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Prostate Cancer Discovered in 40% of Men Who Test Negative for the Disease

State-of-the-art biopsy procedure is catching

prostate cancer that hasn’t been diagnosed

Westmont, IL, January 18, 2008 Forty percent of men with prostate cancer may not even know they have it, according to a new research study by the Prostate Cancer Foundation of Chicago.  The study revealed the standard office biopsy procedure often isn’t enough to properly detect prostate cancer.

This new research will be published in an upcoming issue of Urology, a national medical journal.

Researchers used an advanced biopsy technique called stereotactic transperineal prostate biopsy (STPB).  This was performed on patients with persistent elevated prostate specific antigen (PSA) levels who previously had at least one negative office biopsies.  All patients had received transrectal prostate biopsies (TRPB), administered by a urologist.

“Men who have negative transrectal biopsies and continue to have elevated PSA levels should consider STPB because 40% will harbor malignancy, “says Michelle Braccioforte, director of research and education for the Prostate Cancer Foundation of Chicago.  “Our level of confidence is greatly enhanced with regards to the presence or absence of cancer, and more specifically, the exact location of the cancer within the prostate.”

STPB is performed by taking a median of 40 samples of the prostate through the perineum while the patient is under general anesthesia.  Performed as an outpatient procedure, it allows more comprehensive sampling, compared to the transrectal method, which takes fewer samples through the rectum.  In addition, by taking more samples during STPB, the exact location of the cancer can be pinpointed.

Between April 2004 and January 2008, 747 patients with high PSA levels were studied. All patients had been tested using TRPB at least once and all results had been negative.  All patients received the STPB.  Biopsy results identified the presence of cancer in 291 (39%) of the patients.

One in six men in the U.S. will be diagnosed with prostate cancer, the most common form of cancer among men.  For those with elevated or rising PSA levels, this is a sign that further testing should be administered to rule out prostate cancer.

“The information obtained from this kind of comprehensive biopsy allows us to design and perform more sophisticated treatment plans”, says Dr. Brian Moran, medical director of the Prostate Cancer Foundation of Chicago and the Chicago Prostate Cancer Center.  This procedure is also a stepping stone towards focal therapy, where more limited treatment can result in less side effects, yet achieve cure rates equal to more radical forms of treatment. ”

The Prostate Cancer Foundation of Chicago, located in Westmont, IL, is a not-for-profit organization that conducts ongoing research intended to improve the diagnosis and treatment of prostate cancer.  For more information, or to obtain a white paper of the “Stereotactic Transperineal Prostate Biopsy,” please visitwww.chicagoprostatefoundation.org to download or call Michelle at 630.654.2515.

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Swedish Study Concludes Prostate Cancer Screening Reduces Deaths by 50%

An article was recently published summarizing the results of a 14 year study by the University of Gothenburg in Sweden on prostate cancer screening.  The article, written by Kristen Hallam, states that PSA testing for prostate cancer helped reduce prostate cancer deaths by 50% after 14 years of study.  Of 10,000 men screened using PSA tests every 2 years, 44 died of prostate cancer.  The other 10,000 men in the study were not given PSA tests and 78 of them died of prostate cancer.  Total deaths were almost identical in both groups with 1,981 deaths in the screening group and 1,982 in the non-screening group. The study also found that 11.4% of men in the screening group and 7.2% of the non-screening group were diagnosed with prostate cancer.

There has been much debate over whether there has been too much screening for prostate cancer, which some feel results in unnecessary treatment of the disease that can impair quality of life.  However, Chicago Prostate Cancer Center highly recommends annual PSA screening accompanied by digital rectal exams for men over the age of 50.  (African American men and men with a family history of prostate cancer should begin screening at the age of 40.)  Prostate cancer is much easier to treat and cure in the early stages, which can be detected by screening.

