Howard Waage ---- Editor
Our monthly meeting will be in the Bennett & Suzy Katz Cancer Resource Center on the 1st Floor of the two-story redwood Education Building behind Santa Cruz Dominican Hospital.
It is the last Tuesday each month, so this month that is October 27th, 2009 at 7:00 PM. For more information, please call - The Bennett and Suzy Katz Cancer Resource Center at Dominican Hospital (831) 462-7770 .
ScienceDaily (Sep. 14, 2009) — Appropriately selected prostate cancer patients, including older men and men with small, low-risk tumors, may safely defer treatment for many years with no adverse consequences, according to a new study in the Journal of Clinical Oncology (JCO). Led by researchers at Beth Israel Deaconess Medical Center (BIDMC), the study appears online today.
"With the advent of PSA [prostate antigen] screening nearly 20 years ago, we started to detect prostate cancers at much earlier stages," explains corresponding author Martin Sanda, MD, Director of the Prostate Cancer Center at BIDMC and Associate Professor of Surgery at Harvard Medical School. "Consequently, while PSA testing has enabled us to successfully begin aggressive treatment of high-risk cancers at an earlier stage, it has also resulted in the diagnosis of cancers that are so small they pose no near-term danger and possibly no long-term danger," he adds.
Sanda, together with coauthors from Brigham and Women's Hospital, the Harvard School of Public Health and the University of California, San Francisco, looked at the Health Professionals Follow-Up Study, a large cohort study comprising 51,529 men who have been followed since 1986. Every two years, the participants respond to questionnaires inquiring about diseases and health-related topics, including whether they have been diagnosed with prostate cancer.
A total of 3,331 men reported receiving a diagnosis of prostate cancer between 1986 and 2007. Further analysis found that among this sub-group, 342 men – just over 10 percent – had opted to defer treatment for one year or longer. Ten to 15 years later, half of the men who had initially deferred treatment still had not undergone any treatment for prostate cancer.
"We wanted to find out how this group of men fared in the long-term," explains Sanda. "So we looked at the data they provided us at an average of eight years after their initial diagnosis, and compared it with data provided by prostate-cancer patients who had opted for aggressive treatment, such as surgery, radiotherapy or hormonal therapy. "We found that the deaths attributed to prostate cancer were very low among the men with low-risk tumors," explains Sanda. "Our analysis showed that only two percent of the men who deferred treatment eventually died of the disease, compared with one percent of the men who began treatment immediately following their diagnosis. This is not a statistically significant difference."
There are three types of prostate cancer: High risk, which are large, faster-growing cancers; intermediate risk; and low-risk, which are small and slower growing cancers. While there is ample evidence that treating intermediate and high-risk cancers with either surgery, radiation or hormone therapy can save lives, whether and how best to care for low-risk cancers remains uncertain.
The Wall Street Journal recently published a letter to the editor under the heading, “Lifestyle Is Fine, but Cancer Needs Effective Treatment.” The physician writing the letter vilified the idea of using anything but surgery to treat his prostate cancer. Unfortunately, his uninformed convictions are prevalent throughout the medical community. Now definitive, well-performed studies unequivocally prove that overtreatment is the norm (New England Journal of Medicine 2009;360:1310-9 and 1320-8) .
As has been the case for years, the a priori assumption that “all cancer needs treatment” has confused the expert commentators who are interpreting these crystal-clear study results as being part of an ongoing unresolved controversy about PSA testing. The reality is that huge amounts of precious research dollars are being spent to answer a foolish question. Whether or not to do PSA testing is not the issue. The issue is deciding what to do with the information the PSA provides.
Right now the nation is in the grip of 8-billion dollar industry hell-bent on administering treatment to every kind of prostate cancer whether it is life-threatening or not. The solution to the problem of over-treating prostate cancer is not less PSA testing. The solution is educating physicians to forgo recommending immediate surgery or radiation to every last man who gets a diagnosis of prostate cancer.
