Metastatic progression following multimodal therapy for unfavorable-risk prostate cancer.

INTRODUCTION: Identifying the optimal management of unfavorable-risk (Prostate Cancer Risk Stratification [ProCaRS] high intermediate-, high-, and very high-risk categories) non-metastatic prostate cancer is an important public health concern given the large burden of this disease. We compared the rate of metastatic progression-free survival among men diagnosed with unfavorable-risk non-metastatic prostate cancer who were initially treated with radiation therapy or radical prostatectomy. METHODS: Information was obtained from medical records at two academic centers in Canada from 333 men diagnosed with unfavorable-risk non-metastatic prostate cancer between 2007 and 2012. Median followup was 90.4 months. Men were eligible for the study if they received either primary radiation therapy (n=164) or radical prostatectomy (n=169), in addition to various adjuvant and salvage therapies when deemed clinically appropriate. Patients were matched on prognostic covariates using two matching techniques. Multivariable Cox proportional hazards models were used to estimate the hazard ratios (HR) and confidence intervals (CI) for metastatic progression-free survival between groups. RESULTS: After matching, treatment groups were balanced on prognostic variables except for percent core positivity. Hazard ratios from all Cox proportional hazards models (i.e., before and after matching, and with and without multivariable adjustment) showed no difference in the rate of metastatic progression-free survival between groups (adjusted unmatched HR 1.16, 95% CI 0.63, 2.13, p=0.64). CONCLUSIONS: Metastatic progression-free survival did not differ between men diagnosed with unfavorable risk non-metastatic prostate cancer who were treated with either radiation therapy or radical prostatectomy.

Transperineal Prostate Biopsies Using Local Anesthesia: Experience with 1,287 Patients. Prostate Cancer Detection Rate, Complications and Patient Tolerability.

PURPOSE: We report our experience with transperineal prostate biopsy as well as the cancer diagnosis rate, complications and patient tolerability in 1,287 consecutive patients at risk for prostate cancer. MATERIALS AND METHODS: Beginning in October 2016 transperineal prostate biopsy was performed using local anesthesia in all patients undergoing prostate biopsy. Data on prebiopsy characteristics and results, including the cancer detection rate, complications and patient tolerability scores, were collected retrospectively from patient records. RESULTS: The cancer detection rate of transperineal prostate biopsy was 49.8% (641 of 1,287 patients). Clinically significant prostate cancer was detected in 385 patients and 62 (9.7%) had exclusively anterior zone pathology findings. Urinary retention developed in 20 patients (1.6%) following transperineal prostate biopsy, requiring temporary catheterization. In 4 patients (0.3%) lower urinary tract symptoms were suggestive of infection but only 1 had a positive urine culture. The only hospital admission was for a patient with persistent hypotension after biopsy. Patients tolerated transperineal prostate biopsy reasonably well and generally reported only mild levels of discomfort on a pain visual analogue scale. Infiltration of the anesthesia was rated more painful than the biopsy. CONCLUSIONS: Transperineal prostate biopsy with the patient under local anesthesia is a feasible alternative to transrectal biopsy in the detection of prostate cancer. Transperineal prostate biopsy has an acceptable cancer detection rate with additional detection of anterior zone cancers. It is a safer alternative in patients due to the low risk of complications, in particular urosepsis, and it is well tolerated. Transperineal prostate biopsy using local anesthesia could be considered a standard modality for the initial diagnosis of prostate cancer.

Diagnosis, referral, and primary treatment decisions in newly diagnosed prostate cancer patients in a multidisciplinary diagnostic assessment program.

INTRODUCTION: We aimed to report on data from the multidisciplinary diagnostic assessment program (DAP) at the Gale and Graham Wright Prostate Centre (GGWPC) at North York General Hospital (NYGH). We assessed referral, diagnosis, and treatment decisions for newly diagnosed prostate cancer (PCa) patients as seen over time, risk stratification, and clinic type to establish a deeper understanding of current decision-making trends. METHODS: From June 2007 to April 2012, 1277 patients who were diagnosed with PCa at the GGWPC were included in this study. Data was collected and reviewed retrospectively using electronic patient records. RESULTS: 1031 of 1260 patients (81.8%) were seen in a multidisciplinary clinic (MDC). Over time, a decrease in low-risk (LR) diagnoses and an increase intermediate-risk (IR) diagnoses was observed (p<0.0001). With respect to overall treatment decisions 474 (37.1%) of patients received primary radiotherapy, 340 (26.6%) received surgical therapy, and 426 (33.4%) had conservative management; 57% of patients who were candidates for active surveillance were managed this way. No significant treatment trends were observed over time (p=0.8440). Significantly, different management decisions were made in those who attended the MDC compared to those who only saw a urologist (p<0.0001). CONCLUSIONS: In our DAP, the vast majority of patients presented with screen-detected disease, but there was a gradual shift from low- to intermediate-risk disease over time. Timely multidisciplinary consultation was achievable in over 80% of patients and was associated with different management decisions. We recommend that all patients at risk for prostate cancer be worked up in a multi-disciplinary DAP.

Do the benefits of finasteride outweigh the risks in the prostate cancer prevention trial?

PURPOSE: The Prostate Cancer Prevention Trial demonstrated that finasteride could reduce the incidence of prostate cancer by 25%. However, its use was also associated with an increased risk of high grade cancer resulting in uncertainty surrounding the net benefits of therapy. MATERIALS AND METHODS: We used the Montreal Prostate Cancer Model, a validated Markov model of prostate cancer progression, to compare the forecasted survival in treated and untreated men. The conditions of the model were varied to reflect different assumptions about whether the cancer grade difference observed in the PCPT was real or a treatment associated artifact, and whether cancers detected on end of study biopsies were clinically significant. RESULTS: For a hypothetical cohort of 1,000, 62-year-old men treated with finasteride, an increased survival of 140 life-years (0.14 years per individual) is forecasted if all diagnosed cancers are considered. If tumor grade differences are held to be artifactual, the forecasted benefits increase to 200 life-years. However, if the tumor grade difference is real and only clinically detected cancers are considered, estimated increased survival is only 20 life-years (0.02 years per individual). CONCLUSIONS: The primary prevention of prostate cancer with finasteride looks promising. However, at the present time it should only be considered with caution until we have answered critical questions surrounding the difference in cancer grade observed in the PCPT and the clinical significance of cancers detected on protocol directed end of study biopsies.