Home: PCU
5|2003: Joseph A Smith Jr, MD
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Joseph A Smith Jr, MD |
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William L Bray Professor and Chair,
Department of Urologic Surgery,
Vanderbilt University School of Medicine |
Edited Comments by Dr Smith
Assessing prognosis after radical prostatectomy
I review my patients' pathology reports, their preoperative PSA and other prognostic factors to come up with a rough estimate of their prognosis. I let them know whether their prognosis is good, poor or intermediate based upon their pathology. I may not be more specific than that, unless they request it. If they want to look at a nomogram together and come up with an exact figure, I'll do that with them as well.
Postprostatectomy adjuvant therapy with high-risk cancers
I believe in aggressive postoperative adjuvant therapy, but I don't believe very early treatment has been shown to be better than early treatment. In other words, regardless of the pathologic features and how poor the prognosis, I don't generally start treatment until there is evidence of PSA recurrence. If the patient's initial postprostatectomy PSA is undetectable, I may suggest a period of watchful waiting. I'll tell the patient that while their risk of PSA recurrence is very high, and that I may even be expecting it, that we may be able to withhold treatment until PSA recurrence is evident. I follow the same philosophy in the rare patient with positive nodes. I tell the patient that we can probably safely defer treatment until the PSA rise becomes evident.
Defining PSA recurrence
My definition of PSA recurrence varies. In the patient in whom I expect to see a PSA recurrence (i.e., the patient with positive nodes), I may consider any detectable PSA a sign of recurrence. Since I know it's going to happen, why wait until the PSA becomes 0.4 ng/mL? In a patient whose tumor had favorable histologic features, in whom I'm surprised to see a PSA recurrence, I may continue to follow a watchful waiting approach to see if he is one of the rare patients who will have a minimally detectable PSA without a subsequent rise.
PSA recurrence: Assessing the extent of the disease
To determine appropriate treatment for patients with PSA recurrence, it is important to assess whether the patient's disease is local, regional or systemic. If there's a significant possibility that the disease is only local, I'm more inclined to use postoperative radiation therapy. If I believe the disease is regional or systemic, I'm more inclined to use hormonal therapy from the start.
I consider a number of factors when attempting to determine the extent of the patient's disease recurrence. The recurrence is more likely to be systemic if the grade of the cancer was higher, the PSA recurrence occurred rapidly, the PSA never declined to an undetectable level or the PSA doubling time was rapid.
Selection of hormonal therapy for patients with PSA recurrence
The type of hormonal therapy selected varies from person to person, depending on their desires and ability to pay for the medication. If a man's sexual function has been preserved and it's important to him, then I'm more inclined to use antiandrogen monotherapy, such as bicalutamide, to try to preserve libido and sexual function. If a man's sexual function was not preserved or it's not an important parameter, then an LHRH analog could be used. Presumably, osteoporosis is also avoided with antiandrogen monotherapy; so there are some advantages. There are also some disadvantages, such as gynecomastia and breast tenderness, but I discuss the use of pretreatment breast irradiation because I believe it is effective. Ability to pay for these two hormonal therapies is also an important factor.
In some men with PSA recurrence, I use intermittent androgen suppression. I realize that its effectiveness is not proven, and ongoing studies are evaluating this approach. In terms of quality of life, intermittent androgen suppression has some advantages, especially when we're using an LHRH analog.
Use of intermittent androgen suppression for patients with PSA recurrence
In a patient with what appears to be a good-prognosis tumor who develops a very slow and late rise in his PSA, it would not be in his best interest to be on continuous androgen suppression for a decade or longer. I would likely treat that patient with hormonal therapy until his PSA was undetectable, which often is very quickly, perhaps within three months. If that were the case, I would continue hormonal therapy for at least another three months. Once I initiate hormonal therapy, I keep patients on it for six to nine months, then discontinue it and restart it when the PSA reaches some arbitrary value.
The point at which I restart therapy varies from person to person. Often, the patient is anxious to restart therapy. I tell them, "We'll restart therapy when we see a substantial change," and I don't necessarily define the substantial change. In other words, if their PSA is rising very slowly, I am more likely to keep them off therapy than if their PSA doubling time is rapid.
Most patients like the idea of intermittent therapy. When the PSA becomes detectable after radical prostatectomy, most men want treatment. Once they receive hormonal therapy and their PSA becomes undetectable, they feel very gratified and more reassured. Then, the idea of discontinuing hormonal therapy by going on intermittent therapy has some emotional appeal. They are more accepting of the fact that their PSA may rise and become detectable again. On the other hand, some patients who are feeling well and tolerating the hormonal therapy without difficulty don't want to rock the boat. In those men, I won't rock the boat either; I'll keep them on continuous therapy.
Clinical research on early hormonal therapy
Credit goes to the radiation oncologists who have been able to conduct a number of important trials in this area, such as the Bolla study and others, which have helped to define the role of hormonal therapy. The post-prostatectomy study published by Ed Messing evaluating early hormonal therapy in patients with node-positive disease and the Medical Research Council Study from Britain are also important trials. Those trials have put me into the early hormonal therapy camp. There are problems with all of these studies and none of them are definitive, but these and others are what lead me to utilize early hormonal therapy.
Counseling men about radical prostatectomy
My role primarily is to advise patients about the pros and cons of surgery. I tell them whether or not they are surgical candidates, and I very clearly outline the side effects and what they can anticipate from surgery. We talk about the operation, specifically about the way we do it at Vanderbilt. In our hands, the procedure takes one and a half or two hours. Patients can expect to be in the hospital for two days and to wear a Foley catheter for a week to 10 days. Their risk of requiring a blood transfusion is one percent or less.
The exact words I use are, "Things can happen, and they can happen with any operation, but fortunately with this one we don't usually have major perioperative complications." Then, we focus on the most important outcome measures - tumor control, continence and potency. I outline the likelihood of being able to cure their cancer (i.e., maintaining an undetectable PSA forever). I'm not hesitant to use the word cure. We do cure patients with radical prostatectomy.
We specifically discuss the risk of incontinence and the pros and cons of a nerve-sparing procedure in their particular case. I tell them that there's a 90 percent chance that they'll be pad-free and that two percent of men have enough problems with incontinence that they will seek additional treatment, such as a sphincter or collagen injection.
Postoperative sexual function depends on the patient's age and preoperative sexual function and whether or not the nerves are spared. Eighty to 90 percent of men in their fifties without any preoperative sexual dysfunction are able to engage in intercourse postoperatively, perhaps with the use of sildenafil. I tell men in their late sixties that the chances of maintaining sexual function are less than 50 percent. I tell men in their seventies that more likely than not, they will have erectile dysfunction.
Postoperative sexual rehabilitation
There's no question that sildenafil helps, and most surgeons no longer have data about sexual function in men who don't use it. Even men who can achieve penetration without sildenafil often use it because it improves erectile function. Unfortunately, it doesn't help everybody. If a man has very poor postoperative erectile function, sildenafil is not very effective.
Early on in the postoperative period, I often recommend that my patients try the vacuum pump devices. Although they're completely noninvasive, younger men don't find them to be an acceptable long-term method.
However, they are a good way to bridge the gap between the surgery and the time when erectile function returns. There can be improvements in sexual function for a full two years after surgery.
After waiting a sufficient period of time, a prosthesis may be considered for men who have failed to regain erectile function, especially if they have not had satisfactory results with the less invasive methods.
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