Seminars in urologic oncology最新文献

Patients diagnosed with prostate cancer who elect to pursue active treatment of their disease must choose among the many available treatment alternatives. Several treatment options now exist for similar stage disease (clinical T1-3N0M0), including radical prostatectomy, external beam radiotherapy, prostate brachytherapy, cryosurgical ablation of the prostate (CSAP), and various combination therapies. This article focuses principally on the authors' philosophy regarding the role of CSAP in the treatment of clinically localized prostate cancer and is written to aid patients in their treatment decision. There is limited information on CSAP in the standard resources, such as the Internet and books frequently used by patients to make their treatment decisions. This article can serve as a resource on the evolution, results, and complications of CSAP that are reported. Cryosurgical ablation of the prostate has a role in the primary treatment of men with high risk, clinically localized prostate cancer (defined as prostate-specific antigen >10, Gleason score > or =7, or clinical stage > or =cT2B). Cryosurgical ablation of the prostate (occasionally followed by external beam radiotherapy) appears to offer improved rates of cancer control over other types of single or combination therapies for this high risk prostate cancer, and is associated with an acceptable side effect profile. Cryosurgical ablation of the prostate should also be the treatment of choice for men with recurrent local disease after external beam radiotherapy.

Multiple treatment options are available for the radiation therapy of prostate cancer including whole pelvic radiotherapy (WPRT), prostate-only radiotherapy (PORT), three-dimensional conformal radiotherapy (3DCRT), intensity modulated radiotherapy (IMRT), as well as proton or neutron beam based therapies and brachytherapy. Numerous technical variations hamper objective assessment of these different treatment modalities. These variations are extensive and often subtle (dose to the prostate, the dose per fraction, number and size of fields, the photon energy, patient positioning, prostatic motion, the use of immobilization devices, 2D or 3D planning for treatment, and others) may cause interpretive uncertainty. Despite this confusion, there is some consensus. Prostate-specific antigen (PSA) nadirs, as well as pretreatment PSA levels, significantly alter outcome. Low-risk patients do well no matter which treatment they receive, although the question of dose-escalation therapy to improve results remains unanswered. High-risk patients do poorly regardless of treatment, although the addition of androgen ablation and dose-escalation therapy may improve results. Quality of life (QOL) studies continue to show a problem for radical prostatectomy (RP) patients secondary to impotence and incontinence and a problem for radiotherapy patients due to gastrointestinal (GI) disturbances. Patients can have access to any specific study through technologies such as the Internet. Although this information can be useful, the subtleties of each different article are usually beyond the understanding of most patients. This report examines some of the new radiotherapy modalities as well as corrects some misconceptions regarding radiotherapy results and morbidity. In addition, we discuss some studies comparing surgery and radiotherapy and attempt to objectively compare different radiation therapy strategies for localized prostate cancer.

To help the patient with prostate cancer, his family, and his friends, in coping with the diagnosis and its treatment, health care providers need to understand the controversies about treatment options and the impact that such controversies have on medical decision-making. To update health care providers, the authors reviewed all pertinent citations in the medicine database from 1966 to 2000, and in other relevant publications. These resources are also available to our patients through the Internet and other avenues, such as books and magazines. It is the role of the physician to counsel patients about their individual circumstances to allow them to make the best individualized treatment option. Patients who have appropriate information and are actively involved with the decision-making process are, in general, psychologically healthier. Though watchful waiting has no side effects, men must cope psychologically with issues of long-term cancer survivorship. With early detection, men can choose between different treatment options (eg, radiation versus radical prostatectomy). Urinary incontinence, sexual dysfunction, and fatigue are major emotional and physical stressors for this population. Providers of care need to be aware of the psychosocial sequelae of prostate cancer and treatment-related side effects and assist their patients in processing ever-growing data on the management of prostate cancer that technology brings.

Patients and physicians often face a difficult process in determining which treatment option to pursue for localized prostate cancer. Observation, hormonal therapy, cryotherapy, various forms of radiation therapy, and surgery all may be offered as options depending on many factors, such as age, the patient's overall health, clinical stage, and opinions of both the physician and the patient. In the information age of computers and the new openness about prostate cancer, a wealth of data can be obtained by the patient, the patient's family, and the physician on these various modalities. This article focuses on the role of surgery as a primary treatment modality for clinically localized prostate cancer from the urologist's prospective. The indications, the merits of retropubic versus perineal, and the reported morbidity and mortality associated with radical prostatectomy are discussed. The procedure is also compared with conservative management and radiation as treatment modalities for localized prostate cancer.

Carcinoma of the prostate is the most common form of cancer in males in the United States, second only to skin cancer. Recently, there has been increased public awareness of cancer-related diseases and specifically prostate cancer. As a result, more individuals are routinely screened and diagnosed with prostate cancer. When a man first discovers he has prostate cancer, he is faced with a multitude of questions. Health care providers realize in counseling patients that there is no single treatment choice best suited for every patient. Because of multiple treatment choices for prostate cancer and complex counseling needs due to a varied side effect profiles of the different options, the Internet may be an ideal tool to extend the health care provider. Furthermore, because men may be reluctant to discuss issues with the health care provider directly, the anonymity of the Internet may be of particular value in the disease. The Internet has created a massive body of information with an estimated 320 million Web sites. The provider can use the Internet as a patient educational tool thus affording the patient time to absorb sometimes complicated information. The Internet can help patients focus on specific aspects of their disease making the patient-provider encounter more productive and allow the patient to take an active role in the treatment decision-making process. More knowledgeable patients can make better decisions about treatment options and have more realistic expectations of their outcomes. We have developed an Internet-based decision for prostate cancer available to both patients and physicians.