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Brian Moran, M.D. — Vancouver Study Comparing Brachytherapy versus IMRT

Recently over the past two years there has been a large increase in the number radiation centers that are being built to provide treatment for prostate cancer patients.  The technology advocated is IMRT (Intensity Modulated Radiation Therapy).  Clearly this is an advanced type of radiation delivery system compared to earlier models such as 3-D conformal treatment.  Data has shown that radiation therapy in the form of IMRT is effective.  There is controversy regarding whether IMRT or radioactive seed implant is more effective in treating prostate cancer.  An earlier study by Zelefsky at Memorial Sloan Kettering suggested a 10% benefit using brachytherapy with 7 year follow-up.  More recently, a study by Dr. Pickles and associates was published in the International Journal of Radiation Oncology, Biology and Physics (Volume 76, 1, pp 43-49, 2010).  This study reviewed 601 patients treated from 1998 through 2001 using a matched-pair analysis.  There were 278 perfect matches between patients who had undergone either radioactive seed implant or external beam radiation therapy using IMRT technology.  This group was divided with 139 patients in each arm.  At 5 years of follow-up, the group that underwent brachytherapy had a 10% higher likelihood of having no evidence of tumor recurrence with 95% cure rate.  While the IMRT group at 5 years had an only 85% cure rate.  At 7 years, this difference became even more pronounced in that the radioactive seed implant group maintained its cure rate at 95% while the IMRT group was now only 75%, meaning there was a 25% failure rate for the IMRT group.  The PSA nadir, or the level to which the PSA bottoms out, was very different at 0.04 ng/ml median value for radioactive seed implant versus 0.62 ng/ml median nadir for IMRT.  This was statistically significant with a p value of <0.001.  This study was performed at the Vancouver, B.C. Cancer Treatment Center.  I think that this data is very worthwhile and it further demonstrates the efficacy of prostate seed implant.  I think this has implications regarding patient outcome obviously, with regard to cure rate, quality of life issues, which are very favorable for brachytherapy if performed properly, and certainly cost considerations as brachytherapy is without question the most cost-effective treatment for prostate cancer.

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Prostate Cancer Patients who receive Brachytherapy and remain disease-free for 5 years or greater are unlikely to have a recurrence at 10 years

Prostate Cancer Blog:  From MedicineWorld.org, July 4, 2009

Patients with prostate cancer who receive brachytherapy and remain free of disease for five years or greater are unlikely to have a recurrence at 10 years, as per a research study in the July 1 issue of the International Journal of Radiation Oncology*Biology*Physics, the official journal of the American Society for Radiation Oncology (ASTRO).

Brachytherapy is the placement of radioactive sources in or just next to a tumor either permanently or temporarily, depending on the cancer.

In the study, scientists at The Mount Sinai Medical Center of Radiation Oncology and Urology in New York followed 742 patients with prostate cancer who were treated with brachytherapy alone, brachytherapy and hormonal treatment, or combined brachytherapy and external beam radiotherapy (EBRT) between 1991 and 2002.  None of these patients had recurred during their first five years post-treatment.  They observed that the PSA level taken at five years was an indicator of how well a patient would do in the future and the overall chance of being cancer free at 10 years was 97 percent.

Also, none of the study participants developed metastatic disease or died from prostate cancer.

“Our data have indicated that improvements in therapy are continuing and that these will continue to have an effect on prostate brachytherapy data for years to come,” Richard Stock, M.D., main author of the study and chairman of radiation oncology at The Mount Sinai Medical Center, said.  “Late failure rates will continue to decrease, making prostate brachytherapy alone and combined with hormonal treatment and/or EBRT an increasingly attractive therapy option.”

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Sexual Function Highest after Brachytherapy

Summary of Article from the Journal Urology:

Quality of Life After Open or Robotic Prostatectomy, Cryoablation or Brachytherapy for Localized Prostate Cancer.

J Urol. 2010 Mar 17 [Epub ahead of print]

Malcolm JB, Fabrizio MD, Barone BB, et al.