Newly-diagnosed patients need to research all their options before agreeing to irreversible radical treatment. PSA testing (in conjunction with other means) has a useful role in determining which men harbor the more aggressive types of prostate cancer. Only with a “go slow” approach, ongoing monitoring known as Active Surveillance, can we distinguish men with aggressive disease who need treatment from men with indolent disease who don’t need treatment.
Mark Scholz, M.D. Prostate Cancer Research Institute Los Angeles, California Source: http://www.prostate-cancer.org/aboutus/press/news_debate_prostate_test.html
San Antonio Express-News, August 10, 2009 - In recent years, a small but growing number of men with prostate cancer have opted for another treatment choice -- holding their breaths. The idea is that men with small, slow-growing tumors undergo regular check-ups and begin treatment only if the disease worsens -- a process known as watchful waiting, or active surveillance. Now two national studies taking place in San Antonio are focusing on watchful waiting. Both aim to give men more definitive answers as they consider the trade-offs between the anxiety of living with prostate cancer and the well-known side effects of surgery and radiation.
"If the treatments had no side effects, it would be a very straightforward thing," said Dr. Ian Thompson, professor of urology at the University of Texas Health Science Center, who heads the local arm of both studies. "Unfortunately the treatments have a risk of urinary, bowel and sexual side effects."
And with more people being screened -- and more cancers being found that are lower risk -- one option increasingly being considered by men is active surveillance, added Thompson, who has followed for a decade about 200 local patients doing just that. "We don't want to find all those cancers," he said. "What we want to do is find those cancers that need to be found and treated."
More than half of all men have cancer cells in their prostates by age 80, most of them undiagnosed. Yet a small fraction -- only 3 percent -- die from the disease. Most prostate tumors are small and slow-growing, and most of the men who get them will die from something else first. In effect, about two-thirds of all men diagnosed with prostate cancer are possible candidates for watchful waiting -- if they choose that option.
Two years ago, the American Urological Association recommended that most patients whose disease hadn't spread to other parts of the body be given the choice of four treatment options: surgical removal of the prostate; beam radiation; radioactive seed implants; and active surveillance.
The question: Will some of those who chose to delay treatment have tumors that become incurable between six-month check-ups? And is it possible to better identify those men in advance?
Early evidence is promising. For the past 15 years, Dr. Laurence Klotz, chief of urology at Toronto Sunnybrook Regional Cancer Center in Canada, has followed 500 men who selected watchful waiting. A third of them eventually required and received treatment. Five have died of prostate cancer. Four died within a few months of diagnosis, suggesting they would have died regardless of treatment, Klotz said. Earlier treatment possibly would have made a difference with only one, they believe. "The likelihood of patients dying of other causes compared to dying of prostate cancer is about 19-to-1," he said.
Klotz has launched a large study, Surveillance Therapy Against Radical Treatment, or START, to compare the risk of death and disability between immediate treatment and watchful waiting. Some 2,100 men worldwide will be randomly selected to one of the two groups and followed for several years. Those who receive treatment can pick from any -- surgery, radiation or seeds.
And a second international study, the Prostate Active Surveillance Study, or PASS, someday could help identify the best method for each patient. The study is funded by the Canary Foundation, founded by high tech multimillionaire Don Listwin, whose mother died of misdiagnosed ovarian cancer. The foundation is dedicated to finding better tests for early detection. "There exists a blood test, PSA, but it is not cancer-specific -- meaning it naturally occurs in healthy men," Listwin said. "Further, it doesn't necessarily indicate lethal cancer. Canary, through its PASS program, is trying to identify a cancer-specific blood test that identifies lethal subtypes of prostate cancer."
By comparing the blood and cancer cells of patients whose tumors get worse to those who don't, it might be possible to develop new tests to identify those at high risk, Thompson said. Source: http://www.seattlepi.com/health/409155_prostate0810.html?source=rss
Many cases of prostate cancer progress so slowly that it can literally take decades to learn whether a treatment works. Just ask Dr. Ian Thompson, who chairs the department of urology at the University of Texas Health Science Center at San Antonio. In 1985, he was a young researcher just starting out when he proposed a study to find out whether the practice of giving radiation therapy to some men after prostate cancer surgery was actually helping and not just causing side effects.
