Early prostate cancer--which treatment do men prefer and why?

STUDY TYPE: Preference (prospective cohort). LEVEL OF EVIDENCE: 1b. What's known on the subject? and What does the study add? In general the literature suggests that there is a need for improvement in aiding men diagnosed with early prostate cancer in their decision making about treatment options and that our understanding of this process is inadequate. There is limited data analyzing the reasons why these men decide between potentially curative or observational treatments and data evaluating patients' views before and after definitive therapy are scarce. This study begins the process of understanding the reasons underlying a patient's final treatment decision. Being a prospective study, it looks at the thought processes of these men before treatment during the time the decision is made. It also documents how satisfied patients are with their choice after their treatment and whether they would choose the same treatment again. OBJECTIVE: To identify the reasons for patients with localised prostate cancer choosing between treatments and the relationship of procedure type to patient satisfaction post-treatment. PATIENTS AND METHODS: 768 men with prostate cancer (stage T1/2, Gleason≤7, PSA<20 ug/L) chose between four treatments: radical prostatectomy, brachytherapy, conformal radiotherapy and active surveillance. Prior to choosing, patients were counselled by a urological surgeon, clinical (radiation) oncologist and uro-oncology specialist nurse. Pre-treatment reasons for choice were recorded. Post-treatment satisfaction was examined via postal questionnaire. RESULTS: Of the 768 patients, 305 (40%) chose surgery, 237 (31%) conformal beam radiotherapy, 165 (21%) brachytherapy and 61 (8%) active surveillance. Sixty percent of men who opted for radical prostatectomy were motivated by the need for physical removal of the cancer. Conformal radiotherapy was mainly chosen by patients who feared other treatments (n=63, 27%). Most men chose brachytherapy because it was more convenient for their lifestyle (n=64, 39%). Active surveillance was chosen by patients for more varied reasons. Post-treatment satisfaction was assessed in a subgroup who took part in the QOL aspect of this study. Of the respondents to the questionnaire, 212(87.6%) stated that they were satisfied/extremely satisfied with their choice and 171(92.9%) indicated they would choose the same treatment again. CONCLUSION: Men with early prostate cancer have clear reasons for making decisions about treatment. Overall, patients were satisfied with the treatment and indicated that despite different reasons for choosing treatment, they would make the same choice again.

Radical prostatectomy practice in England.

PURPOSE: As there is paucity of data on radical prostatectomy (RP) as a primary treatment for patients with localized prostate cancer, we analyzed the trends in the RP practice in England. MATERIALS AND METHODS: This study was carried out on 14 300 patients who underwent RP for carcinoma of the prostate. Database was prepared from hospital episode statistics of the Department of Health in England. National trends in RP practice were summarized as well as volume outcome analysis. RESULTS: Annual number of RPs exponentially increased from 972 (1998 to 1999) to 3092 (2004 to 2005). Laparoscopic RPs increased from 2 to 257 over the study period. Median waiting duration increased by more than 10 days (13 days). Significant decrease in median length of hospital stay from 8 (range, 7 to 10) days to 6 (range, 5 to 8) days was observed (P < .001). More than 90% mortality was seen in patients of ≥ 60 years of age. Significant inverse correlation was found between the hospital volume (Odds Ratio: 0.40) and in-hospital mortality rate following RP. High volume surgeons (≥ 16) and high volume hospitals (≥ 26) had significantly lower mortality (Odds Ratio: 0.32) and shorter in-hospital stay in comparison to low volume surgeons and hospitals. CONCLUSION: There is an exponential increase in the number of RPs with an increasing trend towards laparoscopic RP in England. This study showed a significant inverse correlation between provider volume (hospital and surgeon) and outcome (in-hospital mortality and hospital stay) for RP in England; thus, supporting the recommendations for centralization of care for complex radical procedures, including RP.

Impact of hospital provider volume on outcome for radical urological cancer surgery in England.