This article provides a review of one patient's experience with prostate cancer. It examines the various aspects of the decision-making process-the discovery of the disease, the research undertaken to learn about the disease and the treatment options, the decision as to course of action, the resultant radical prostatectomy, and the short- and long-term follow-up. Throughout the analysis, both the emotional aspects of dealing with the disease and the lessons that can be learned by both the patient and the physician are analyzed and discussed along with the information resources available. The concluding section discusses the critical role of the physician in the decision-making process, especially in the age of information technology and the resultant information overload.

The hallmark of the age of personal computers is the ability to obtain information and communicate with others on nearly any subject using a computer connected to the global network known as the Internet. Information on many diseases is available on the World Wide Web. Information on prostate cancer, including its characteristics, diagnosis, and treatment, is abundantly present on the Internet. This article provides an overview of Internet prostate cancer resources, presenting a brief history of the Internet and its ubiquitous application, the World Wide Web, with a discussion of search engines, the utilization of web resources by physicians (including evaluating web sites, and a highly selected list of noteworthy sites), and the growing use of electronic mail (e-mail) in the patient-physician relationship.

Increased consumerism, patient empowerment, and autonomy are creating a health care revolution. In recent years, the public has become better informed and more sophisticated. An extraordinary amount of treatment advice from books, the media, and the Internet is available to patients today, although much of it is confusing or conflicting. Consequently, the traditional, paternalistic doctor-patient relationship is yielding to a more consumerist one. The new dynamic is based on a participatory ethic and a change in the balance of power. This shared decision-making creates a true partnership between professionals and patients, in which each contributes equally to decisions about treatment or care. Evidence suggests that in diseases such as prostate cancer, where there may be a number of appropriate treatment options for a particular patient, shared decision-making may lead to improved clinical and quality-of-life outcomes. This article explores the evolving relationship between the physician and patient, the pros and cons of shared decision-making, and the use of video technology in the clinical setting. The authors review the use of medical decision aids, including a video-based educational program called CHOICES, in the treatment of prostate cancer and other diseases.

The purpose of this article was to determine what planned treatment margin (TM) would allow for implant-related prostate volume changes and still achieve an adequate periprostatic cancercidal dose. Twenty consecutive, unselected patients who underwent (125)I implantation (144 Gy prescription dose) were studied. The treated volume (TV) was calculated as the volume encompassed by the 144 Gy isodose distribution. A post-implant computed tomography scan was obtained the following day, using 5-mm images at every 5 mm. The distances between the prostate margin (GTV) and TV were determined by measuring the distance between the ultrasound-defined prostatic margin and the prescription isodose, perpendicular to the prostatic margin. The lateral, anterior, and posterior TM margins were determined at the base, mid-level, and apex of the prostate. The pre-implant TV was nearly twice as large as the GTV, ranging from 36 to 199 mL (median, 73 mL). The anterior, lateral, and posterior planned TMs varied substantially between patients, due to lack of a consistent policy the magnitude of the CTV and the acceptable CTV-to-TV distance. For all measurement points, the median planned treatment margin was 3 mm (range, -16 mm to 14 mm). Overall, there was only a loose correlation between pre- and post-implant treatment margins primarily due to variable, implant-related prostatic dimensional changes. Patients with a greater implant-related volume increase tended to have smaller post-implant treatment margins. The post-implant TMs were negatively correlated with dimensional changes, and the negative correlation was most marked for the anterior and posterior TMs due to predominant anterior-posterior dimensional increase. As expected, the post-implant target coverage was higher when larger planning TMs were used, but the correlation was loose due to the unpredictable, highly variable degree of implant-related volume increase. We currently are using 5-mm TMs around the GTV, as identified on pre-implant transrectal ultrasonography or computed tomography. However, the poor correlation between planned and actual post-implant TMs call into question any attempt to make a rational recommendation regarding optimal TMs.

This article reviews the fundamental assumptions for survival analysis and discusses some of the difficulties specific to the treatment evaluation and the analysis of prognostic factors in clinically localized prostate cancer. What makes clinically localized prostate cancer different from other forms of cancer is the chronic nature of the disease and the introduction of prostate-specific antigen (PSA) evaluation following a primary treatment. It is known that a study evaluating survival benefit for localized prostate cancer requires a long-term follow-up. This brings up issues of time varying treatment effect and the necessary use of cause-specific survival. In addition, biochemical failure following radiation therapy based on ASTRO consensus definition is another major topic. We question the appropriateness of the last observation approach that censors patients at their last observation and uses the Kaplan-Meier method. We show that the last observation approach can underestimate the biochemical failure rate for a treatment, especially when follow-up is short. The estimate of lower and upper bounds for biochemical failure is recommended. Examples based on Radiation Therapy Oncology Group prostate cancer trials are provided. This article concludes with a discussion of some novel statistical approaches to the design of prostate cancer studies and the analysis of trajectories of PSA values.