Don't Change Much.

Few studies have assessed differences in the prevalence of and economic burden attributable to tobacco smoking, excess weight, physical inactivity, and alcohol use by gender. This article examines these gender differences in Canadians between the ages of 30 and 64 years. It also estimates the potential cost avoidance if the prevalence of the four risk factors (RFs) were reduced modestly in males. Data on the prevalence of the RFs and the relative risk of disease associated with each of the RFs were combined to calculate population-attributable fractions. A prevalence-based cost-of-illness approach was used to estimate the economic burden associated with the four RFs. Middle-aged Canadian males are more likely to smoke tobacco (26.4% vs. 20.2%), consume hazardous or harmful levels of alcohol (14.6% vs. 8.2%), and have excess weight (65.6% vs. 47.1%) than middle-aged Canadian females, resulting in an annual economic burden that is 27% higher in males than females. No significant differences were observed in the proportion of males who are physically inactive (48.4% vs. 49.4%). Modelling only a 1% annual relative reduction each year through to 2036 would result in a cumulative cost avoidance between 2013 and 2036 of $50.7 billion. The differences in RF prevalence between middle-aged males and females have an important effect on the population's economic burden. A modest annual reduction in the four RFs in males can significantly affect population health and the economy over time.

Patient preference and the impact of decision-making aids on prostate cancer treatment choices and post-intervention regret.

The number of prostate cancer survivors is rapidly growing in the Western world. As a result of better oncologic outcomes, more patients are living longer with the adverse effects of treatment, which can be both functional and psychological. Clinicians, in an era of shared decision-making, must not only cure the cancer, but also ensure that, after treatment, their patients experience the best quality of life and minimal post-treatment decisional regret. To participate in the decision-making process, men and their involved partners and family need to fully understand the relative benefits and harms of prostate cancer treatments.Patient preference studies indicate that men with prostate cancer are not well informed. Decision-making aids are a positive treatment adjunct both to convey information and to allow patients to explore their own beliefs and values during the decision-making process. The evidence suggests that decision-making aids better prepare patients for involvement in treatment decisions, but further studies are required to investigate the relationship between the use of decision-making aids and post-treatment decisional regret in prostate cancer.

Intermittent versus continuous androgen suppression therapy: do we have consensus yet?

Androgen deprivation therapy (ADT) has been a cornerstone in the management of advanced prostate cancer for more than 50 years, but several aspects of the therapy remain controversial. Research since the mid-1980s has looked at the use of intermittent androgen suppression (IAS) as a way to reduce the side effects and costs of continuous androgen suppression. During that same time, testing for prostate-specific antigen resulted in forward stage migration both at diagnosis and at the time of treatment initiation. Earlier treatment has led to prolonged periods of ADT and increasing recognition of the resultant metabolic complications. With preclinical evidence suggesting a potential benefit for ias in terms of time to androgen independence, with phase II and III studies producing optimistic results, and with the potential for reductions in cost and complications, ias has become a popular modality of therapy around the globe. Large prospective randomized studies, currently ongoing, will ultimately determine the legitimate place of IAS in the treatment of prostate cancer.

Preferences for sexual information resources in patients treated for early-stage prostate cancer with either radical prostatectomy or brachytherapy.

OBJECTIVE: To identify the preferences for sexual information resources of patients before and after definitive treatment for early-stage prostate cancer with either radical prostatectomy (RP) or brachytherapy. PATIENTS AND METHODS: Two hundred patients (mean age 64 years) treated with either RP or brachytherapy were recruited from radiation oncology (100) and urology (100) outpatient clinics. Patients completed a survey questionnaire to identify the types of information used, preferred sources of information, knowledge of treatments for erectile dysfunction (ED), effect of sexual function on the treatment decision, and the International Index of Erectile Function (IIEF) to assess their current level of sexual function. RESULTS: Urologists were identified as the main source of sexual information. Written information, Internet access and videos were identified as preferred sources of information before and after treatment. The effects of treatment on sexual function had no apparent significant influence on the men's definitive treatment choice. Compared with patients in the brachytherapy group, patients in the RP group reported having significantly higher levels of sexual desire (P < 0.001) after treatment, but otherwise the erectile domains of the groups were remarkably similar. Two-thirds of patients wanted more information on the effects of treatment on sexual function, and on available treatments for ED. CONCLUSIONS: These results support the need for physicians to offer patients access to information on the effect of treatment for early-stage prostate cancer on erectile function before and after treatment.