INTRODUCTION: Complex surgical procedures are associated with higher mortality and morbidity. There is a paucity of data supporting a volume-outcome relationship in the United Kingdom. We analysed Hospital Episode Statistics (HES) to contemplate the association of hospital provider volume and short-term outcomes (mortality rate and hospital stay) for 3 radical urological procedures in England. MATERIALS AND METHODS: The HES database was extracted for radical prostatectomy (RP), radical cystectomy (RC) and radical nephrectomy (RN) using ICD-10 and OPCS-4 codes for 7 years. Hospitals were divided into quartiles depending on the annual hospital volume. The impact of hospital provider volume was analysed for outcomes. RESULTS: Overall 43,946 patients were included in the study. RP patients had the lowest mortality rate (0.2%) and shorter in-patient stay (7 days). Mortality from RC and RN were 475 (5.3%) and 537 (2.6%), respectively. There was no significant difference for mortality following RP in four volume groups (p = 0.76). The mortality rate for RC decreased from 6.9% in the very low-volume group to 4.1% in the high-volume group (p < 0.001) without change in the in-hospital stay. The proportion of patients treated at high-volume centres for RP, RC and RN has increased from 0 to 42, 22 to 35 and 10 to 38%, respectively, over a 7-year study period. CONCLUSION: In England, hospital provider volume has a significant impact on outcome measures for radical pelvic urological procedures with a lower mortality (RC) and shorter in-patient stay (RP). Thus HES data from England support the hospital volume-outcome relationship and emphasise the centralisation of care for radical urological procedures.

Orthotopic neobladder versus ileal conduit urinary diversion after cystectomy--a quality-of-life based comparison.

INTRODUCTION: Radical cystectomy remains the gold standard in treatment of muscle invasive bladder cancer. Evolution of pathological guidelines has empowered centres to offer orthotopic substitution (OBS) to patients undergoing radical cystectomy. We compared health-related quality of life (HRQoL) between patients who underwent OBS or ileal conduit urinary diversion (ICD) following radical cystectomy. PATIENTS AND METHODS: A total of 57 patients who underwent cystectomy were assessed pre-operatively using Karnofsky performance scale (KPS). Of these, 52 patients (28 OBS and 24 ICD) who responded to a postal questionnaire consisting of SF-36 and a functional index questionnaire were included. RESULTS: Median age of patients was 70 years. Pre-operative KPS scores were similar. All eight HRQoL scales were favourable in both groups. OBS patients had significantly better physical functioning. In the cohort, 42% of men with OBS and 25% of diversions could maintain an erection to varying degrees. Of the OBS patients, 85% were continent with two patients reporting reduced QoL with pad usage. Of ICD patients, 63% felt less complete and 42% were embarrassed due to the stoma, with 58% apprehensive of stomal leakage. Of OBS patients, 96% had significant relationships and a more active life-style. CONCLUSIONS: In a similar age-group population, there was no significant difference in most QoL indices but body image issues persist in ICD patients. OBS patients had significantly better physical function, continuing to have a more active lifestyle. They attained urethral voiding with good continence. A detailed discussion of long-term functional outcome would engender a realistic expectation allowing better adaptation.

Prostate abscess: a rare complication of brachytherapy for prostate cancer.

Brachytherapy involves the therapeutic implantation of a radio-active seed source into, or close to, prostate cancer. We report the rare case of a 76-year-old man who presented with a prostate abscess after months of intractable pelvic pain following prostate cancer treatment with iodine-125 brachytherapy. Despite multiple investigations, the diagnosis was made only once the abscess discharged exudate per-urethra.

Prostate cancer diagnosis: should patients with prostate specific antigen >10ng/mL have stratified prostate biopsy protocols?

