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Rapid Responses: Rapid Responses published:
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Organ removal is not necessary for cure of Cancer
- Santhanam Sundar (26 November 2006)
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United Kingdom Perspective
- Helena P Burden, Mr Raj Persad, Consultant Urological Surgeon (28 November 2006)
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Please keep sight of the woods
- Richard G Richards (30 November 2006)
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HIFU as a possible treatment option
- Nourdin Kadi, Kyung-Jae Rhee, Mohammed Khalifa and Amir V. Kaisary (18 December 2006)
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Santhanam Sundar, Consultant Oncologist Nottingham University Hospital. City Campus. Nottingham. NG5 1PB
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In an otherwise excellent article summarising the treatment options for prostate cancer, Wilt and Thompson, inadvertently promote an outmoded surgical concept i.e. removal of an organ is essential for cure of cancer. (1). In discussing the disadvantages of external beam radiotherapy and Brachytherapy, they imply that failure to cure with radiation is related to not removing the prostate. There is no evidence to support this and indeed cancer control rates with radiotherapy are equivalent to radical surgery (2). In many other cancers, radical mutilating surgery has not been shown to improve cure rates. For example, in breast cancer, organ preserving surgery and post operative breast radiotherapy is as good as radical disfiguring mastectomy (3). Management of all cancer patients involves consideration of quality of life and organ preservation can improve quality of life. Removal of an organ and its resultant commodity is unnecessary in treatment of many cancers and indeed could be ethically indefensible in some patients with cancers of larynx, anus and cervix. (4) (5). References 1. Wilt JW , Thompson IM. Clinically localised prostate cancer. BMJ. 2006; 333: 1102-1106 2. Kupelian PA, Potters L, Khuntia D, et al. Radical prostatectomy, external beam radiotherapy <72 Gy, external beam radiotherapy > or =72 Gy, permanent seed implantation, or combined seeds/external beam radiotherapy for stage T1-T2 prostate cancer. Int J Radiat Oncol Biol Phys. 2004; 58(1):25-33. 3. Fisher B, Anderson S, Bryant J, et al.: Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002. 347(16): 1233-41. 4. Landoni F, Maneo A, Colombo A, et al.: Randomised study of radical surgery versus radiotherapy for stage Ib-IIa cervical cancer. Lancet 1997. 350: 535-40. 5. Forastiere AA, Goepfert H, Maor M, et al.: Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 349 (22): 2091-8, 2003. Competing interests: None declared |
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Helena P Burden, Urology Research Fellow Bristol Royal Infirmary, Marlborough Street, Bristol, BS2 8HW, Mr Raj Persad, Consultant Urological Surgeon
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We read with interest the review by Wilt and Thompson upon clinically localised prostate cancer, and have two points to clarify. Firstly, the authors of the review seem to recommend a current Prostate Specific Antigen (PSA) cut-off value of 4.0ng/mL, which could mislead many medical practitioners reading this article, and lead to inappropriate urology referrals from General Practitioners. The American Guidelines 1 suggest a cut-off of 4.0ng/mL, however the United Kingdom Department of Health guidelines 2, which are not referred to in this article, suggest age related PSA cut-offs ( age 50-59 > 3.0ng/mL, 60-69 >4.0ng/mL, >70 >5.0ng/mL). Secondly, the authors have quoted the Thompson et al. 3 paper concerning finasteride as a proposed prevention for prostate cancer. They have stated the initial interpretations of the data, which were that despite appearing to reduce the risk of prostate cancer, the cancers that were detected in men taking finasteride were of a higher grade than the control group. This data has since been re-analysed in several papers, the most recent paper by D'Amico et al. 4 suggested that finasteride decreases the contribution that PSA makes to Benign Prostatic Hyperplasia and in doing so it makes changes in PSA more cancer-specific. Therefore until we understand at what PSA levels at which we should be recommending a biopsy for men taking finasteride, should Wilt and Thompson really be recommending prescribing this for the prevention of prostate cancer to men over 50 years old? References 1. Ferrini R, Woolf S. Screening for prostate cancer in American men. Practice policy statement.: American College of Preventive Medicine, 1997. 2. The NHS Prostate Cancer Plan. In: Health Do, editor: NHS Executive, 2000. 3. Thompson IM, Goodman PJ, Tangen CM, Lucia MS, Miller GJ, Ford LG, et al. The influence of finasteride on the development of prostate cancer. N Engl J Med 2003;349(3):215-24. 4. D'Amico AV, Barry MJ. Prostate cancer prevention and finasteride. J Urol 2006;176(5):2010-2; discussion 2012-3. Competing interests: None declared |