785 patients were included in a study by the authors to compare quality of life outcomes after being treated for prostate cancer.  The study was conducted between February 2000 and December 2008 and all patients treated with open radical prostatectomy, robot assisted laparoscopic prostatectomy, brachytherapy or cryotherapy were asked to complete a quality of life survey for up to 36 months after treatment.  The article states that all health related quality of life symptoms were negatively affected by all treatments and recovery profiles varied significantly by treatment type.  However, urinary function scores were significantly higher after brachytherapy and cryotherapy compared to radical prostatectomy and robotic assisted laparoscopic prostatectomy. In addition, sexual function scores were the highest after brachytherapy, with a 5 times higher rate of return to baseline function compared to cryotherapy, open radical prostatectomy and laparoscopic radical prostatectomy.

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Athletic Brothers Shocked by Common Diagnosis of Prostate Cancer

— Studies show brothers are more likely to be diagnosed

with early onset prostate cancer —

 

Westmont, IL, August 25, 2009 – When former golf pro Joe Leskis of Bartlett discovered he had prostate cancer two years ago at age 55, he was shocked that someone his age with such an active lifestyle could be diagnosed with the “big C”.  “Everyone has a fear of cancer and I definitely thought the worst,” he explains.

What came as even more of a shock to Joe was just two years later when his younger brother, Guy, of Winthrop Harbor, and Joe’s former caddy, was diagnosed with prostate cancer at age 53.  Like Joe, Guy is an active golfer, traveler and fisherman and neither brother was aware of prostate cancer in their family history.  Since their diagnoses, both men have chosen and successfully undergone brachytherapy (radiation seed implantation) treatment at the Chicago Prostate Center and have learned that they may share a hereditary susceptibility predisposing them to early onset prostate cancer.

The Leskis brothers’ story is consistent with new research on prostate cancer.  According to an article published in the Journal of Urology, more than 40% of the cases in men diagnosed with prostate cancer before the age of 55 may be due to heredity. Men whose fathers or brothers had prostate cancer are, on average, diagnosed six to seven years earlier than men with no family history of this disease.*

While both men enjoy an active, healthy and normal lifestyle today, what  differentiates the Leskis brothers is how their prostate cancer was diagnosed.  Both brothers had blood tests to determine their PSA levels, an indicator of potential cancer cells.  Elder brother Joe, after watching his PSA level climb steadily to a score of 11 (desired range is 0-4), discovered his cancer after his urologist performed a traditional, in-office transrectal biopsy (TRPB) which took eight samples of his prostate gland.  Guy, on the other hand, watched his PSA slowly climb (any increase in the level can be a warning sign) to a 3.3 and his transrectal biopsy tested negative.  Concerned about a rising PSA with no answers, his brother recommended a visit to Dr. Moran who performed a new state-of-the art biopsy called the stereotactic transperineal prostate biopsy (STPB), which he helped develop.  Guy’s STPB showed cancer in five of a total 31 samples taken and he, too, underwent brachytherapy at the Chicago Prostate Center.

A study by the Prostate Cancer Foundation of Chicago published in the February, 2009 issue of Urology, shows that among men testing negative for prostate cancer who have had at least one TRPB biopsy, nearly 40% of them will test positive for cancer after undergoing the STPB biopsy.

The Chicago Prostate Center was established in 1997 with the goal of providing patients with comprehensive care focused on the treatment of prostate cancer with brachytherapy. The Chicago Prostate Center is the country’s only free-standing facility dedicated to the treatment of prostate cancer.  For more information, visit www.prostateimplant.com or call 630.654.2515.  To view theUrology article, visit http://www.chicagoprostatefoundation.org or call 630-654-2515.

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Brian Moran, M.D. – Comprehensive Biopsy Predictive of Final Pathology

Some patients have been told that one of the advantages of having surgery to remove the prostate (radical prostatectomy) is that it is the only true way to thoroughly review the pathology of the disease.  At Chicago Prostate Cancer Center, we now know that Stereotactic Transperineal Biopsy (STPB), sometimes referred to saturation biopsy, is very predictive of final pathology at time of radical prostatectomy.  Below is an article we have written comparing results of the two procedures.