BACKGROUND: Trans-rectal ultrasound (TRUS) guided systematic prostate biopsy is a standard tool in prostate cancer (CaP) diagnosis. Extended biopsy techniques using 10-12 cores are the norm. Controversy exists on extended TRUS biopsy in men with PSA>10ng/mL. We evaluated cancer detection rates on an individual core basis, to stratify prostate biopsy protocols based on PSA levels. PATIENTS AND METHODS: Over a five-year period, 1036 patients underwent TRUS guided prostate biopsy for raised serum PSA (>2.5ng/mL). 436 patients had PSA>10ng/mL. Patients with PSA<50ng/mL underwent a 12-core TRUS guided prostate biopsy including six peripheral biopsies. The six peripheral biopsies were directed laterally towards the base, mid-zone and apices. Remainder were standard para-sagittal sextant biopsies. Patients were stratified into three groups (PSA 10-20ng/mL, 20-50ng/mL and >50ng/mL). RESULTS: Mean age of 436 patients with PSA>10ng/mL was 70.3years. 270 (62%) men had cancer. Cancer detection rates for different PSA levels were 46% (10-20ng/mL), 76% (20-50ng/mL) and 93% (>50ng/mL). Higher PSA levels and advanced clinical stage were associated with increased cancer detection rates. All patients with clinical T3 and T4 disease had biopsy diagnosed CaP. CONCLUSION: TRUS guided prostate biopsy in patients with PSA>10ng/mL did not require 12 cores to diagnose CaP. CaP diagnosis required 8 cores in men with PSA 10-20ng/mL. These cores were right and left peripheral basal and apical, and right and left para-sagittal basal and apical biopsy. Only 6 cores were necessary to diagnose CaP in men with PSA>20ng/mL which were right and left peripheral basal and apical, and para-sagittal apical biopsies. We suggest limited TRUS prostate biopsy protocols for men with PSA>10ng/mL.

Radical cystectomy: defining the threshold for a surgeon to achieve optimum outcomes.

BACKGROUND: The reorganisation of cancer services in England will result in the creation of specialist high volume cancer surgery centres. Studies have suggested a relationship between increasing surgical volume and improved outcomes in urological pelvic cancer surgery, although to date, they have pre-defined the definition of "high" and "low" volume surgeons. AIM: To derive the minimum caseload a surgeon requires to achieve optimum outcomes and to examine the effect of the operating centre size upon individual surgeon's outcomes. METHODS: All cystectomies performed for bladder cancer in England over 5 years were analysed from Hospital Episode Statistics (HES) data. Statistical analysis was undertaken to describe the relationship between each surgeon's annual case volume and two OUTCOME MEASURES: in-hospital mortality rate, and hospital stay. The surgeon's outcomes were then analysed with respect to the overall level of activity in their operating centre. RESULTS: A total of 6308 cystectomies were performed; the mean number of surgeons performing them annually was 327 with an overall mortality rate of 5.53%. A significant inverse correlation (-0.968, p<0.01) was found between case volume and mortality rate. Applying 95% confidence interval estimation, the minimum caseload required to achieve the lowest mortality rate was eight procedures per year. Increasing caseload beyond eight operations per year did not produce a significant reduction in mortality rate. CONCLUSION: Analysis of HES data confirms an inverse relationship between surgeon's caseload and mortality for radical cystectomy. A caseload of eight operations per year is associated with the lowest mortality rate.

A randomized controlled trial of topical glyceryl trinitrate before transrectal ultrasonography-guided biopsy of the prostate.

OBJECTIVES: To evaluate the use of topical glyceryl trinitrate (GTN) ointment as an adjunct to periprostatic nerve block in reducing pain associated with transrectal ultrasonography (TRUS)-guided prostatic biopsy. PATIENTS AND METHODS: In all, 148 consecutive patients (mean age 67.0 years) having their first TRUS-guided biopsy were randomized to receive either 0.2% GTN ointment or placebo 10 min before biopsy. All patients had a biopsy preceded by an injection with 10 mL of 1% lidocaine local anaesthesia. A 10-point visual analogue score was used to record 'Overall discomfort due to the presence of the probe', the biopsy itself and pain after the procedure. RESULTS: There was no significant difference in age, PSA level and prostate volume between the groups. There was a significantly lower mean pain score due to probe insertion in the GTN than placebo group (1.94 vs 3.24, P < 0.01); pain perception was lower for the whole procedure in the GTN group, and was most pronounced in men aged <60 years (2.13 vs 4.61, P < 0.005). CONCLUSIONS: Topical GTN ointment is safe and effective in reducing the discomfort associated with TRUS-guided biopsy of the prostate, in particular the insertion of the ultrasound probe. It might be of maximum benefit in the younger patient and those having a repeat biopsy who previously failed to tolerate the procedure well.

