Localized Prostate Cancer: Treatment Options.

In the United States, prostate cancer will be diagnosed in one out of seven men in his lifetime. Most cases are localized, and only one in 39 men will die from the disease. Prostate cancer is most often detected using serum prostate-specific antigen testing. The National Comprehensive Cancer Network guidelines use four main factors to stratify risk of disease progression or recurrence and to determine the recommended treatment: clinical stage, pathologic grade, prostate-specific antigen level, and comorbidity-adjusted life expectancy. Radical prostatectomy or external beam radiation therapy should be considered for patients with high-risk prostate cancer regardless of comorbidity-adjusted life expectancy. These treatments are almost equivalent in effectiveness but have different adverse effect profiles. Patients who undergo radical prostatectomy are more likely to experience urinary incontinence and trouble obtaining or sustaining an erection compared with patients who opt for radiation therapy. Brachytherapy is an option for patients with low-risk disease and some patients with intermediate-risk disease. Active surveillance is an option for patients with low-risk and very low-risk disease. With active surveillance, patients are closely followed and undergo invasive treatments only if the cancer progresses. Prostate cancer progression may be indicated by an increase in the pathologic grade, a significant rise in serum prostate-specific antigen level, or an abnormality on digital rectal examination.

Associations of serum vitamin A and carotenoid levels with markers of prostate cancer detection among US men.

Associations of serum vitamin A and carotenoid levels with markers of prostate cancer detection were evaluated among 3,927 US men, 40-85 years of age, who participated in the 2001-2006 National Health and Nutrition Examination Surveys. Five recommended definitions of prostate cancer detection were adopted using total and free prostate-specific antigen (tPSA and fPSA) laboratory measurements. Men were identified as high risk based on alternative cutoffs, namely tPSA > 10 ng/ml, tPSA > 4 ng/ml, tPSA > 2.5 ng/ml, %fPSA < 25%, and %fPSA < 15%. %fPSA was defined as (fPSA÷tPSA)× 100%. Serum levels of vitamin A (retinol and retinyl esters) and carotenoids (α-carotene, ß-carotene, ß-cryptoxanthin, lutein + zeaxanthin, lycopene) were defined as quartiles and examined as risk/protective factors for PSA biomarkers. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using binary logistic models. After adjustment for known demographic, socioeconomic, and lifestyle confounders, high serum levels of retinyl esters (tPSA > 10 ng/ml: Q4 vs. Q1 â†’ OR = 0.38, 95% CI: 0.14-1.00) and α-carotene (%fPSA < 15%: Q4 vs. Q1 â†’ OR = 0.49, 95% CI: 0.32-0.76) were associated with a lower odds, whereas high serum level of lycopene (tPSA > 2.5 ng/ml: Q4 vs. Q1 â†’ OR = 1.49, 95% CI: 1.01-2.14) was associated with a greater odds of prostate cancer detection. Apart from the three significant associations observed, no other exposure-outcome association was significant. Monitoring specific antioxidant levels may be helpful in the early detection of prostate cancer.

Self-rated health as a tool for estimating health-adjusted life expectancy among patients newly diagnosed with localized prostate cancer: a preliminary study.

PURPOSE: Localized prostate cancer (LPC) patients are faced with numerous treatment options, including observation or watchful waiting. The choice of treatment largely depends on their baseline health-adjusted life expectancy (HALE). By consensus, physicians recommend treatment if the patient's HALE is ten or more years. However, the estimation of HALE is difficult. Although subjective by nature, self-rated health (SRH) is a robust predictor of mortality. We studied the usefulness of SRH in estimating HALE in patients who are considering treatment for LPC. METHODS: A total of 144 LPC patients from a large urology private practice in Norfolk, Virginia, were surveyed before they had chosen a treatment option. RESULTS: HALE determined by SRH correlated well with objective health measures and was higher than age-based life expectancy by an average of 2 years. The observed difference in life expectancy due to SRH adjustment was higher among patients with a better socioeconomic and health profile. CONCLUSIONS: SRH is an easy-to-use indicator of HALE in LPC patients. A table for HALE estimation by age and SRH is provided for men aged 70-80 years. Additional research with larger samples and prospective study designs are needed before the SRH method can be used in primary care and urology settings.

Treatment options for localized prostate cancer.

In the United States, more than 90 percent of prostate cancers are detected by serum prostate-specific antigen testing. Most patients are found to have localized prostate cancer, and most of these patients undergo surgery or radiotherapy. However, many patients have low-risk cancer and can follow an active surveillance protocol instead of undergoing invasive treatments. Active surveillance is a new concept in which low-risk patients are closely followed and proceed to intervention only if their cancer progresses. Clinical guidelines can help in selecting between treatment or active surveillance based on the cancer's stage and grade, the patient's prostate-specific antigen level, and the comorbidity-adjusted life expectancy. Radical prostatectomy or external beam radiation therapy is recommended for higher-risk patients. These treatments are almost equivalent in effectiveness, but have different adverse effect profiles. Brachytherapy is an option for low- and moderate-risk patients. Evidence is insufficient to determine whether laparoscopic or robotic surgery or cryotherapy is superior to open radical prostatectomy.

Development of a scale to assess patient misperceptions about treatment choices for localized prostate cancer.