FINAL PATHOLOGY IN PATIENTS UNDERGOING RADICAL PROSTATECTOMY: A CORRELATION STUDY BETWEEN stereotactic transperineal prostate biopsy AND RADICAL PROSTECTOMY

Dean J. Conterato, MD, Michelle H. Braccioforte, BS and Brian J. Moran, MD

Prostate Cancer Foundation of Chicago, Westmont, Illinois USA

 

Purpose:  Biopsy of the prostate is the most influential factor regarding prostate cancer treatment decisions. Stereotactic transperineal prostate biopsy (STPB) provides a more comprehensive assessment of cancer extent and location due to the large number of systematic biopsies.  The purpose of this study was to analyze patients who underwent STPB prior to radical prostatectomy (RP), and to correlate the pathologic findings between the two procedures.

 

Materials and Methods:  1452 consecutive patients with continued rising total prostate specific antigen (PSA) having had a minimum of 1 prior benign transrectal extended systematic sextant prostate biopsy (range 1-10), underwent STPB at a single out-patient institution between 04/2004 and 11/2009.  Median patient age, total PSA, prostate volume and number of specimens obtained were 63.11 years, 7.9 ng/ml, 45.1 cm3 and 38 specimens, respectively (Table 1).  Specimens were obtained according to x, y, and z coordinates from equal octants with pathology reported accordingly.  STPB yielded adenocarcinoma in 582/1452 (40%) patients.  103/582 (18%) patients with positive biopsy chose to undergo radical prostatectomy.  Radical prostatectomy and pathologic review was performed by multiple physicians at both community and university hospitals. Consent forms and pathologic reports were obtained in 85/103 (82.5%), of patients and reviewed.

 

Results:  There was a 62/85 (73%) concordance rate between Gleason score reported on STPB and final prostatectomy specimen.  Gleason score increased in 13/85 (15%) while downgrading was noted in 10/85 (12%) of patients.  18/85 (21%) patients had positive margins.  There was a strong correlation of Gleason score and prostatectomy positive pathologic margins.  In 81/85 (95%) patients, STPB accurately predicted location of malignancy with prostatectomy specimen.

Conclusions:  STPB is efficacious for diagnosis of non-palpable, isoechoic occult prostate malignancy as demonstrated by the high concordance rate between biopsy and prostatectomy.  It may also enhance research efforts regarding targeted therapy within the prostate gland.  Furthermore, STPB may result in more reliable diagnosis with less undergrading compared to other biopsy techniques.  Finally, histologic grade can suggest probability of positive pathologic margin.  Considering this group of patients was previously undiagnosed and after radical prostatectomy, 21% were found to have positive margins, TRPB may be inadequate for a subset of patients.  This information may influence the decision making process regarding appropriate treatment options.

Table 1: Patient Characteristics

MEAN MEDIAN RANGE
Age (years) 62.84 63.11 40.7 – 85.1
PSA (ng/ml) 9.95 7.9 0.6 – 92.8
Volume (cm3) 49.56 45.1 5 – 163
# Prior TRPB Sets 1.54 1 1 – 10
# Cores on prior TRPB 12.68 12 4 – 56
# Cores on STPB 36 38 10 – 117
# Malignant Tissue Cores 4.21 3 1 – 26
Highest % Involvement 26.8 15 1 – 100

 

Ongoing work and research is moving us closer to offering focal therapy for prostate cancer.  Soon we intend to demonstrate that focal therapy in select patients is a reasonable alternative to whole gland treatment such as prostate brachytherapy or external beam radiation. Provided cancer control is equal to standard treatment options, there are additional benefits, mainly that of dramatically reduced toxicity for the patient and reduced cost.  In conclusion, this approach is not new, as it has been proven in breast cancer treatment with lumpectomy and kidney cancer treatment with partial nephrectomy.  At Chicago Prostate Cancer Center, we have favorable experience using focal therapy in the form of hemi-implant (half prostate implant).  These are patients who have been previously biopsied with STPB, which maps the malignancy.  We have then been able to design an implant for the same side of the prostate as the positive biopsy.  Based on our biopsy information, patients have done well with no local failures and essentially no toxicity.

