Tuesday, April 16, 2013

New Procedure May Shrink Enlarged Prostate Without Surgery

Men who need treatment for an enlarged prostate may soon have a new nonsurgical option, a small, early study suggests.

Called prostatic artery embolization (PAE), the technique uses a catheter threaded into an artery in the leg. The catheter is guided to the artery that supplies blood to the prostate. Then, tiny beads are injected into the artery, which temporarily block the blood supply to the prostate.

The temporary loss of blood supply causes the prostate to shrink, relieving symptoms, according to study lead author Dr. Sandeep Bagla. What's more, the new treatment doesn't appear to have the same risk of serious complications, such as incontinence and impotence, that often accompany enlarged prostate treatment.

"This is fantastic news for the average man with benign prostatic hyperplasia. Many men decline current treatments because of the risks. But, for the average man, PAE is a no-brainer," said Bagla, an interventional radiologist at Inova Alexandria Hospital, in Virginia.

The procedure has only been available as part of Bagla's trial until recently, but he said some interventional radiologists have started doing prostatic artery embolization, and he expects the procedure will become more widely available by the end of the year.

Benign prostatic hyperplasia is the medical term for an enlarged prostate. An enlarged prostate is very common as men get older. As many as half of all men in their 60s will have an enlarged prostate, according to the U.S. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). By the time men are in their 70s and 80s, up to 90 percent have benign prostatic hyperplasia, according to the NIDDK.

Some men experience no symptoms, while others may feel the need to urinate frequently, but they have a weak urinary stream, the NIDDK says. There are a number of treatments available for benign prostatic hyperplasia, including medications and surgery.

Bagla said that interventional radiologists in Europe and South America have been using prostatic artery embolization, and that the current study is the first in the United States to test the procedure.

He and his colleagues hope to treat a total of 30 patients, but they're reporting on the results from the first 18 patients on Monday at the annual meeting of Society of Interventional Radiology, in New Orleans. The data and conclusions should be viewed as preliminary until published in a peer-reviewed journal.

For the study, the average age of the patients who underwent prostatic artery embolization was 67 years. None of the men had to be admitted to the hospital after the procedure.

Ninety-four percent of the men (17 of 18) had a significant decrease in their symptoms one month after surgery. And, none reported any major complications following the surgery.

Bagla said the exact cost of the new procedure is difficult to estimate right now, but prostatic artery embolization will be cheaper than most of the currently used procedures, he said, because there's no need for an operating room and overnight hospital stays. In addition, he said, because the new procedure doesn't appear to cause complications, that will save health care dollars as well.

"This may become part of the armamentarium of treatments that can be offered for [benign prostatic hyperplasia]," said Dr. Art Rastinehad, director of interventional urologic oncology at North Shore-LIJ Health System in New Hyde Park, N.Y. He was not involved with the new study.

"This was a small series and a limited study to draw significant conclusions from. But, it's very exciting to see it evaluated and moving forward," he said.

New Study Questions Prostate Cancer Screening for Older Men

Only one-third of men over age 65 who receive an abnormal result from their PSA test actually undergo prostate biopsy to look for disease, a new study finds.

Prostate-specific antigen (PSA) screening is a common test that measures the level of a key marker for prostate cancer in the blood. In general, the higher the level of this protein, the more likely it is that a man has prostate cancer, according to the U.S. National Cancer Institute.

The value of the PSA test has recently come into question, however, with several studies suggesting it causes men more harm than good -- spotting too many slow-growing tumors that, especially in older patients, may never lead to serious illness or death.

The new study focused on this issue once again, tracking outcomes for nearly 300,000 men, aged 65 and older, who underwent PSA screening in the U.S. Veterans Affairs health care system in 2003. The men's health was followed for up to five years.

There were more than 25,000 men with clinically abnormal PSA levels. According to the study authors, during the five-year follow-up period, only 33 percent of those men underwent at least one prostate biopsy to check for evidence of cancer. About 63 percent of those who did have a biopsy were diagnosed with prostate cancer, of whom 82 percent were treated for their cancer.

The older the man, the less likely he was to have a prostate biopsy after having an abnormal PSA screening test result. Men with other health problems were also less likely to undergo a prostate biopsy, the investigators reported.

The study was published online April 15 in the journal JAMA Internal Medicine.