Patients' preferences for communicating a prostate cancer diagnosis and participating in medical decision-making.

OBJECTIVES: To assess patients' preferences about how physicians' deliver news of a prostate cancer diagnosis, and patients' preferred participation in medical decision-making, with a secondary objective being to validate the Measure of Patients' Preferences (MPP) scale with these patients. PATIENTS AND METHODS: Eighty-seven men (mean age 62.4 years) referred to an ultrasound/radiology department for their first transrectal ultrasonography (TRUS)-guided biopsy completed the MPP and Control Preferences measures. Patients were asked to identify how they would like to be told about a potential prostate cancer diagnosis by their physician, and what role they would like in making treatment-related decisions with their physicians. RESULTS: Most patients wanted either an active (43%) or collaborative (47%) role in medical decision-making if the TRUS showed prostate cancer. Men rated content items (what and how much information is provided by their physician) as more important than supportive (emotional support during interaction) or facilitative (setting and context variables) items. Men who preferred a collaborative role in the patient-physician interaction wanted significantly (P = 0.04) more content (detailed information on available treatments and the effect of these treatments on their quality of life) than men who had a preference for either an active or passive role in medical decision-making. Demographic characteristics were not indicative of either preferred role in decision-making or communication preferences. The MPP was shown to be reliable. CONCLUSIONS: Men have expectations about how physicians disclose a diagnosis of prostate cancer and how they wish to participate in making treatment decisions. These results underline the importance of identifying patient preferences before embarking on treatment discussions, as the way 'bad news' is disclosed has previously been identified as a predictor of the outcome of the patient-physician interview.

Long-term followup of a randomized trial of 0 versus 3 months of neoadjuvant androgen ablation before radical prostatectomy.

PURPOSE: In 1992 we initiated a national randomized prospective trial of 3 months of cyproterone acetate before radical prostatectomy compared to prostatectomy alone. Initial results indicated a 50% decrease in the rate of positive surgical margins. This decrease did not translate into a difference in prostate specific antigen (PSA) progression at 3 years. This report is on the long-term outcome (median followup 6 years) of this cohort. MATERIALS AND METHODS: This prospective, randomized, open label trial compared 100 mg cyproterone acetate 3 times daily for 3 months before surgery to surgery alone. Randomization occurred between January 1993 and April 1994. Patients were stratified according to clinical stage, baseline serum PSA and Gleason sum. A total of 213 patients were accrued. Biochemical progression was defined as 2 consecutive detectable PSAs (greater than 0.2 ng/ml) at least 4 weeks apart, re-treatment or death from prostate cancer. RESULTS: A total of 34 (33.6%) patients undergoing surgery only and 42 (37.5%) patients given neoadjuvant hormone therapy (NHT) had biochemical recurrence during the median followup of 6 years. Despite the significant pathological down staging in this study, there was no significant difference in number of patients with no evidence of biochemical disease (bNED) survival (p = 0.732). A bNED survival benefit favoring NHT was seen in men with a baseline PSA greater than 20 (p = 0.015). CONCLUSIONS: After 6 years of followup there was no overall benefit with 3 months of NHT. Improved bNED survival was seen in the highest risk PSA group (PSA greater than 20). The possibility that high risk patients may benefit from NHT warrants further investigation.

Decisional regret and quality of life after participating in medical decision-making for early-stage prostate cancer.

OBJECTIVE: To determine the effect of men's reported levels of involvement in medical decision-making and quality of life (QoL) on their levels of decisional regret after definitive treatment. PATIENTS AND METHODS: Men referred to a hospital-based resource centre completed QoL and decisional-regret measures after definitive treatment for localized prostate cancer. Data from these questionnaires were linked with a previous study conducted to determine if providing individualized information to men newly diagnosed with prostate cancer would lower their levels of psychological distress and enable them to become more active participants in treatment decision-making. The preferred role in medical decision-making and QoL had previously been measured at the time of diagnosis and the assumed role at 4 months after the definitive treatment decision. This postal survey was conducted approximately 18 months after diagnosis. RESULTS: Of 74 men, 67 (91%) responded; the mean (sd) time since definitive treatment was 10.3 (4.7) months and the mean age of the men 62.5 (6.9) years. Radical prostatectomy was the most frequent treatment (72%). Most (94%) patients participated in medical decision-making either actively or collaboratively and did not regret their treatment choice. The type of definitive treatment received had no effect on decisional regret; patients' QoL scores were similar to the levels before treatment. Levels of sexual function were significantly lower after definitive treatment, but urinary incontinence was not significantly affected. Men who had neoadjuvant hormone therapy reported having significantly more treatment-related symptoms. CONCLUSIONS: There is no evidence that providing information to facilitate participation in medical decision-making causes decisional regret or psychological distress within the first year after definitive treatment. A longitudinal follow-up of these patients is required to adequately assess the long-term effects of treatment on QoL and decisional regret.