Importance of peripheral biopsies in maximising the detection of early prostate cancer in repeat 12-core biopsy protocols.

OBJECTIVE: To assess cancer-detection rates in repeat 12-core biopsy protocols, as extended multicore prostate biopsy protocols have become standard when investigating men with a raised prostate-specific antigen (PSA) level, but repeat prostate biopsy protocols are still developing. PATIENTS AND METHODS: During a 4.5-year period, 241 of 590 patients with persistently high age-specific PSA levels of 2.6-10 ng/mL and an initial benign biopsy were invited for repeat transrectal ultrasonography-guided 12-core prostatic biopsy. The protocol for repeat biopsy was identical to the first biopsy, and included a periprostatic nerve block. The first six biopsies were obtained from the periphery of the gland directed more laterally at the base, mid-zone and apices. The remainder were parasagittal sextant biopsies. Pathological findings were analysed on an individual core basis. RESULTS: The mean age of the 241 men was 63.4 years; cancer was diagnosed in 40 (16.6%) on repeat biopsy. Men with cancer were older and had a higher median PSA level. The median Gleason score was 6, with a median of two cores positive for cancer. Maximum cancer detection rates were from peripheral apices (37.5%), basal biopsies had the lowest detection rates (23.8% and 16.3%), and parasagittal biopsies missed 35% of detected cancers. Patients with cancer also had significantly lower prostate volumes and higher PSA densities (both P < 0.001). CONCLUSION: A low cancer yield from both peripheral basal and parasagittal basal specimens on repeat biopsy indicates adequate sampling at initial biopsy. The maximum cancer yield in the peripheral mid-zones and apical zones suggests the necessity for concentrated sampling of these zones in repeat biopsy protocols.

Site of local anaesthesia in transrectal ultrasonography-guided 12-core prostate biopsy: does it make a difference?

OBJECTIVE: To prospectively compare the efficacy of bi-basal vs bi-apical periprostatic nerve block (PPNB) during 12-core prostate biopsy guided by transrectal ultrasonography (TRUS), and to evaluate the pain experienced on inserting the probe compared to the biopsy procedure, as PPNB with lignocaine local anaesthesia has been used for over a decade for minimizing pain during prostatic biopsy. PATIENTS AND METHODS: In all, 143 men who were to have a TRUS-guided prostate biopsy were systematically randomized to two groups, to receive PPNB at the apex or base. A 10-cm visual analogue score was used to record the pain experienced during probe insertion, the biopsy and just before to leaving the department . RESULTS: The mean pain score on biopsy in the apical group was similar to that of the basal group (apex 1.9, base 1.6, P = 0.36). Probe introduction produced a significantly higher pain score (probe 2.2, biopsy 1.7, P < 0.001) than at the biopsy. CONCLUSIONS: Patients who experienced greater pain with the introduction of the probe also reported more pain with the biopsy procedure. The site of local anaesthetic before prostatic biopsy showed no significant difference in pain scores. Older men tolerated the procedure better. Analgesia after PPNB at near either the apex or base appears equal, regardless of the site of injection. We suggest that topical perianal anaesthetic agents could significantly reduce not only pain perception, but also improve tolerance.

Defining the minimum hospital case-load to achieve optimum outcomes in radical cystectomy.