About a third of men with this cancer who elect to have their prostates removed surgically learn, after the operation, that the disease has spread beyond the confines of the prostate. Dr. Thompson and his colleagues wanted to know whether giving additional (adjuvant) radiation, as was being done at the time, could delay a recurrence and prevent metastatic disease.
Two decades later, they have their answer. Men in the trial who received radiation therapy within 12 weeks of surgery delayed a recurrence of the cancer, and this led to longer survival compared with men with did not receive the treatment. Results from the randomized 425-person trial appeared in the March Journal of Urology. This evidence is bolstered by similar results from Europe. Last week, German investigators reported in the Journal of Clinical Oncology that adjuvant radiation therapy reduced the risk of prostate cancer progression compared with men who did not have the therapy. Though only the SWOG trial has had enough data to report on survival, the collective results all point in the same direction. “It took 20 years, but we now know that adjuvant radiation therapy does reduce a man’s risk of developing metastatic cancer and it can improve survival by almost 2 years,” said Dr. Thompson. “In a disease that is as common as prostate cancer, this advance will affect tens or hundreds of thousands of men for many years to come.”
Tremendous international cooperation among investigators and long-term commitments from more than 1,800 participants led to the advance, Dr. Thompson noted. The SWOG trial was a partnership between U.S. and Canadian researchers, while the other trials were led by the German Cancer Society and the European Organization for Research and Treatment of Cancer (EORTC).
“The field is now convinced that there is a benefit from adjuvant radiation therapy for the right patients,” said Dr. Eric A. Klein, chairman of the Glickman Urological and Kidney Institute at the Cleveland Clinic. But the success of these studies, he noted, has raised a question that may be harder to answer: When is the optimal time to give the radiation?
Specifically, will benefit be the same whether the radiation comes immediately after surgery or later on, only after a man shows signs of a recurrence? Considering the time and resources that would be involved, a trial that could answer this question seems unlikely, the researchers said. But clues may eventually come from a British and Canadian study called RADICALS that, in part, will compare radiation after surgery with radiation at the time of progression, or salvage radiation therapy.
Some physicians advocate withholding radiation until there is evidence of a recurrence in order to spare men who may not need the treatment. After all, not every candidate for the treatment will develop life-threatening disease, and those who do develop a recurrence can be identified by rising blood levels of the prostate specific antigen, or PSA, a protein marker for prostate cancer.
The choice “is really a matter of philosophy more than anything else,” Dr. Klein said, though he noted that radiation therapy has side effects such as urethral strictures, which can be hard to treat and lead to a condition called bladder outlet obstruction or incontinence.
More side effects were reported in the radiation therapy group in the SWOG trial, but after the first few years both groups reported a similar quality of life. The people who seemed to benefit the most from the radiation therapy were the men at the highest risk of a recurrence, based on the pathology report and other factors.
There is no evidence yet that salvage radiation therapy is associated with an improvement in survival, Dr. Thompson cautioned. And one of his concerns, based on the study results, is that for some men, by the time a recurrence is evident it may be too late to control the cancer.
Nonetheless, among his patients, only some men who are eligible for adjuvant radiation choose the treatment. Men who are feeling better after surgery and want to avoid additional side effects often choose surveillance, he said, while men who, above all else, want to control the cancer opt for radiation. The choice is up to them. “As physicians, we work for the patient,” said Dr. Thompson. “In the age of evidence-based care, our responsibility is to inform these men about the results of the three clinical trials, and let them decide which approach is the best fit for them.” Source: http://www.cancer.gov/ncicancerbulletin/051909/page5 From the National Cancer Institute
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The Santa Cruz County Prostate Cancer Support Group does not endorse any provider, organization, product or individual. All medical decisions should be made with the advice and consultation of medical professionals.
Many THANKS to the American Cancer Society for assisting with the printing and mailing of this newsletter and the Katz Cancer Resource Center for allowing us to use their facility.
Many THANKS to Century 21 Classic Properties in Watsonville for their donations raised for our support group and presented to the Steering Committee at the July meeting.