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Richard G Richards, Consultant in Publis Health Nottinghamshire County tPCT
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Can we please keep sight of the woods. Radical treatment of early prostatic cancer in under 65s would deliver an additional 1 year of life to those men (it has little impact on those 65+)[1]. That is an additional 1 year on the overall general life expectancy of no more than 20 years for a 60 year old (just 5% improvement), during which time these men will suffer the consequences of surgery. If all 6000 (under 65) cases each year in England and Wales were identified early and treated, the total gain would be 6000 life years. With a total of 250,000+ male deaths each year such an intervention would increase the life expectancy of males at birth by 9 days. If all men stopped smoking the reduction in lung cancer deaths alone would increase life expectancy by 9 months (190,000 avoided years of life lost across 250,000 deaths). Prostate cancer is NOT a major public health issue. It is a disease of survivors with an average age at death of 78.5 years compared to the all cause average age at death of 76. 5 times as many years of life are lost to lung cancer in men or to breast cancer in women. The cause specific fatality rate is 32% compared to 87% for male lung cancer. The incidence rate for prostate cancer in the USA is more than double that in the UK but the mortality rates are only a little lower (with little difference in mortality rates across European countries and the USA). The cause of this high incidence is diagnoses from PSA testing. The results are clearly more men coping with the diagnosis but for no significant benefit in longevity and probably a worse quality of life. Prostate cancer is probably best treated conservatively and certainly not sought for. 1 Bill-Axelson A, Holmberg L, Ruutu M, Haggman M, Andersson SO, Bratell S, et al. Scandinavian Prostate Cancer Group Study No. 4. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 2005;352:1977-84. Competing interests: None declared |
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Nourdin Kadi, Clinical Fellow Department of Urology, Royal Free Hospital Hampstead NW3 2Q, Kyung-Jae Rhee, Mohammed Khalifa and Amir V. Kaisary
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This article is informative and very well illustrated, providing a valuable overview of the treatment options available for clinically localized prostrate cancer (1). However, there was unfortunately no mention of High Intensity Focused Ultrasound (HIFU).This treatment option can be offered to patients with localised prostate cancer (stage T1-T2) as an alternative to surgery or to patients who are not ideal for a prostatectomy (because of their age, their general state of being or other co-morbidities). Furthermore, this treatment can be used in patients who have local recurrence after external beam and interstitial radiotherapy. HIFU destroys cancerous prostatic cells by coagulative necrosis (2) without increasing metastasis formation (3). Unlike ionizing radiation, cells in the entry and exit pathway of the HIFU beam are left uninjured. This allows for multiple applications without increased risk to neighbouring tissues. In March 2005, NICE (The National Institute for Health and Clinical Excellence) issued guidance for doctors on HIFU for prostate cancer. Contraindications for HIFU include; a prostate gland size greater than 40cc, rectal stenosis, and a history of rectal fistula. Although the clinical experience with HIFU is still limited, the future of HIFU in the treatment of localized prostate cancer appears very promising. References: 1.Wilt TJ, Thompson IM. Clinically Localised Prostate Cancer. BMJ 2006; 333(7578):1102-6 2. Chapelon JY, Margonari J, Vernier F, Gorry F, Ecochard R, Gelet A. In vivo effects of high-intensity ultrasound on prostatic adenocarcinoma Dunning R3327. Cancer Res. 1992 Nov 15;52(22):6353-7. 3. Oosterhof GO, Cornel EB, Smith GA, et al. Influence of high-intensity focused ultrasound on the development of metastases. Eur Urol 1997; 32:91. 4. Azzouz H, de la Rosette JJMCH. HIFU: Local treatment of prostate cancer. Eur Urol 2006;62-70. Competing interests: None declared |
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