OBJECTIVE: To define 'high-' and 'low-' volume hospitals for radical cystectomy, and the minimum caseload required for a hospital to achieve optimum outcomes, as a relationship between increasing surgical case volume and improved outcomes in radical urological surgery has been suggested in recent North American studies. METHODS: All cystectomies for urological cancer in England over 5 years were analysed from Hospital Episode Statistics (HES) data. The data were analysed statistically to describe the relationship between each hospital's annual case volume and two outcome measures: in-hospital mortality rate (MR) and hospital stay. RESULTS: In all, there were 6317 cystectomies in 210 centres, with an overall MR of 5.6%. There was a significant inverse correlation (-0.733, P < 0.01) between hospital case volume and MR. Applying 95% confidence intervals, the minimum caseload required to achieve optimum outcomes was 11 procedures/year. Increasing the caseload beyond this minimum did not produce a significant reduction in MR. CONCLUSION: Analysis of HES data confirms an inverse relationship between hospital caseload and mortality for radical cystectomy. A caseload of 11 operations/year is associated with the lowest MR.

Trends in prostate cancer incidence and survival in various socioeconomic classes: a population-based study.

OBJECTIVES: Prostate cancer is currently the commonest cancer in men of all ages in UK, but robust demographic data of its distribution in various socioeconomic classes is lacking. We aimed to analyze its incidence, mortality and survival trends in West Midlands, England, from 1986 to 2000 in terms of socioeconomic deprivation. METHODS: Data were collated from the regional cancer registry database and a well-validated demographic score, the Townsend band, was employed as an indicator of social deprivation, including four variables as proxy indicators of socioeconomic status. Individual cases were allocated to one of five deprivation categories using postcode at diagnosis. Regression trend analysis at 1 and 5 years was performed and a P-value derived from the t-test statistic. RESULTS: In the mid-1980s, the incidence rate ratio in affluent:deprived classes was 0.9, with age-standardized rates of 35.23 and 39.53 per 100 000 people. This ratio increased to 1.5 by 2000 with age-standardized rates of 95.98 and 63.13, respectively (172% increase in affluent compared with 60% in deprived). The affluent groups had a 7 and 13% survival advantage at 1 and 5 years; the survival advantage at 1 year was statistically significant (P=0.03). CONCLUSIONS: The preferential changes in incidence and survival in the affluent social classes are likely to be due to heightened awareness, resulting in increased prostate-specific antigen testing, which captures early and relatively slow-growing tumors with a better overall prognosis. If these bipolar trends are allowed to persist, then the gap between the affluent and deprived will continue to widen.

Is a digital rectal examination necessary in the diagnosis and clinical staging of early prostate cancer?

OBJECTIVE: To assess the role of a digital rectal examination (DRE) in the clinical diagnosis of prostate cancer and in predicting the pathological stage, as the diagnosis of early prostate cancer usually comprises prostate-specific antigen (PSA) testing, a DRE and transrectal ultrasonography (TRUS)-guided biopsies. PATIENTS AND METHODS: Over the 4 years between 2000 and 2004, 408 consecutive patients (mean age 63.8 years) referred with age-specific PSA levels of 2.5-10.0 ng/mL and who had a TRUS-guided 12-core prostate biopsy were included in the study. They had a DRE by either of two experienced consultant urologists. The results of the DRE and core biopsy histology were compared with the histology and the radical prostatectomy specimen in a subset (82 men) of the study population. RESULTS: Cancer was detected on biopsy in 152 patients; of the 196 with an abnormal DRE, 47% had cancer on biopsy. In the patients with a normal DRE, 59 cancers were detected. Men with cancer were older and had a higher median PSA level. There was no correlation between the DRE and biopsy findings, and none between an abnormal DRE and histological diagnosis of cancer. Of the patients who had a radical prostatectomy, 38% had a normal DRE. CONCLUSION: There was no correlation between the DRE, biopsy findings and pathological staging. The DRE did not contribute to managing patients with prostate cancer, but this does not mean that there is no longer a place for the DRE in assessing the urological patient. If patients are appropriately counselled before PSA testing, a DRE may not be essential for patients with a PSA level of 2.5-10 ng/mL.