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Re: Association of Cigarette Smoking and Smoking Cessation with Biochemical Recurrence of Prostate Cancer in Patients Treated with Radical Prostatectomy
Urological Survey Urological Oncology: Prostate Cancer Re: Association of Cigarette Smoking and Smoking Cessation with Biochemical Recurrence of Prostate Cancer in Patients Treated with Radical Prostatectomy M. Rieken, S. F. Shariat, L. A. Kluth, H. Fajkovic, M. Rink, P. I. Karakiewicz, C. Seitz, ^t, W. Loidl, Q. D. Trinh, A. Bachmann and G. Pourmand A. Briganti, M. Roupre Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas, Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Boston, Massachusetts, Department of Urology, University Hospital Basel, Basel, Switzerland, Department of Urology, Medical University of Vienna, Vienna and Prostate Cancer Center, Krankenhaus Barmherzige Schwestern Linz, Linz, Austria, Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany, Department of Urology, University of Montreal, Montreal, Quebec, Canada, Department of Urology, San Raffaele Scientific Institute, Urological Research Institute, Milan, Italy, Department of Urology, Hospital Pitie´-Salpe´trie`re, Paris, France, and Urology Research Center, Tehran University of Medical Sciences, Tehran, Iran Eur Urol 2015; Epub ahead of print.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.057 available at http://jurology.com/ Editorial Comment: In this study the authors show a relationship between smoking and risk of biochemical relapse following radical prostatectomy. In a multicenter cohort of men undergoing radical prostatectomy they demonstrated that men who were current or previous smokers carried a greater risk of biochemical recurrence than nonsmokers (HR 1.8), despite the fact that they did not appear to carry more adverse pathological features. Risk of recurrence was not reduced until patients had quit for more than 10 years. This series is one of several recent population based studies to show a relationship between smoking and adverse pathology, relapse and even prostate cancer death. The cumulative suggestion of these series is that smoking, or recent smoking history, has the ability to alter the aggressiveness of disease, although a causal relationship clearly has not been established. The effect on mortality would, of course, be based on longevity. The findings of this study and others are interesting from the point of prostate cancer decision making. As smoking is known to be a risk factor for death due to nonprostate cancer causes, our first instinct might be to avoid aggressive therapy in a man with a heavy and active smoking history at prostate cancer diagnosis, based on the presumption that he is at increased risk for death from other causes. This study, along with others demonstrating similar results, might sway some to say that prostate cancer treatment may be in the best interest of the patient if reasonable longevity is anticipated. Samir S. Taneja, MD
Suggested Reading Simone NL, Singh AK, Cowan JE et al: Pretreatment predictors of death from other causes in men with prostate cancer. J Urol 2008; 180: 2447. Roberts WW, Platz EA and Walsh PC: Association of cigarette smoking with extraprostatic prostate cancer in young men. J Urol 2003; 169: 512.
0022-5347/15/1945-1285/0 THE JOURNAL OF UROLOGY® Ó 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.08.057 Vol. 194, 1285-1288, November 2015 Printed in U.S.A.
www.jurology.com
j
1285
1286
PROSTATE CANCER
Re: Long-Term Follow-up of a Large Active Surveillance Cohort of Patients with Prostate Cancer L. Klotz, D. Vesprini, P. Sethukavalan, V. Jethava, L. Zhang, S. Jain, T. Yamamoto, A. Mamedov and A. Loblaw Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada J Clin Oncol 2015; 33: 272e277.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.058 available at http://jurology.com/ Editorial Comment: This article is among the most critical for urologists treating prostate cancer to read and understand. In this single institution series of men on active surveillance for low risk prostate cancer extremely low rates of progression, metastasis and cancer death were noted at 10 and 15 years of followup. Of 993 men enrolled in surveillance for low risk prostate cancer 149 died at a median followup of 6.4 years, although only 15 deaths (1.5%) were due to prostate cancer. An additional 13 men had metastatic disease, suggesting an overall metastatic progression rate of 2.8%. It is noteworthy that many men were treated along the way (63.5% and 55% of men remained on surveillance at 10 and 15 years, respectively), showing that surveillance must include active treatment to maintain the high survival rates observed. What is truly remarkable to me is that these men were selected for surveillance by standard systematic biopsy. A multitude of studies have demonstrated that such biopsies are likely to underestimate disease risk in 40% to 50% of men with low risk disease noted. Despite this prevalence of occult higher risk disease, men fared extremely well in long-term followup. Newer methods of biopsy, including saturation biopsy and magnetic resonance imaging targeted sampling, appear to identify a larger subset of men with occult high grade (Gleason 7 or higher) prostate cancer through more accurate sampling of tumor. It has been thought that such methods identify a subset of men for whom treatment is warranted, although, in fact, this study would suggest that a number of these men may have done well on surveillance anyway. What is not known is how many of these men would ultimately need therapy due to upgrading on conventional sampling. As such, the value of improved targeting on biopsy may be not in selecting men for immediate therapy, but in improving risk stratification such that repetitive biopsy is not needed. The important message here is that active surveillance is largely safe for most men with low risk prostate cancer. Surveillance should be offered as an option to all with consideration of the desires of the patient. A caveat is that the true safety of the paradigm must be measured by comparing outcomes of those treated on surveillance and those treated at diagnosis. In this series it appears that the outcomes as measured by mortality are similar. Further definition of the proper indication for treatment while on surveillance must also remain under investigation. Samir S. Taneja, MD
