Faculty Bibliography

OBJECTIVES: To retrospectively compare the biochemical disease-free survival (BDFS) of patients treated with standard dose external beam radiotherapy (SD-EBRT), SD-EBRT plus androgen deprivation (AD), and brachytherapy-based treatment (brachytherapy with or without EBRT with or without AD). METHODS: All 297 patients with intermediate-risk prostate cancer treated with these radiation-based treatments at our institution from August 1989 to June 2001 were included. Biochemical relapse was defined according to the American Society for Therapeutic Radiology and Oncology (ASTRO) definition, a prostate-specific antigen level of 1.5 ng/mL or greater and rising on two consecutive occasions (the 'Bolla' definition), and the current prostate-specific antigen nadir plus 2 ng/mL with failure dated 'at call' (the 'Houston/Phoenix' definition). The number of patients treated with SD-EBRT, SD-EBRT plus AD, and brachytherapy-based treatment was 141, 84, and 72, respectively. The year of treatment was analyzed as a prognostic factor. The median follow-up was 32.3, 34.7, and 41.5 months for the ASTRO, Bolla, and Houston/Phoenix definitions, respectively. RESULTS: The brachytherapy-based treatment resulted in improved BDFS compared with SD-EBRT (ASTRO definition, 5-year BDFS rate 88% +/- 5% versus 49% +/- 5%, P <0.01; Bolla definition, 88% +/- 8% versus 49% +/- 5%, P <0.01; Houston/Phoenix definition, 81% +/- 10% versus 64% +/- 5%, P = 0.01). SD-EBRT plus AD was superior to SD-EBRT alone using the Bolla definition (5-year BDFS 76% +/- 7% versus 49% +/- 5%, P <0.01) and the Houston/Phoenix definition (85% +/- 6% versus 64% +/- 5%, P = 0.01), but not using the ASTRO definition (P = 0.17). Multivariate analysis, including prostate-specific antigen, clinical stage, Gleason score, and year of treatment, demonstrated improved biochemical outcomes for brachytherapy-based treatment versus SD-EBRT (ASTRO, P <0.01; Bolla, P <0.01; and a trend toward significance with Houston/Phoenix, P = 0.07) and for the addition of AD to SD-EBRT (Bolla, P <0.01 and Houston/Phoenix, P = 0.03). The year of treatment trended toward significance (P = 0.077) on multivariate analysis using the ASTRO definition. CONCLUSIONS: For patients with intermediate-risk prostate cancer, brachytherapy-based treatment and the addition of AD to SD-EBRT resulted in improved biochemical outcomes compared with the outcomes with SD-EBRT alone; however, these findings were dependent on the definition of biochemical failure used. The year of treatment may be an important prognostic factor in intermediate-risk prostate cancer

Having a high probability of experiencing prostate cancer during their lifetime, men are increasingly seeking protection against this disease with the use of over-the-counter dietary supplements containing herbs, vitamins, or plant-derived biochemical agents. The use of these agents for prostate cancer prevention is driven by epidemiology supporting the idea that regional diets and consumption of specific dietary components (certain herbs, vitamins, isoflavones, and polyphenols) are associated with a lower risk for prostate cancer, in conjunction with basic research that is defining molecules within food substances that kill or suppress growth of cultured human prostate cancer cells. Moreover, there is a sense that these dietary agents lack side effects, although this assumption often is faulty. Unfortunately, at this time, there is insufficient clinical evidence to support the widespread use of these dietary supplements for chemoprevention of prostate cancer, although ongoing clinical trials of the most promising vitamins and minerals are approaching conclusion.

