pretreatment PSA (p = 0.0004). Overall survival was significantly lower in patients with higher T stage (p = 0.047) or GS (p = 0.0191), but not pretreatment PSA (p = 0.284). On multivariate analysis, pretreatment PSA was found to be statistically significant in association with bNED survival, and GS was associated with overall survival, cause-specific survival, and distant metastasis. Few late complications were reported: 13/391 and 13/391 Grade 2-3 gastrointestinal (GI) and genitourinary (GU) complications respectively, with two patients having required surgery with or without a permanent colostomy. CONCLUSION: For a representative cross-section of institutions in the United States, radiotherapy achieved high rates of bNED and CSS in selected groups of prostate cancer patients. When studied retrospectively, increased pretreatment PSA was a strong predictor of both biochemical failure and death due to prostate cancer. New strategies for patients with high-stage, high-grade tumors and/or pretreatment PSA >20 deserve testing.

The Patterns of Care Survey of radiation therapy in localized prostate cancer: similarities between the practice nationally and in minority-rich areas.

PURPOSE: Over the last two decades, the chance for the cure of localized prostate cancer by radiation has been improved by the widespread use of PSA for early detection and by a number of technical advances in treatment delivery. This study was designed to determine whether the stage of presentation and the quality of radiation treatment delivered are comparable between Caucasian and minority patients nationally and within minority-rich areas. METHODS AND MATERIALS: A random survey conducted for the Patterns of Care Study in Radiation Oncology of 80 facilities treating patients with radiation in the USA. Of these, 67 comprise the "National Survey" and 13 a "Minority-Rich" survey (>40% of treated patients are minorities). Nine hundred twenty-six men with localized prostate cancer were treated in 1994. Five hundred ninety-five were in the national and 331 in the minority-rich survey. The main outcome measures were the clinical features of Caucasian and minority men at presentation and technical characteristics of the treatment delivered to them. RESULTS: African-American men presented with more advanced disease (higher-presenting PSA and T-stage) than Caucasians in both the national and the minority-rich surveys. Hispanics also presented with later disease and could be grouped with African-American men rather than Caucasians. Overall the stage and PSA at presentation was earlier than seen in the previous Patterns of Care Study survey of 1989. The quality of treatment delivered has improved since 1989, with no distinction seen between those facilities sampled nationally and those within minority-rich areas. CONCLUSION: African-American and Hispanic men with prostate cancer present for therapy at a later stage than Caucasian men, but when they do, the treatment received is of comparable quality.

Increased hypoxia correlates with increased expression of the angiogenesis marker vascular endothelial growth factor in human prostate cancer.

OBJECTIVES: To test the hypothesis that increasing levels of hypoxia are associated with increased expression of vascular endothelial growth factor (VEGF) in prostate cancer by correlating the level of median tissue oxygenation in human prostate tumors with the immunohistochemically determined level of VEGF expression. METHODS: Custom-made Eppendorf oxygen microelectrodes were used to quantitate the pO(2) levels in prostate tumors of 13 men undergoing radical prostatectomy. All pO(2) measurements were performed under fluorine-based general anesthesia. Paraffin-embedded tumor tissue from these men was analyzed to measure the level of VEGF expression by immunohistochemical staining. The significance of the associations between the pO(2) levels and VEGF staining were determined by the Pearson correlations. RESULTS: The range of the median pO(2) levels (based on between 97 and 129 individual measurements) among 13 prostate tumors was 0.5 to 44.9 mm Hg. The blinded comparison of pO(2) levels and VEGF staining intensity demonstrated a significant correlation between increasing hypoxia and the percentage of cells staining positive for VEGF (r = -0.721, P = 0.005). This correlation was also significant when pO(2) levels were compared with the overall immunoreactive score, which takes into account staining intensity (r = -0.642, P = 0.018). CONCLUSIONS: To our knowledge, this is the first study demonstrating a significant association between increasing levels of hypoxia and increased expression of the angiogenesis marker VEGF in human prostate carcinoma. The results of our study further support the exploration of antiangiogenesis strategies for the treatment of human prostate cancer.