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Brian Moran,M.D. – Brachytherapy – Best Radiation Treatment for Prostate Cancer

There has been much controversy over the past several years regarding the best treatment option for prostate cancer.  To date, there is no clear-cut data to prove the advantage of surgery over other treatment options.  Recently, there has been a new enthusiasm for IMRT (Intensity Modulated Radiation Therapy) and proton beam radiation therapy for the treatment of prostate cancer.  Again, there is no data to support that either therapy is superior to brachytherapy for the treatment of prostate cancer. However, there is data suggesting that brachytherapy is superior to IMRT.  Data from the latest Meeting of the American Brachytherapy Society, presented by Michael Zelefsky, M.D. from Sloan-Kettering Cancer Center, NY (June 2009), compared 2292 patients that were treated with IMRT or brachytherapy.  Results found that the 7-year PSA relapse-free survival (PRFS) for low-risk patients was 92.4% for patients treated with brachytherapy and 91.6% for patients treated with IMRT.  However, the 7-year PRFS for intermediate-risk patients treated with brachytherapy and IMRT were 91% and 79% respectively.  There appears to be a trend to late failures with IMRT for intermediate-risk patients, thus proving the superiority of brachytherapy over IMRT.[1]  In addition, there is no data suggesting proton beam radiation therapy is better than IMRT [2].  Therefore, using the classic logic argument, if A (brachytherapy) > B (IMRT), and B = C (Proton Beam), then A > C. There will never be a randomized study of brachytherapy vs. IMRT vs. proton beam because of physician bias and patient preference.  Unfortunately, in today’s healthcare market, some physicians are making patient recommendations based on their own financial gain and not regarding the patient’s best interest. (See our blog below regarding Dr. Simone’s article “The Gullible Decade”). [3]

Aside from scientific data, there are other reasons why brachytherapy is superior to other forms of external beam radiation therapy.  A big reason is cost.  Brachytherapy is a much more cost effective form of treatment.  On average, brachytherapy runs $8,000 plus the cost of the seeds.  While the cost of IMRT ranges from $35,000 – $55,000 and proton beam therapy can exceed $100,000.  One must also look at patient consideration when evaluating treatments.  Brachytherapy is a 1-time (1 day, out-patient) procedure with a patient able to resume daily activities within 1-2 days.  However, both IMRT and proton beam therapy involve 30-60 min. treatments 5 times per week over 8 weeks.  Not to mention the travel time to and from the radiation facility which are usually not located right in a patient’s community.

In conclusion, there is much data out there to support brachytherapy as a superior therapy in the treatment of prostate cancer.

1.  Zelefsky MJ, Yamada Y, Kollmeier MA, et al: Comparison of tumor control outcomes and toxicity between LDR brachytherapy and high dose IMRT for clinically localized prostate cancer. Brachytherapy 8:105-180,2009.

2.  Nguyen PL, Trofimov A, Zietman A:  Proton-beam vs intensity-modulated radiation therapy; Which is best for treating prostate cancer? Oncology 22:748-754, 2008.

3.  Simone JV: The gullible decade. Oncology Times  6, Jan 25, 2010.

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Suicide Risk Higher in Patients Diagnosed with Prostate Cancer

According to a recent article published in Reuters (Feb. 2, 2010), being diagnosed with prostate cancer roughly doubles the risk of suicide or death from a heart attack.  A team of researchers from Harvard and Brigham & Women’s Hospital in Boston looked at data from 340,000 prostate cancer patients between 1979 and 2004.  While this particular study found that the elevated suicide risk of patients in this database has decreased since PSA screening became standard practice in 1993, there is still an increased risk of death from heart attacks and strokes.  However, a study in Sweden last month by the same team, did find an elevated suicide risk associated with PSA testing.

