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Re: Are Elderly Patients with Clinically Localized Prostate Cancer Overtreated? Exploring Heterogeneity in Survival Effects
Urological Survey Urological Oncology: Prostate Cancer Re: Does Discontinuous Involvement of a Prostatic Needle Biopsy Core by Adenocarcinoma Correlate with a Large Tumor Focus at Radical Prostatectomy? J. A. Arias-Stella, III, K. R. Varma, D. Montoya-Cerrillo, N. S. Gupta and S. R. Williamson Department of Pathology and Laboratory Medicine, Henry Ford Health System, Detroit, Michigan, and School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru Am J Surg Pathol 2014; Epub ahead of print.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.01.057 available at http://jurology.com/ Editorial Comment: The interpretation of prostate needle biopsy samples has evolved into a largely standardized process. However, some controversy remains regarding the proper methods for reporting and risk stratification. In the case of core samples consisting of cancer with intervening benign tissue the standard has been to report the cumulative length of discontinuous cancer within the core as a surrogate of disease volume. In this study the investigators compared the findings of radical prostatectomy to biopsy in men with cores demonstrating discontinuous cancer. They noted that in the majority of men the region of the discontinuous core contained 1 contiguous focus of cancer rather than multiple small foci, suggesting that the current practice of reporting total length of cancer would be most valid in representing tumor volume. It is important to recognize that defining single vs multiple foci of cancer within a prostate is difficult, and often what appear to be segregated foci may be connected by serpiginous bridges in other sections. The interpretation of biopsy cores will require reevaluation within the context of targeted biopsy as oversampling of a tumor may inflate disease volume and aggressiveness. Samir S. Taneja, MD
Re: Are Elderly Patients with Clinically Localized Prostate Cancer Overtreated? Exploring Heterogeneity in Survival Effects A. Basu and J. L. Gore Departments of Health Services, Pharmacy and Economics, and Urology, University of Washington, Seattle, Washington Med Care 2015; 53: 79e86.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.01.058 available at http://jurology.com/ Editorial Comment: This study concludes a minimal impact of radical prostatectomy (RP), as compared to watchful waiting (WW), on overall or cancer specific survival in men diagnosed with prostate cancer in the SEER (Surveillance, Epidemiology and End Results)-Medicare population in the years 1996 to 2002. The authors use statistical modeling to determine variations in survival benefit in individual groups within the whole cohort. I will first admit that despite reading the article closely several times, my knowledge of the outcomes field is not sufficient to understand or critique the methods. However, I believe several observations are noteworthy for the practicing urologist.
0022-5347/15/1934-1252/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
1252
j
www.jurology.com
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.01.057 Vol. 193, 1252-1253, April 2015 Printed in U.S.A.
TESTIS CANCER AND ADVANCES IN ONCOLOGIC THERAPY
1253
First, all cause mortality rates during the first 10 years are similar between RP and WW treated patients, and they are relatively high, suggesting that urologists have tended to select men for therapy based on disease characteristics rather than longevity assessment. In addition, prostate cancer mortality rates were similarly low among men undergoing RP and WW within the study period. This finding illustrates the long lead time to mortality observed for men diagnosed with early stage prostate cancer. The authors conclude that benefit of RP appears minimal and that few men on subset analyses have any prolonged improvement in survival. My concern is that the model is based on men destined to die largely of other causes within 10 years, which in this case represents about 21% of the population. Only 4% died of prostate cancer in the same period. So what does it mean? Would we expect that RP would show great benefit during a period in which death from prostate cancer is such an unlikely event? Probably not, but it is notable that we seem to be unsuccessful in excluding from therapy men likely to die of other causes. The question that remains unanswered is, what is the benefit of therapy in survivors? In men destined to live more than 10 years (76% of men in this study) what will be the benefit of treatment? The answer cannot be determined from a model, which suggests (and I hope is already the case) that we should not be telling men that treatment is likely to prolong their short-term longevity. I remain concerned that the infatuation of the medical field with the elegance of population based outcomes research leaves us with few answers regarding how to approach patients on a daily basis. As we continue to buy into the idea that the only valid data are those derived from large populations, the divide from individualized approaches to disease grows wider. Samir S. Taneja, MD
Suggested Reading Kent M and Vickers AJ: A systematic literature review of life expectancy prediction tools for localized prostate cancer patients. J Urol 2014. Epub ahead of print.