Mass spectral analysis of PC-SPES confirms the presence of diethylstilbestrol.

INTRODUCTION/OBJECTIVES: PC-SPES is an herbal mixture available over the counter for the treatment of prostate cancer. It was re-called in January 2002 due to alleged contamination with warfarin. Other laboratories, including our own, claim that the potent synthetic estrogen, diethylstilbestrol (DES) which has been used for many years to treat hormone dependent prostate cancer, could be detected in the herbal mixture. Recent clinical studies report objective responses in men with hormone dependent and naïve prostate cancer, and also describe isolated cases of estrogenic side effects. A lack of effective conventional treatments for advanced hormone refractory prostate cancer has led to a widespread use of PC-SPES by patients across the North America continent. The presence of DES in PC-SPES might explain both clinical response and observed side effects in men taking 6-9 capsules per day. METHODS: We tested five batches of commercially available PC-SPES using gas chromatography (GC) and high performance liquid chromatography (HPLC) upon methanolic extraction. Duplicate aliquots were tested for each batch and the results compared to standard curves generated using DES (99% purity). RESULTS AND CONCLUSIONS: We detected significant levels of DES in three out of five tested batches. The presence of a synthetic steroid in PC-SPES is not likely to have occurred as a result of its extraction from a herbal source. The implications of this finding highlight the necessity of regulated quality control and standardization of natural health products.

Rising prostate specific antigen after radical prostatectomy: a case based review.

Prostate specific antigen (PSA) has been proven to be a valuable tool in the diagnosis and staging of early prostate cancer and as a sensitive marker of residual or recurrent cancer after curative therapy. In 1998, 200 000 new cases of prostate cancer were reported in the SEER database. Two-thirds of these, or 134 000 men, underwent definitive therapy for localized cancer, including approximately 75 000 radical prostatectomies. It has been reported that 20%-50% of radical prostatectomy patients will have a PSA only recurrence. One can therefore estimate that every year 15 000 to 38 000 men will have a rising PSA following definitive surgical therapy. This elevation of PSA often precedes clinical failure by many years and poses a difficult management problem for which there are not, as yet, definitive management guidelines. This paper will review the definition of PSA recurrence, the natural history, diagnostic options and the therapeutic choices, as illustrated by several genuine cases.

Randomized comparative study of 3 versus 8-month neoadjuvant hormonal therapy before radical prostatectomy: biochemical and pathological effects.

PURPOSE: A prospective phase 3 trial was initiated to determine whether 8 compared with 3-month neoadjuvant hormonal therapy reduces prostate specific antigen (PSA) recurrence rates after radical prostatectomy. Our interim analysis includes secondary end points of differences in biochemistry, pathology and adverse events between the 2 groups. MATERIALS AND METHODS: Men with clinically confined prostate cancer were randomized to receive 7.5 mg. leuprolide intramuscularly monthly and 250 mg. flutamide orally 3 times daily for 3 or 8 months before radical prostatectomy. Our study was powered to detect a 35% decrease in PSA recurrence, assuming a 30% recurrence rate in the 3-month arm after 3 years. RESULTS: A total of 547 men were randomized between August 1995 and April 1998. Men in the 8 and 3-month groups were equally stratified for T stage (29% T1c, 70% T2), Gleason grade (68% less than 4, 32% 4 or greater) and pretreatment PSA (63% less than 10, 27% 10 to 20 and 10% greater than 20 microg./l.). Mean pretreatment PSA was slightly higher in the 8-month compared with the 3-month group (11.64 versus 9.95 microg./l., respectively, p = 0.0539). A total of 44 men withdrew from study before surgery and, therefore, were nonevaluable. Preoperative PSA nadir was less than 0.1 microg./l. in 43.3% versus 75.1% (p <0.0001), and 0.3 microg./l. or greater in 21% versus 9.2% after 3 versus 8 months, respectively (p <0.0006). Mean serum PSA decreased 98% to 0.12 microg./l. after 3 months, with a further 57% to 0.052 microg./l. from 3 to 8 months. Transrectal ultrasound determined that prostatic volume decreased 37% from a mean of 40.6 to 25.4 cc after 3-month neoadjuvant hormonal therapy (p = 0.0001) and a further 13% to 22.2 cc after 8 months (p = 0.03). Mean hemoglobin decreased 15% (148.2 to 125.4 gm./dl.) after 3-month neoadjuvant hormonal therapy but stabilized thereafter. Radical prostatectomy was completed in 500 men, while surgery was aborted intraoperatively in 3. Positive margin rates were significantly lower in the 8 than 3-month group (12% versus 23%, respectively, p = 0.0106). There were no fatal adverse events and no differences between the 2 groups in the severity or causality (p = 0.287, 0.0564) of adverse events, or incidence of increased liver enzymes or diarrhea (p = 0.691, 0.288, respectively). However, men in the 8-month group noticed a higher number of newly reported adverse events (4.5 versus 2.9, p <0.0001) and higher incidence of hot flushes than the 3-month group (87% versus 72%, respectively, p <0.0001). CONCLUSIONS: Ongoing biochemical and pathological regression of prostate tumors occurs between 3 and 8 months of neoadjuvant hormonal therapy, suggesting that the optimal duration of neoadjuvant hormonal therapy is longer than 3 months. Longer followup is needed to determine whether longer therapy alters PSA recurrence rates.

