Management of Medium and Long Term Complications Following Prostate Cancer Treatment Resulting in Urinary Diversion – A Narrative Review
Even Grade Group 1 Prostate Cancer Can Be Lethal
Gleason grade group 1 (GGG1) prostate cancer, despite being considered to have an excellent prognosis, can be lethal in the presence of a high-risk feature, investigators report. These features include more than 50% of systematic biopsy samples containing cancer or a PSA exceeding 20 ng/mL.
Approximately 1 in 12 patients diagnosed with GGG1 prostate cancer during non-targeted prostate biopsy may harbor aggressive disease, Anthony V. D'Amico, MD, PhD, of Brigham and Women's Hospital and Dana Farber Cancer Institute in Boston, Massachusetts, and colleagues revealed in their paper published in European Urology Oncology.
Despite calls to term GGG1 disease "noncancerous," the research findings generally support retaining the cancer designation.
Dr D'Amico's team evaluated the odds of adverse pathology at radical prostatectomy (RP) using clinical data at presentation for 10,228 patients diagnosed with GGG1 cT1-2N0M0 adenocarcinoma of the prostate at biopsy. Of the cohort, 980 underwent combined targeted and systematic MRI fusion biopsy (CBx group) and 9248 underwent transrectal ultrasound-guided systematic biopsy only (SBx group).
More than 50% of biopsies positive for cancer and PSA levels exceeding 20 ng/mL were significant factors for both adverse pathology at RP and early PSA failure, the team reported. The odds for adverse pathology were significantly increased 1.7- and 3.5-fold with these respective features in the SBx group, and 1.8- and 2.8-fold, respectively, in the CBx group. Adverse surgical pathology included grade group 4 or 5, pT3b or pT4, or positive pelvic lymph nodes. The risk for early PSA failure was significantly increased 1.5- and 4.4-fold, respectively, in the SBx group and 2.9- and 7.8-fold, respectively, in the CBx group. PSA failure was considered a rise to more than 0.1 ng/mL.
Dr D'Amico's team further found increased death risks among the SBx group. More than 50% of biopsies positive for cancer and PSA exceeding 20 ng/mL were significantly associated with a 2.6- and 3.7-fold increased risk for prostate cancer-specific mortality, respectively, and a 1.5- and 2.0-fold increased risk for all-cause mortality, respectively, in the SBx group. SBx may have led to undergrading compared with CBx, the investigators suggested
"Maintaining the 'cancer' classification for patients with GGG1 and either [percent positive biopsies] >50% or PSA>20 ng/ml and considering rebiopsy to identify unsampled high-grade disease may minimize the risk of mortality for this subgroup," Dr D'Amico and colleagues wrote. They added that patients could also consider germline testing and/or molecular classifiers.
Among the study's limitations, data for the SBx group were collected before the 2014 ISUP grade group classification was implemented, so some patients might have had grade group 2 disease.
This article originally appeared on Renal and Urology News
Dear Doctor: Do I Just Have To Live With Sexual Disfunction After Prostate Cancer Treatment?
DEAR DR. ROACH: I am a 73-year-old who underwent successful treatment for prostate cancer, using hormone suppression and radiation in 2015. After the treatment concluded, my testosterone level increased back to 435 ng/dL, and my PSA remained below 0.1 ng/mL. I was once again able to perform sexually, although not at the same frequency I did before treatment.
In the past six months, I have noticed a dramatic reduction in my libido, much like it was when undergoing treatment. My doctor wouldn't check my testosterone level. I understand that testosterone replacement is not recommended for men who've had prostate cancer because it may trigger a recurrence of the cancer. Are there any other options for me, or do I just live with it? -- J.C.
ANSWER: Sexual problems after a diagnosis of prostate cancer are common, no matter what kind of treatment is given. For men who are treated with surgery, sexual troubles (most commonly erectile dysfunction) tend to happen immediately after surgery and get better over time. For men treated with hormone suppression (where medication is given so a man cannot make testosterone), sexual troubles include both low libido and erectile dysfunction, which usually occurs immediately after treatment.
With radiation, sexual troubles tend to start well after the radiation is finished, up to two years afterward. This is thought to be due to long-term damage by radiation to the nerves, arteries and other structures. Since you are well past the period of time where sexual dysfunction due to radiation is expected to occur, I'd be concerned that your testosterone has fallen, as you suspect.
I disagree with your physician about testing. Even if you weren't going to treat your low testosterone, it is important to know why you are having symptoms.
If your testosterone is low, then a decision to try testosterone replacement needs to be carefully considered. Some evidence suggests that it is pretty safe and unlikely to cause the cancer to recur, but many prostate cancer experts recommend against it. Only your urologist or oncologist can answer this for you. Most of my patients in your situation elect to try testosterone replacement.
Finally, low testosterone, erectile dysfunction, and just the diagnosis of prostate cancer itself can contribute to low libido. There are dedicated clinics to the treatment of sexual dysfunction, and these often use testosterone (where appropriate), Viagra, or similar medicines, injection treatments and other modalities to help. Still, I regret to say that most men do not regain their full sexual function after treatment for prostate cancer.
DEAR DR. ROACH: I live downwind from a wildfire. I smelled the fire faintly when I went outside for my walk this morning. Is there a point when it's counterproductive to exercise outside if there's a fire, especially when it's further away, as opposed to closer ones? We've had ones that made my eyes burn when I went outside; I obviously stayed inside until the fire was contained. I have been diagnosed with mild chronic obstructive pulmonary disease (COPD) and would appreciate some guidance. -- L.H.
ANSWER: I recommend checking the air quality index (AQI). Many weather apps for your smartphone will give you this information, or you can check AirNow.Gov. I don't recommend exercising outside when the air quality is moderate or worse, and for my patients with COPD, I don't recommend being outside more than you have to once the AQI is above 100.
Last year, due to the large Canadian wildfires, the AQI where I practice in New York was so bad that I called my patients with lung disease to ask them to switch to telehealth visits.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.Cornell.Edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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Understanding Prostate-Specific Antigen (PSA) Testing
Panelists discuss how the PSA test is conducted and interpreted, and clarify the definitions of high-risk and advanced prostate cancer types, including their implications for prognosis and subsequent treatment decisions.
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