Among men with biopsy-detected prostate cancer, the risk of death from causes other than prostate cancer increased with age and with the presence of other health problems, Dr. Louise Walter, of San Francisco Veterans Affairs Medical Center, and colleagues pointed out in a journal news release.

Two experts not connected to the study said the findings weren't surprising, given the patients' ages.

"PSA screening has been controversial as it has a relatively low yield for finding clinically significant cancer as well as potential complications and expense related to diagnosis and treatment," said Dr. Louis Kavoussi, chairman of urology at North Shore-LIJ's Arthur Institute for Urology in New Hyde Park, N.Y.

In the new study, "as age and other chronic illnesses of aging increased, the less likely biopsy was performed," he said. "This makes sense as the authors report that older individuals and those with [other illnesses] are more likely to die of a non-prostate cancer-related cause."

Therefore, the decision to test for PSA levels in older men must take into account their relatively low risk of dying of prostate cancer, Kavoussi said. "Overall, it is known that about 10 percent of individuals diagnosed with prostate cancer succumb to the disease," he said. "In this older patient population study it was 2.2 percent -- much lower, but not zero."

Another expert agreed, saying that younger men may benefit most from regular PSA screening.

"For screening to be effective, we need to focus on men with a long life expectancy," said Dr. Stacy Loeb, assistant professor in the department of population health at NYU Langone Medical Center, New York City. "Screening allows us to diagnose the life-threatening cancers in time for cure [but] diagnosis does not mandate treatment," she explained.

"Once a diagnosis is made, many patients with low risk disease can be safely monitored conservatively," Loeb said. "Men should be actively involved in all of these choices, with a discussion about risks and benefits."

What's really needed, according to Kavoussi, is a screen that can tell a patient whether his prostate cancer is aggressive or not.

There's a "need for better ways of detecting clinically significant disease in this older population, both to avoid overtreatment and to minimize the risk of missing significant disease," Kavoussi said.

More information

The U.S. National Cancer Institute has more about prostate cancer screening.

Wednesday, April 3, 2013

On-and-off approach to prostate cancer treatment may compromise survival

Taking a break from hormone-blocking prostate cancer treatments once the cancer seems to be stabilized is not equivalent to continuing therapy, a new large-scale international study finds.

Based on previous smaller studies, it looked like an approach called intermittent androgen deprivation therapy might be just as good as continuous androgen deprivation in terms of survival while meanwhile giving patients a breather from the side effects of therapy. In fact, researchers believed intermittent therapy might help overcome treatment resistance that occurs in most patients with metastatic hormone-sensitive prostate cancer.

But this new study, which treated 1,535 patients with metastatic prostate cancer and followed them for a median of 10 years, finds that's not the case. Results appear in the New England Journal of Medicine.

"We tried to see whether intermittent androgen deprivation is as good as continuous androgen deprivation, but we did not prove that. We found that intermittent therapy is certainly not better and moreover we cannot even call it comparable," says lead study author Maha Hussain, M.D., FACP, a prostate cancer expert oncologist at the University of Michigan Comprehensive Cancer Center.

The study was sponsored by SWOG, a National Cancer Institute-supported cancer clinical trials cooperative group.

In the study, men with metastatic hormone-sensitive prostate cancer were given an initial course of androgen deprivation therapy (hormone therapy), which is standard therapy for this disease. Patients with a stable or declining PSA level equal to or below a cut-off of 4 ng/ml were then randomly assigned either to continue or to discontinue the hormone therapy. Patients were carefully monitored with monthly PSAs and a doctor's evaluation every three months and therapy was resumed in the intermittent arm when PSA climbed to 20 ng/ml. The intermittent cycle continued on-and-off based on the PSA levels.

Survival among the two groups showed a 10 percent relative increase in the risk of death with intermittent therapy, with average survival of 5.8 years for the continuous group and 5.1 years for the intermittent group from the time of randomization.

Further, the researchers looked at quality of life between the two groups of patients. Initially the intermittent therapy group showed significant improvement in impotence and emotional function in the first three months and had improved trends in other aspects of quality of life compared to the continuous group. But these differences leveled off over time.

"The improvements in some aspects of quality of life that were observed early were not sustained after a few months as patients had to resume therapy," says Hussain professor of internal medicine and urology at the U-M Medical School.

"If a patient is coming in with newly metastatic prostate cancer, hormone treatment continuously is the standard. If they wish to do intermittent treatment, they should be counseled that based on this data, their outcome might be compromised," she adds.