Suggested Reading Dinh KT, Mahal BA, Ziehr DR et al: Incidence and predictors of upgrading and up staging among 10,000 contemporary patients with low risk prostate cancer. J Urol 2015; 194: 343. Jain S, Loblaw A, Vesprini D et al: Gleason upgrading with time in a large prostate cancer active surveillance cohort. J Urol 2015; 194: 79. Welty CJ, Cowan JE, Nguyen H et al: Extended followup and risk factors for disease reclassification in a large active surveillance cohort for localized prostate cancer. J Urol 2015; 193: 807. Klotz L: Active surveillance with selective delayed intervention: using natural history to guide treatment in good risk prostate cancer. J Urol, suppl., 2004; 172: S48.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.057 available at http://jurology.com/ Editorial Comment: In this study the authors show a relationship between smoking and risk of biochemical relapse following radical prostatectomy. In a multicenter cohort of men undergoing radical prostatectomy they demonstrated that men who were current or previous smokers carried a greater risk of biochemical recurrence than nonsmokers (HR 1.8), despite the fact that they did not appear to carry more adverse pathological features. Risk of recurrence was not reduced until patients had quit for more than 10 years. This series is one of several recent population based studies to show a relationship between smoking and adverse pathology, relapse and even prostate cancer death. The cumulative suggestion of these series is that smoking, or recent smoking history, has the ability to alter the aggressiveness of disease, although a causal relationship clearly has not been established. The effect on mortality would, of course, be based on longevity. The findings of this study and others are interesting from the point of prostate cancer decision making. As smoking is known to be a risk factor for death due to nonprostate cancer causes, our first instinct might be to avoid aggressive therapy in a man with a heavy and active smoking history at prostate cancer diagnosis, based on the presumption that he is at increased risk for death from other causes. This study, along with others demonstrating similar results, might sway some to say that prostate cancer treatment may be in the best interest of the patient if reasonable longevity is anticipated. Samir S. Taneja, MD
Suggested Reading Simone NL, Singh AK, Cowan JE et al: Pretreatment predictors of death from other causes in men with prostate cancer. J Urol 2008; 180: 2447. Roberts WW, Platz EA and Walsh PC: Association of cigarette smoking with extraprostatic prostate cancer in young men. J Urol 2003; 169: 512.
0022-5347/15/1945-1285/0 THE JOURNAL OF UROLOGY® Ó 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2015.08.057 Vol. 194, 1285-1288, November 2015 Printed in U.S.A.
www.jurology.com
j
1285
1286
PROSTATE CANCER
Re: Long-Term Follow-up of a Large Active Surveillance Cohort of Patients with Prostate Cancer L. Klotz, D. Vesprini, P. Sethukavalan, V. Jethava, L. Zhang, S. Jain, T. Yamamoto, A. Mamedov and A. Loblaw Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada J Clin Oncol 2015; 33: 272e277.
Abstract for this article http://dx.doi.org/10.1016/j.juro.2015.08.058 available at http://jurology.com/ Editorial Comment: This article is among the most critical for urologists treating prostate cancer to read and understand. In this single institution series of men on active surveillance for low risk prostate cancer extremely low rates of progression, metastasis and cancer death were noted at 10 and 15 years of followup. Of 993 men enrolled in surveillance for low risk prostate cancer 149 died at a median followup of 6.4 years, although only 15 deaths (1.5%) were due to prostate cancer. An additional 13 men had metastatic disease, suggesting an overall metastatic progression rate of 2.8%. It is noteworthy that many men were treated along the way (63.5% and 55% of men remained on surveillance at 10 and 15 years, respectively), showing that surveillance must include active treatment to maintain the high survival rates observed. What is truly remarkable to me is that these men were selected for surveillance by standard systematic biopsy. A multitude of studies have demonstrated that such biopsies are likely to underestimate disease risk in 40% to 50% of men with low risk disease noted. Despite this prevalence of occult higher risk disease, men fared extremely well in long-term followup. Newer methods of biopsy, including saturation biopsy and magnetic resonance imaging targeted sampling, appear to identify a larger subset of men with occult high grade (Gleason 7 or higher) prostate cancer through more accurate sampling of tumor. It has been thought that such methods identify a subset of men for whom treatment is warranted, although, in fact, this study would suggest that a number of these men may have done well on surveillance anyway. What is not known is how many of these men would ultimately need therapy due to upgrading on conventional sampling. As such, the value of improved targeting on biopsy may be not in selecting men for immediate therapy, but in improving risk stratification such that repetitive biopsy is not needed. The important message here is that active surveillance is largely safe for most men with low risk prostate cancer. Surveillance should be offered as an option to all with consideration of the desires of the patient. A caveat is that the true safety of the paradigm must be measured by comparing outcomes of those treated on surveillance and those treated at diagnosis. In this series it appears that the outcomes as measured by mortality are similar. Further definition of the proper indication for treatment while on surveillance must also remain under investigation. Samir S. Taneja, MD
Suggested Reading Dinh KT, Mahal BA, Ziehr DR et al: Incidence and predictors of upgrading and up staging among 10,000 contemporary patients with low risk prostate cancer. J Urol 2015; 194: 343. Jain S, Loblaw A, Vesprini D et al: Gleason upgrading with time in a large prostate cancer active surveillance cohort. J Urol 2015; 194: 79. Welty CJ, Cowan JE, Nguyen H et al: Extended followup and risk factors for disease reclassification in a large active surveillance cohort for localized prostate cancer. J Urol 2015; 193: 807. Klotz L: Active surveillance with selective delayed intervention: using natural history to guide treatment in good risk prostate cancer. J Urol, suppl., 2004; 172: S48.