Intermittent androgen suppression for prostate cancer: Canadian Prospective Trial and related observations.

The Canadian Prospective Trial of intermittent androgen suppression was a prototype therapeutic initiative started in 1995 for the management of patients in biochemical relapse after radiation for localized prostate cancer. An interim analysis has yielded several observations on the relations between baseline serum prostate specific antigen (PSA), nadir serum PSA, Gleason score, and time off-treatment. In a typical androgen-dependent tumor, the response of serum PSA to androgen withdrawal is biphasic, but with early tumor progression, plateauing of serum PSA is observed. Ligand-independent activation of the androgen receptor, a mechanism subserving the initiation of androgen independence, can be counteracted experimentally with decoy molecules and clinically with nonsteroidal antiandrogens. In some patients, it is possible to lengthen the off-treatment interval by inhibiting the enzyme 5 alpha-reductase, an effect that can be reinforced by lowering serum testosterone with an antigonadotropin. Serial measurements of serum PSA indicate that intermittent androgen suppression engenders a more diverse range of hormone-related responses than previously appreciated. These include: (1) repeated differentiation of tumor with recovery of apoptotic potential; (2) inhibition of tumor growth by rapid restoration of serum testosterone; and (3) restraint of tumor growth by subnormal levels of serum testosterone. These responses are aspects of regulation that should be taken into account when planning long-term treatment of prostate cancer with intermittent androgen suppression.

Neoadjuvant hormone therapy: the Canadian trials.

The Canadian Urologic Oncology Group has carried out three studies of neoadjuvant hormonal therapy (NHT) in prostate cancer. The first, a study of 3 months of cyproterone acetate (CPA) 100 mg TID in patients undergoing external-beam radiation therapy, showed a benefit with respect to time to biochemical progression. There are no survival or clinical progression data available from this study. The second study involved 3 months of CPA prior to radical prostatectomy compared with radical prostatectomy alone and enrolled 200 patients. The probability of biochemical progression at 36 months was similar in the two groups (CPA 40%; surgery alone 30%; P = 0.3233). More recently, we have carried out a randomized trial of 3 v 8 months of leuprolide plus flutamide prior to radical prostatectomy in 547 patients. Patients were stratified by clinical stage, Gleason grade, and serum prostate specific antigen (PSA) concentration. In the 3- and 8-month groups, presurgery PSA concentrations were <0.1 ng/mL in 35% v 73%, and >0.3 ng/mL in 37% v 10%, respectively. In the 3- and 8-month groups, the positive margin rates were 17% and 5% and the organ-confined rates 71% and 91% (P < 0.01). One-year follow-up is now available on the entire cohort. Data regarding time to biochemical and clinical progression and overall and disease-specific survival will be required to determine whether this change in the pathologic findings translates into a patient benefit.

Long-term neoadjuvant hormone therapy prior to radical prostatectomy: evaluation of risk for biochemical recurrence at 5-year follow-up.