OBJECTIVES: To develop a questionnaire to assess a patient's knowledge of his cancer, understanding of treatment choices, and judgement of his survival (KUJ) with and without treatment, as treatment for localized prostate cancer (LPC) can lead to urinary, sexual and bowel side-effects and might not improve survival in 75% of patients. PATIENTS AND METHODS: Although >90% of patients in the USA are diagnosed with LPC, approximately 94% of them choose treatment, such that newly diagnosed patients need individualized counselling to address misperceptions about the management of LPC. The internal consistency of an 18-item KUJ scale was evaluated among 184 patients recently diagnosed with LPC at a major urology practice. Principal-component analyses were applied for computing a KUJ index. Logistic regression modelling was used to identify predictors of the KUJ index. RESULTS: Cronbach's alpha for the KUJ scale was 0.76. Nearly half of the patients provided incorrect answers to most KUJ items. Of the patients, 68% had an income of >US$50,000 and 90% had at least high (or secondary) school literacy level. Quality-of-life measures suggested that most patients were physically, mentally and socially healthy. Higher education, income and functional capacity were associated with worse KUJ. CONCLUSION: The KUJ scale is internally consistent and clinicians can use it to identify the educational needs of patients with LPC before treatment selection. Overall, patients who were socioeconomically disadvantaged and those with physical ailments were better informed about the diagnosis, treatment options and prognosis of prostate cancer.

Feasibility of using guidelines to choose treatment for prostate cancer.

INTRODUCTION: Treatment for localized prostate cancer (LPC) may not improve survival and commonly impairs health related quality of life. National guidelines provide algorithms to choose between treatment or observation for LPC, but the algorithms require the factoring of the patient's baseline comorbidity adjusted life expectancy (CALE). However, no method is available to estimate CALE of 10 or more years. MATERIALS AND METHODS: A mailed survey was completed by newly diagnosed untreated LPC patients. Their baseline CALE was estimated by weighting their age based life expectancy by quartiles of comorbidity scores, and a national guideline was used to find if treatment or observation was recommended for each patient. Demographic, health and cancer characteristics, and beliefs were compared in patients who chose treatment or observation concordant with the guideline, and those who chose under treatment or over treatment. RESULTS: Of 184 survey participants, 10 chose under treatment, 144 chose concordant treatment, and 30 chose over treatment. Under treatment patients had similar sociodemographic and health characteristics to patients who were concordant. In comparison to concordant patients, over treatment patients were older, had a lower Gleason grade or PSA level, a higher comorbidity score, a lower CALE, and lower scores on the Fear of Cancer Recurrence scale. CONCLUSION: Comorbidity scores can be used to estimate CALE in LPC patients, and estimation of CALE allows the use of guidelines in the choice of treatment. In our study, over treatment occurred more frequently than under treatment. Factors known to limit the survival benefit of treatment were associated with over treatment. Over treatment patients also had lower fear of cancer recurrence.

CanSupport: a model for home-based palliative care delivery in India.

BACKGROUND: According to the 2014 WHO Global Atlas of Palliative Care, there is insufficient access to palliative care services worldwide, with the majority of unmet need in low- and middle-income countries. In India, there are major disparities in access to palliative care, with the majority of services being offered by non-governmental organizations (NGOs) scattered throughout the country. The barriers to expanding palliative care services in India are common to many lower- and middle-income countries-a lack of financial resources, a paucity of trained staff, and a focus on curative rather than comfort care. In this paper, we describe a model of palliative care being used by CanSupport, a non-governmental organization based in Delhi that was formed in 1996. They offer home-based services provided by multidisciplinary teams consisting of a physician, nurse, and social worker who are trained in palliative care. METHODS: Data on patient demographics, services provided, and outcomes were collected retrospectively for patients treated by CanSupport for the year 2009-2010. Sources include CanSupport's population data and direct discussions with CanSupport staff. RESULTS: During the year 2009-2010, CanSupport served 746 patients, with an average of 10 home visits per patient. Only 29% of patients were referred from hospitals or physicians, with the rest being self-referred or referred from CanSupport's help line. Pain scales were administered on each visit and 31% of patients received morphine. Of the 514 patient deaths, 76% occurred at home and a majority of families received bereavement counseling for up to 6 months. CONCLUSIONS: CanSupport has shown that a home-based care model can be successful in India and is desired by patients at the end of life or with chronic illness. Their model of care saves the patients the cost of a hospital visit while still providing evaluation by staff with training in palliative care. In addition, the multidisciplinary nature of the teams allows for symptom management and emotional counseling for both the patients and their families. CanSupport has developed a way to provide reliable, cost-effective palliative care to patients that can serve as a model for building palliative care capacity in low- and middle-income countries.

Patients' survival expectations before localized prostate cancer treatment by treatment status.

BACKGROUND: Cancer-specific mortality is projected to be only 1% in 15 years in approximately 75% of patients with screen-detected localized prostate cancer (LPC). Nearly 94% of patients choose treatment even though treatment damages health-related quality of life. No data are available regarding what survival benefit patients expected from treatment. OBJECTIVES: A self-administered mailed survey was sent to 184 men with newly diagnosed LPC to query patients about expected survival with treatment versus observation. RESULTS: More than 90% of patients had at least a high school education and a ninth-grade health literacy. In addition, 68% patients had income of > or =$50,000. Mean cancer grade was 6.6. Twenty-three patients chose observation and 161 patients chose surgery or radiotherapy. Mean comorbidity adjusted life expectancy (CALE) without the cancer was 22.9 years. Without cancer treatment, 15.2% of patients expected to live <5 years, 48.8% 5 to 10 years, 33.5% 11 to 19 years, and 2.4% > or =20 years. With treatment, survival expectations were <5 years in 0.6%, 5 to 10 years in 6.5%, 11 to 19 years in 30.0%, and > or =20 years in 62.9% of patients. Age, prostate-specific antigen level, CALE, anxiety, depression, and social support were factors that predicted differences between CALE and patient survival expectations with and without treatment. CONCLUSION: LPC patients grossly underestimated their life expectancy without treatment and grossly overestimated the survival benefit of treatment.