Exploring the feasibility and acceptability of couple-based psychosexual support following prostate cancer surgery: study protocol for a pilot randomised controlled trial.

BACKGROUND: Men who undergo surgery for prostate cancer frequently experience significant side-effects including urinary and sexual dysfunction. These difficulties can lead to anxiety, depression and reduced quality of life. Many partners also experience psychological distress. An additional impact can be on the couple relationship, with changes to intimacy, and unmet psychosexual supportive needs in relation to sexual recovery and rehabilitation. The aim of this exploratory randomised controlled trial pilot study is to determine the feasibility and acceptability of a novel family-relational-psychosexual intervention to support intimacy and reduce distress among couples following prostate cancer surgery and to estimate the efficacy of this intervention. METHODS/DESIGN: The intervention will comprise six sessions of psychosexual and relationship support delivered by experienced couple-support practitioners. Specialist training in delivering the intervention will be provided to practitioners and they will be guided by a detailed treatment manual based on systemic principles. Sixty-eight couples will be randomised to receive either the intervention or standard care (comprising usual follow-up hospital appointments). A pre-test, post-test design will be used to test the feasibility of the intervention (baseline, end of intervention and six-month follow-up) and its acceptability to couples and healthcare professionals (qualitative interviews). Both individual and relational outcome measures will assess sexual functioning, anxiety and depression, couple relationship, use of health services and erectile dysfunction medication/technologies. An economic analysis will estimate population costs of the intervention, compared to usual care, using simple modelling to evaluate the affordability of the intervention. DISCUSSION: Given the increasing incidence and survival of post-operative men with prostate cancer, it is timely and appropriate to determine the feasibility of a definitive trial through a pilot randomised controlled trial of a family-relational-psychosexual intervention for couples. The study will provide evidence about the components of a couple-based intervention, its acceptability to patients and healthcare professionals, and its influence on sexual and relational functioning. Data from this study will be used to calculate sample sizes required for any definitive trial. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01842438.Registration date: 24 April 2013; Randomisation of first patient: 13 May 2013.

Midterm oncological outcome and clinicopathological characteristics of anterior prostate cancers treated by endoscopic extraperitoneal radical prostatectomy.

PURPOSE: The purpose of the study is to characterise the clinicopathological characteristics of anterior prostate cancer (APC) compared to posterior prostate cancer (PPC)s and to determine the midterm oncological outcomes of patients with APCs undergoing endoscopic extraperitoneal radical prostatectomy (EERPE). METHODS: A retrospective review was carried out on all EERPEs performed in 2009. Pathology reports (transrectal ultrasound biopsy and surgical specimen), specimen photographs, demographic details and oncological outcome data from a prospectively maintained database were reviewed. Unpaired t test, chi-squared test and Kaplan-Meier curves were used for the analysis. RESULTS: Of 139 patients identified, 53 were APCs (38 %) and 86 were PPCs (62 %). Significantly, greater number of repeat biopsies were required to diagnose APCs (p = 0.02) and they had significantly fewer positive biopsy cores (p = 0.0005). The APC group had a significantly higher PSA density (PSAd) with (<5 and 5-25 %) tumour involvement in positive cores compared to PPCs (p = 0.036 and 0.024, respectively). APCs had higher positive surgical margin (PSM) rates (p = ns), the apical margin more likely positive than PPCs (p = 0.0006). Biochemical recurrence-free survival (BRFS) for APCs at 1, 2 and 3 years was lower than PPCs, although not statistically significant (p = 0.16). CONCLUSION: In our study, APCs proved more difficult to diagnose and stage, had a higher PSM rate and a trend towards a worse bRFS than PPCs. Additionally, the use of PSAd low core involvement biopsies might aide clinicians to investigate this cohort of patients more thoroughly before advising active surveillance.

Could prostate biopsies be avoided in men older than 75 years with raised PSA?

OBJECTIVES: Our purpose was to review current practice regarding the use of prostate biopsies in men older than 75 years with raised PSA by presenting the results of a retrospective audit and to identify these older men who really benefit from prostate biopsies. METHODS: A high-volume tertiary center's prospectively maintained prostate biopsy database of contemporary biopsies was reviewed. Men were stratified by age and PSA. Logistic regression analysis, Mantel-Haenszel and Fisher's exact tests were used for statistical analysis. RESULTS: Overall, 1,593 men underwent prostate biopsies between April 2004 and August 2006. Of these, 293 patients (18.4%) with a mean age of 82.62 years and mean PSA of 30.37 ng/ml were eligible for the study with an overall incidence of prostate cancer of 73.7%. Elderly men with PSA >20 ng/ml had a prostate cancer detection rate of 91%. They were more likely to have-high grade disease (OR = 5.4, 95% CI = 2.8-10.8, p < 0.0001) and receive hormone deprivation therapy (RR = 3.0, 95% CI = 2.1-4.3, p < 0.0001). Elderly men with PSA <20 ng/ml had a 3-fold risk of being placed on active monitoring. Almost 20% of them had 1 complication following biopsy, of whom 12 (4.1%) needed hospitalization. CONCLUSIONS: Given the high probability of detecting prostate cancer and receiving conservative treatment, prostate biopsies can be omitted in men >75 years with PSA >20 ng/ml. However, they are still useful in fit men >75 and <80 years with PSA <20 ng/ml who can be the potential candidates for treatment with curative intent.

Trends in reporting Gleason score 1991 to 2001: changes in the pathologist's practice.

OBJECTIVE: The prostate specific antigen (PSA) era has been associated with a grade migration towards moderately-differentiated (Gleason 5-7) prostate cancer. We investigated whether changes in interpretation of the Gleason system could be a contributing factor by reviewing the Gleason scores for prostate cancer in our region. PATIENTS AND METHODS: Records of patients with prostate cancer assigned a Gleason score between 1991-2001 were retrospectively reviewed. We analysed trends in Gleason score, method of diagnosis and age at diagnosis. Following this, 50 cases from the dataset were randomly selected (stratified to contain half Gleason 2-4 reports) and reviewed in a blinded manner by an uropathologist and given a new Gleason score. RESULTS: 2737 patients were diagnosed and given a Gleason score; 1484 by prostate biopsy (PB) and 1172 by transurethral resection of prostate (TURP). 273 radical prostatectomy (RP) specimens were received, although the results of pre-operative biopsies were available in only 192 of these patients. Over time, there was an increase in the proportion of patients with Gleason 5-7, and a significant decrease in reporting of Gleason 2-4 cancer (r2 = 0.81, p < 0.0001). In 1991, 24% of cancers were Gleason 2-4; in 2001 this had decreased to 2.4%. TURP was associated with more Gleason 2-4 reports (23%) compared with PB (13.2%) and RP (9.2%). On blinded review, all Gleason 2-4 reports were upgraded to Gleason 5-7 cancer (p < 0.001). CONCLUSION: Over time, the proportion of Gleason 2-4 prostate cancer reported has significantly decreased. Our study suggests that a change in practice by the pathologist is a significant factor in this grade migration.