OBJECTIVES: To assess the effects of 8 months of neoadjuvant therapy on pathologic stage and biochemical recurrence rates. METHODS: One hundred fifty-six men with clinically localized prostate cancer were treated with neoadjuvant combined androgen withdrawal therapy for 8 months prior to radical prostatectomy. Preoperative clinical stage, Gleason score, and serum prostate-specific antigen (PSA) levels were compared with treatment outcome (pathologic stage and PSA recurrence). RESULTS: PSA at diagnosis was 10 microg/L or higher in 36% with a mean of 11.5 microg/L. Clinical stage was T1c in 18%, T2 in 74%, and T3a in 8%. Gleason score was 6 or lower in 76% and 7 or higher in 24%. Pathologic stage was T0 in 13%, T2 in 66%, T3 (specimen confined) in 13%, T3 (margin positive) in 6%, and TxN+ in 2%. Incidence of positive margins increased with clinical stage T3a versus organ-confined disease (25% versus 4%, P <0.05), pretreatment Gleason scores 7 or higher versus Gleason scores 6 or lower (11% versus 4%, P = NS), and pretreatment PSA levels higher than 10 microg/L compared with PSA levels lower than 10 microg/L (15% versus 0%, P <0.01). Overall PSA recurrence rate was 12.2% after a mean postoperative follow-up of 54 months. Risk of PSA recurrence increased with clinical stage (25% T3 versus 11% organ confined, P <0.01), pretreatment PSA (7% if PSA lower than 10 microg/L versus 21% if 10 microg/L or higher, P <0.02), Gleason score (9% if 6 or lower versus 22% if 7 or higher, P <0.02), and pathologic stage (6% of pT2, 24% of pT3M-, and 56% of pT3M+, P <0.01). PSA recurrences occurred in 6% of patients with no adverse preoperative risk factors, 12% with any one of the high-risk factors, and 29% with any two of the high-risk factors. CONCLUSIONS: Risk of PSA recurrence after 8 months of neoadjuvant therapy is low after 5 years of follow-up and remains proportional to the presence of adverse preoperative risk factors. Prospective randomized studies are required to determine whether longer duration of neoadjuvant therapy reduces the risk of biochemical recurrence after radical prostatectomy.

Practice patterns of Canadian urologists in benign prostatic hyperplasia and prostate cancer. Canadian Prostate Health Council.

PURPOSE: We reviewed the practice patterns of Canadian urologists in benign prostatic hyperplasia (BPH) and prostate cancer, and assessed the changes that occurred between 1995 and 1998. MATERIALS AND METHODS: In 1995 and 1998 questionnaires were mailed to all active members of the Canadian Urological Association who practiced adult urology in Canada. Many questions were similar, allowing for the assessment of changes in practice patterns. RESULTS: A number of changes were observed between 1995 and 1998. Cystoscopy and imaging of the upper urinary tract were used less often to evaluate uncomplicated cases of BPH. However, 39% of respondents continued to perform cystoscopy routinely. Finasteride was no longer administered in men with a smaller prostate. In 1998 before radical prostatectomy 28% of respondents routinely performed a bone scan, 29% cystoscopy and 57% chest x-ray. The number believing that maximal androgen blockade is the most effective hormonal therapy decreased from 90% to 62%, while 24% reported in the 1998 survey that they frequently administered intermittent hormonal therapy. Comparison with an American study from 1995 indicated that American urologists used the American Urological Association symptom score and performed a prostate specific antigen test more frequently than Canadian urologists. However, Canadian urologists performed cystoscopy more frequently. CONCLUSIONS: These surveys provide a useful insight into the variations in clinical practice of Canadian urologists and help to determine whether changes are occurring in regard to the development of practice guidelines. They also indicate the need to develop further guidelines, and ensure that these guidelines are widely promoted and accepted by the urological community.

Neoadjuvant hormonal therapy prior to radical prostatectomy: promises and pitfalls.

Prostate Cancer and Prostatic Diseases (2000) 3, 136-144

Impact of a shared decision-making program on patients with benign prostatic hyperplasia.

OBJECTIVES: To determine patient views about the Shared Decision-Making Program (SDP), an interactive videodisk program designed to inform patients with benign prostatic hyperplasia (BPH) about their condition and treatment options and to determine its impact on perceived knowledge and treatment preference. METHODS: Six hundred seventy-eight patients with symptomatic BPH from eight Canadian centers viewed the SDP. Before and after viewing the video, patients answered questionnaires designed to assess treatment preference, knowledge gained, and satisfaction with this educational format. A 1-year follow-up survey was also conducted. RESULTS: Most patients showed a high desire for information and high satisfaction with the SDP; this satisfaction persisted at 1 year. Patients' self-reported knowledge increased significantly (P <0.0001). However, the SDP did not alter initial treatment preferences among those with already formed preferences, although it aided almost half of those initially undecided in forming a preference. Viewing the SDP also appeared to enhance the physician-patient relationship. CONCLUSIONS: Patients saw the SDP as an effective method for teaching patients about BPH and the risks and benefits of various treatments, clarifying particular areas about which many patients appear to have a desire for more information than is often provided. Patients were enthusiastic about the educational value of the program, and their active participation in the decision-making process may actually enhance the physician-patient relationship. Contrary to other studies, we found no significant alterations in treatment preferences. Problems relating to the cost and timely updating of the software need to be addressed for these kinds of programs to realize their full potential.