PURPOSE/OBJECTIVE:We hypothesized that intraoperative preplanning for transperineal interstitial permanent prostate brachytherapy may yield better prostate cancer control than preoperative preplanning. We tested this hypothesis by comparing treatment outcomes of patients who underwent implantation using these two preplanning methods. PATIENTS AND METHODS/METHODS:We analyzed the data of 135 consecutive patients with localized prostate cancer treated from 1996 to 2001 with transperineal interstitial permanent prostate brachytherapy+/-preimplantation hormonal therapy: 42 received preoperative preplanning (group 1), and 93 underwent intraoperative preplanning (group 2). Biochemical status was assessed using two failure definitions: American Society for Therapeutic Radiology and Oncology (ASTRO) (three consecutive rises in prostate-specific antigen level) and Houston (prostate-specific antigen level>or=current nadir+2 ng/mL). Clinical disease-free survival and postimplantation dosimetry were also examined. RESULTS:All disease control outcomes were superior for group 2. The 4-year ASTRO biochemical no evidence of disease rate was 80% for group 1 versus 94% for group 2. The 4-year Houston biochemical no evidence of disease rate was 82% for group 1 versus 96% for group 2. The 4-year clinical disease-free survival rate was 87% for group 1 versus 99% for group 2. Preplanning method (preoperative versus intraoperative) remained predictive of disease control outcomes in multivariate analyses with the covariates of pretreatment prostate-specific antigen level, Gleason score, clinical stage, and case sequence number (proxy for brachytherapist experience and "stage migration"). Dosimetric prostate coverage was superior for group 2. The mean percentage of the prescription dose delivered to 90% of the prostate volume (%D90) was 75% for group 1 versus 90% for group 2. A %D90>or=70% predicted for improved disease control; fewer group 1 than 2 patients met this dosimetric criterion (55% versus 87%). DISCUSSION/CONCLUSIONS:Intraoperative preplanning yielded superior disease control outcomes in this analysis, likely due at least in part to improved dosimetric prostate coverage with this method. Although not mandatory for obtaining high prostate brachytherapy efficacy, intraoperative preplanning nevertheless may offer an excellent means of improving dosimetric prostate coverage and therefore disease control outcomes.

The use of botanicals and supplements have markedly increased in men that are seeking increased protection against the potential onset and symptomatic relief of lower urinary tract symptoms that are commonly experienced with benign prostatic hyperplasia (BPH). While this implies a positive trend and considers that men are taking a more active role in health and prevention, dialog between the patient and the clinician is often deficient. This may be due to a number of factors including both the patients' inability to report about the use of certain agents and the clinicians' inability to ask. Moreover, the sense that natural agents may lack side effects coupled with ineffective communication between the doctor and patient could result in potential adverse interactions. We have performed a comprehensive search of articles published from 1990 to 2005 using the Medline databases in order examine clinical data on the most commonly researched herbs for BPH. We provide a brief update on the state of the research.

OBJECTIVES/OBJECTIVE:The current TNM staging system for renal cortical tumors (RCTs) differentiates between tumors confined to the kidney (T1, T2) and tumors that extend through the renal capsule and invade into the perinephric fat (T3a). We examined the relative survival rates of patients with T1 and T3a tumors to determine the accuracy of the current TNM staging classification. METHODS:We analyzed the Columbia University Surgical Urological Oncology Database for all patients with clinically localized Stage T1, T2, and T3a RCTs treated surgically from 1988 to 2004. The primary outcomes included local and distant recurrence. Because the T3a classification is not limited by size, we compared T3a tumors with T1 tumors alone and tumors confined within the renal capsule (Stage T1 and T2 tumors combined). RESULTS:A total of 819 patients underwent partial or radical nephrectomy for RCTs at Columbia University during the study period. After the exclusion criteria were applied, 131 patients with T1N0M0, 19 patients with T2N0M0, and 82 patients with T3aN0M0 conventional renal cell carcinoma were eligible for analysis. The median follow-up was 37 months. The median tumor diameter was 3.2, 3.8, and 5.0 cm for Stage T1, T1 and T2 combined, and T3a lesions, respectively. The estimated 5-year disease-free survival was 95.2% and 90.6% for T1 and T3a RCTs, respectively (P = 0.922). CONCLUSIONS:Patients with Stage T3a tumors experienced similar outcomes as patients with tumors confined to the renal capsule. These data suggest that the T3a classification should be examined more closely to attempt to improve the prognostic validity of the TNM classification.

Having a high probability of experiencing prostate cancer during their lifetime, men are increasingly seeking protection against this disease with the use of over-the-counter dietary supplements containing herbs, vitamins, or plant-derived biochemical agents. The use of these agents for prostate cancer prevention is driven by epidemiology supporting the idea that regional diets and consumption of specific dietary components (certain herbs, vitamins, isoflavones, and polyphenols) are associated with a lower risk for prostate cancer, in conjunction with basic research that is defining molecules within food substances that kill or suppress growth of cultured human prostate cancer cells. Moreover, there is a sense that these dietary agents lack side effects, although this assumption often is faulty. Unfortunately, at this time, there is insufficient clinical evidence to support the widespread use of these dietary supplements for chemoprevention of prostate cancer, although ongoing clinical trials of the most promising vitamins and minerals are approaching conclusion.