Can men with intermediate risk prostate cancer go on active surveillance?
Comparison of Pathological and Oncologic Outcomes of Favorable Risk Gleason Score 3 + 4 and Low Risk Gleason Score 6 Prostate Cancer: Considerations for Active Surveillance Journal of Urology, The, 2018-05-01, Volume 199, Issue 5, Pages 1188-1195
Some guidelines (eg. NCCN - National Comprehensive Cancer Network) suggest that men with small amounts of Gleason 4 (these are men with ISUP GG 2) on their biopsy can go onto active surveillance if other factors are suitable. But not much is known about long-term outcomes compared to that in men in the low risk Gleason score 3+3/Grade Group 1 group.
Inflammation on a prostate biopsy may be linked to a lower prostate cancer risk in the future.
Inflammation on Prostate Needle Biopsy is Associated with Lower Prostate Cancer Risk: A Meta-Analysis. Journal of Urology, The, 2018-05-01, Volume 199, Issue 5, Pages 1174-1181
It is very common to find ‘inflammation’ on a prostate biopsy – 60-80% of biopsies may show this. It has long been debated whether inflammation is a risk factor for future prostate cancer and this has been unclear. This study was not a clinical study, but rather an examination of the medical literature for all studies reporting this finding.
The use of PSMA PET/CT for men who have a measurable PSA after radical prostatectomy
PSMA after radical prostatectomy
“Efficacy, Predictive Factors, and Prediction Nomograms for 68Ga-labeled Prostate-specific Membrane Antigen–ligand Positron-emission Tomography/Computed Tomography in Early Biochemical Recurrent Prostate Cancer After Radical Prostatectomy”. European Urology Volume 73, Issue 5, Pages 656–661
In this study, PSMA PET/CT was used to examine men who had measurable PSA readings after radical prostatectomy. Recurrent disease was seen on imaging in 55% of men (74 out of 134) with very low (0.2–0.5 ng/ml) PSA and in 74% (102/138) of men with low (>0.5–1.0 ng/ml) PSA.
Grade Group (ISUP Group) as the replacement for Gleason Score
The Gleason score has been ‘replaced’ by the ISUP Group for the scoring of the agressiveness of prostate cancer on biopsy or after radical prostatectomy. See below for a descritpion of the new scoring system:
- GG 1(GS 3+3 = 6): cancers comprising only individual discrete and well-formed glands.
- GG 2 (GS 3 + 4 = 7): cancers comprising predominantly discrete and well-formed glands with a lesser component of poorly formed/fused/glomeruloid/cribriform glands.
Active surveillance for prostate cancer – how often do we see no cancer on a second biopsy?
Role of Surveillance Biopsy with No Cancer as a Prognostic Marker for Reclassification: Results from the Canary Prostate Active Surveillance Study. European Urology Volume 73, Issue 5, Pages 706–712
In this study, men on AS for prostate cancer were re-biopsied (surveillance biopsies) as per protocol. On first surveillance biopsy, 32% of men had no cancer, 43% had cancer that was the same ISUP group (Gleason score) as the first biopsy, and 25% had a change in the score on their biopsy.
Focal therapy - prostate cancer treatment for the near future?
What is focal therapy of the prostate?
In some ways, prostate cancer treatment has fallen behind other cancers. Although robotic surgery is a less invasive way of removing the prostate than an open cut, we are still not at the stage of being able to target cancer cells or groups of cells, and leave behind other non-cancerous cells in the prostate. This focused, or focal, treatment could have advantages in that important nearby structures are less at risk of damage compared to an operation to remove the prostate.
Advanced robotic training fellowship in Europe
Nick Brook will be in Belgium from April to Sept 2018
I will be undertaking a period of advanced robotic surgical training at Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium from April to September 2018, under the mentorship of Prof Alex Mottrie.
The OLV is a high-volume robotic surgery hospital with a large department of Urology. The hospital has been undertaking robotic surgery since 2001 and is closely aligned to the OLV Vattikuti Robotic Surgery Institute (ORSI). The urology department produces a large volume of clinical data on outcomes for robotic surgery and regularly reports on new techniques.
Urologist in Adelaide, Nick Brook using the Mona Lisa Biobot
Robotic prostate biopsy
In January 2017, Nick Brook organised for a 6 month free trial of the Biobot robotic biopsy system at the Royal Adelaide Hospital. This is the first such system in South Australia, and was only the third in use in Australia.
The system uses a patient's MRI scan and fuses this with a real-time ultrasound of the prostate to enable targeting of suspicious areas in the prostate.
Increased accuracy of diagnosis leads to increased confidence that the correct treatment can be chosen.
Software controls the robotic arm, to ensure that the needles are placed in the correct position for biopsyThe Advertiser story on the introduction of the Biobot to South Australia by Nick Brook can be found here
Focal therapy for prostate cancer
Focal laser therapy may offer new options for men with prostate cancer
The idea of focal ablation (localised ‘killing off’) of cancers is not new – surgery for breast cancer was revolutionised years ago by the development of lumpectomy or wide local excision of tumours of the breast, rather than mastectomy (removal of the entire organ), in some settings. This idea has been slow to gain traction in prostate cancer, but may be a sensible option for tumours in the near future.
There are various options for focal ablation, and MRI-guided laser ablation shows a lot of promise in low and intermediate risk prostate cancer. Here, the very accurate application of heat energy from a laser is used to destroy prostate tumours. The position of the laser fibre in the prostate is guided by magnetic resonance imaging (MRI) and ultrasound using a fusion system. This is possible under sedation and local anaesthetic, as shown by a group at UCLA in the States. They first reported their findings in the Journal of Urology back in July 2016 (see here), and they followed up the study with a presentation at the American Urological Association Annual meeting in May 2017 (see here).
Low dose rate (seed) brachytherapy for prostate cancer in men under 60 years
Video consults for distant patients offer many advantages for patients who live long distances from their specialists. This article is written by Nick Brook and Rajiv Singal, and covers many of the issues for this exciting development in healthcare.
In 2015, we will be supporting the incredible work of Australian surgeon Dr Catherine Hamlin and her team. They work in Ethiopa and have been transforming the lives of young women devasted by obstetric fistula.