CUOG randomized trial of neoadjuvant androgen ablation before radical prostatectomy: 36-month post-treatment PSA results. Canadian Urologic Oncology Group.

OBJECTIVES: To test the hypothesis that neoadjuvant androgen ablation before radical prostatectomy reduces the likelihood of biochemical progression at 36 months. METHODS: Two hundred thirteen patients with localized prostate cancer were randomized to radical prostatectomy alone (Sx, n = 101) or a 12-week course of 300 mg of cyproterone acetate daily followed by surgery (CPA, n = 112). Biochemical progression (two consecutive detectable prostate-specific antigen [PSA] values) was determined for the entire group and by baseline PSA, Gleason score, clinical stage, and pathologic stage. RESULTS: The probability of biochemical progression at 36 months was similar in both groups (CPA 40.2%, Sx 30.1%; P = 0.3233). CPA patients with baseline serum PSA between 25 and 50 ng/mL had a lower probability of biochemical progression (CPA 63.5%, Sx 84.6%; P = 0.0038). No difference in the probability of biochemical progression was seen between groups when analyzed by clinical stage or Gleason score. When analyzed by pathologic margin status, no difference was observed in the probability of biochemical progression in patients with organ-confined disease (P = 0.4484). There was a trend for a higher probability of progression in the neoadjuvant arm in patients with positive and negative surgical margins (P = 0.0105, P = 0.0459; alpha = 0.005 with Bonferroni adjustment). CONCLUSIONS: Neoadjuvant androgen ablation with CPA reduces the positive margin rate significantly but does not result in a difference in biochemical progression at 3 years. This may be due to a lack of sufficient follow-up, insufficient power of the trial to demonstrate a small benefit, or a true lack of benefit of neoadjuvant androgen ablation before radical prostatectomy.

Early experience with transurethral needle ablation of large prostates.

OBJECTIVE: To evaluate the safety and effectiveness of transurethral needle ablation (TUNA(R)) performed on benign hyperplastic prostates > 60 gms. Patients and methods: Ten patients with bilobar hyperplasia and without a large middle lobe received one TUNA(R) Treatment. The mean age was 67.5 years (range 56-80) and the mean prostatic weight was 76.89 (range 62-98 gms). Symptom scores, quality of life (QOL), maximum and average flow rates were measured before and 1,3, and 6 months post treatment. RESULTS: After 6 months patients showed mean improvements in symptom scores (19.9 to 12.11), maximum flow rates (8.63 mL/sec to 12.75 mL/sec) and QOL (4.2 to 2.33). Recurrence of symptoms occurred in one patient at 13 months post TUNA(R) and he was retreated. One patient developed urinary retention and received a TURP. CONCLUSIONS: Short term results in this small group of patients indicate that TUNA(R) is a safe technique for individuals with large prostates and in this small group of patients resulted in reduced symptoms, high patient satisfaction and acceptable morbidity.

Intermittent androgen suppression for prostate cancer: rationale and clinical experience.

The rationale behind intermittent androgen suppression (IAS) is based on: (1) observations that androgen ablation is palliative, not curative, in most patients with prostate cancer, and that quality of life must be considered; (2) the assumption that immediate androgen ablation is superior to delayed therapy in improving survival; (3) the hypothesis that if tumour cells surviving androgen withdrawal are forced into a normal pathway of differentiation by androgen replacement, then apoptotic potential might be restored and progression to androgen independence delayed. Several centres have now tested the feasibility of IAS therapy in non-randomized groups of prostate cancer patients using serum of prostate-specific antigen levels as trigger points. Clinical data suggest that prostate cancer is amenable to control by IAS and offers clinicians an opportunity to improve patients' quality of life by balancing the benefits of immediate androgen ablation (delayed progression and prolonged survival) while reducing treatment-related side effects and expense. Whether time to progression and survival is affected in a beneficial or adverse way is being studied in randomized, prospective protocols.