The stress of prostate cancer diagnosis alone has its own risks.  If you or a loved one is diagnosed with prostate cancer, please be aware that many options are available to you.  Most importantly, you need to discuss your situation with family, loved ones and physicians to help get through this difficult time. Do not try to go through it alone.

The Prostate Cancer Foundation of Chicago offers a support group the first Wednesday of every month to those who have prostate cancer. The support group meetings are from 7:00-9:00 pm at the Chicago Prostate Cancer Center, 815 Pasquinelli Drive, Westmont, Illinois  60559.

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2 Independent Studies Released on the Effectiveness of Brachytherapy for the Treatment of Prostate Cancer

Westmont, IL, August 27, 2009 – For years, the debate has been ongoing regarding the best treatment method for prostate cancer patients.  Now, two independent studies have reached similar conclusions. Already considered a good option for prostate cancer patients, brachytherapy (radiation seed implants) now has the backing of research from The Prostate Cancer Foundation of Chicago and The Taussig Cancer Center at Cleveland Clinic, proving a superior disease-free survival rate for patients with early stage prostate cancer.

            In an eleven-year study, the Prostate Cancer Foundation of Chicago, a non-profit organization that funds patient support programs, clinical research and public education, analyzed 9,137 patients treated for prostate cancer at the Chicago Prostate Center in Westmont, Il.  From October 1997 to October 2008, patients underwent prostate brachytherapy to treat their cancer.   67.5% of the patients were regarded as low risk, 29.36% as intermediate risk, and 1.01% as high risk.

Of those patients, overall cure rates were 96%, 84%, and 75% for low, intermediate, and high risk patients, respectively. When combined with external beam radiation therapy in intermediate and high risk patients, the brachytherapy results far exceed those of surgery.

The Taussig Cancer Center at The Cleveland Clinic has released their similar 2008 outcomes, demonstrating brachytherapy to be superior to surgery in all cases.  For low risk prostate cancer patients, the study found a 95% survival rate after five years; intermediate risk an 89% rate; high risk 71%.  This research concluded that, for low risk patients, brachytherapy was equally successful as external beam radiation, but more successful than a radical prostatectomy.

Michelle Braccioforte, Research Director at the Prostate Cancer Foundation of Chicago, explains, “There is a misconception that removing the prostate completely results in 100% cure, which is not true.  Not any one treatment is ever 100% successful, but brachytherapy has excellent cure rates, is a one-time, outpatient procedure, and is the most cost-effective.”

In addition to its effectiveness, brachytherapy is a minimally invasive treatment. It involves the implantation of radioactive seeds directly at the source of the cancer. Delivered by a needle and guided by ultrasound, the seeds destroy the DNA within the cancerous cell – effectively killing the tumor. Patients with prostate cancer in the T1 or T2 stages (meaning the cancer hasn’t spread beyond the prostate) choose brachytherapy for a number of reasons:

  • No incisions, minimal pain and blood loss
  • Urinary incontinence rates less than 1% – compared to 10% with surgery
  • 6-25% chance of sexual dysfunction following procedure – compared to 50% with surgery
  • Much lower rates of bowel irritation compared to external beam radiation
  • Convenience – one-time procedure done on an outpatient basis which requires no hospital stay, patients are fully recovered and can return to normal activity within a day
  • Lower cost compared to external beam radiation and surgery

 

With prostate cancer success rates on the rise, it is important to note that early detection can make all the difference when fighting prostate cancer. Doctors recommend that men have a yearly PSA test and digital rectal exam starting at age 50 – and age 40 for African-Americans.

Risk factors have been found to include:

  • Heredity – Greater risk if a father or brother has had prostate cancer
  • Age – Men over 50 are more at risk
  • Race – African-American males are more at risk

For more information on the Chicago Prostate Cancer Foundation research, visitwww.chicagoprostatefoundation.org.  For more information on the Taussig Cancer Center at Cleveland Clinic, visithttp://my.clevelandclinic.org/services/radiation_oncology/outcomes.aspx.

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