Urological Oncology: Testis Cancer and Advances in Oncologic Therapy Re: Organ Preservation Technique without Ischemia in Patients with Testicular Tumor N. Leonhartsberger, R. Pichler, B. Stoehr, W. Horninger and H. Steiner Department of Urology, Medical University Innsbruck, Innsbruck, Austria Urology 2014; 83: 1107e1111.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.01.033 available at http://jurology.com/ Editorial Comment: Radical inguinal orchiectomy remains the gold standard for diagnosis and treatment of testicular cancers. However, organ preservation techniques can be considered in selected patients with marker negative clinical stage 1 tumors (smaller than 3 cm) or tumor in a solitary testis. The authors review 65 patients who underwent this approach. Radical orchiectomy was performed in 35 patients with germ cell tumor and normal contralateral testis, and 30 patients underwent 33 organ preserving procedures without any complications. There was no local recurrence, and all patients remained free of disease. The authors suggest that a no clamping, organ sparing surgical technique is safe and feasible in selected patients with testis tumor. Jerome P. Richie, MD
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.01.057 available at http://jurology.com/ Editorial Comment: The interpretation of prostate needle biopsy samples has evolved into a largely standardized process. However, some controversy remains regarding the proper methods for reporting and risk stratification. In the case of core samples consisting of cancer with intervening benign tissue the standard has been to report the cumulative length of discontinuous cancer within the core as a surrogate of disease volume. In this study the investigators compared the findings of radical prostatectomy to biopsy in men with cores demonstrating discontinuous cancer. They noted that in the majority of men the region of the discontinuous core contained 1 contiguous focus of cancer rather than multiple small foci, suggesting that the current practice of reporting total length of cancer would be most valid in representing tumor volume. It is important to recognize that defining single vs multiple foci of cancer within a prostate is difficult, and often what appear to be segregated foci may be connected by serpiginous bridges in other sections. The interpretation of biopsy cores will require reevaluation within the context of targeted biopsy as oversampling of a tumor may inflate disease volume and aggressiveness. Samir S. Taneja, MD
Re: Are Elderly Patients with Clinically Localized Prostate Cancer Overtreated? Exploring Heterogeneity in Survival Effects A. Basu and J. L. Gore Departments of Health Services, Pharmacy and Economics, and Urology, University of Washington, Seattle, Washington Med Care 2015; 53: 79e86.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.01.058 available at http://jurology.com/ Editorial Comment: This study concludes a minimal impact of radical prostatectomy (RP), as compared to watchful waiting (WW), on overall or cancer specific survival in men diagnosed with prostate cancer in the SEER (Surveillance, Epidemiology and End Results)-Medicare population in the years 1996 to 2002. The authors use statistical modeling to determine variations in survival benefit in individual groups within the whole cohort. I will first admit that despite reading the article closely several times, my knowledge of the outcomes field is not sufficient to understand or critique the methods. However, I believe several observations are noteworthy for the practicing urologist.
0022-5347/15/1934-1252/0 THE JOURNAL OF UROLOGY® © 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
1252
j
www.jurology.com
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.01.057 Vol. 193, 1252-1253, April 2015 Printed in U.S.A.
TESTIS CANCER AND ADVANCES IN ONCOLOGIC THERAPY
1253
First, all cause mortality rates during the first 10 years are similar between RP and WW treated patients, and they are relatively high, suggesting that urologists have tended to select men for therapy based on disease characteristics rather than longevity assessment. In addition, prostate cancer mortality rates were similarly low among men undergoing RP and WW within the study period. This finding illustrates the long lead time to mortality observed for men diagnosed with early stage prostate cancer. The authors conclude that benefit of RP appears minimal and that few men on subset analyses have any prolonged improvement in survival. My concern is that the model is based on men destined to die largely of other causes within 10 years, which in this case represents about 21% of the population. Only 4% died of prostate cancer in the same period. So what does it mean? Would we expect that RP would show great benefit during a period in which death from prostate cancer is such an unlikely event? Probably not, but it is notable that we seem to be unsuccessful in excluding from therapy men likely to die of other causes. The question that remains unanswered is, what is the benefit of therapy in survivors? In men destined to live more than 10 years (76% of men in this study) what will be the benefit of treatment? The answer cannot be determined from a model, which suggests (and I hope is already the case) that we should not be telling men that treatment is likely to prolong their short-term longevity. I remain concerned that the infatuation of the medical field with the elegance of population based outcomes research leaves us with few answers regarding how to approach patients on a daily basis. As we continue to buy into the idea that the only valid data are those derived from large populations, the divide from individualized approaches to disease grows wider. Samir S. Taneja, MD
Suggested Reading Kent M and Vickers AJ: A systematic literature review of life expectancy prediction tools for localized prostate cancer patients. J Urol 2014. Epub ahead of print.
Urological Oncology: Testis Cancer and Advances in Oncologic Therapy Re: Organ Preservation Technique without Ischemia in Patients with Testicular Tumor N. Leonhartsberger, R. Pichler, B. Stoehr, W. Horninger and H. Steiner Department of Urology, Medical University Innsbruck, Innsbruck, Austria Urology 2014; 83: 1107e1111.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.01.033 available at http://jurology.com/ Editorial Comment: Radical inguinal orchiectomy remains the gold standard for diagnosis and treatment of testicular cancers. However, organ preservation techniques can be considered in selected patients with marker negative clinical stage 1 tumors (smaller than 3 cm) or tumor in a solitary testis. The authors review 65 patients who underwent this approach. Radical orchiectomy was performed in 35 patients with germ cell tumor and normal contralateral testis, and 30 patients underwent 33 organ preserving procedures without any complications. There was no local recurrence, and all patients remained free of disease. The authors suggest that a no clamping, organ sparing surgical technique is safe and feasible in selected patients with testis tumor. Jerome P. Richie, MD