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Re: Importance of Local Control in Early-Stage Prostate Cancer: Outcomes of Patients with Positive Post-Radiation Therapy Biopsy Results Treated in RTOG 9408
PROSTATE CANCER
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2010 to 2014 owing to the extremely low rate of screening noted to begin with. Screening rates were greatest in the 60 to 74 years age range (43.6%), and approximately 37% of men older than 75 were screened, while only a quarter of those in the 50 to 59 age group underwent PSA testing. The message that the benefit of screening is greatest in men with sufficient longevity to allow mortality reduction is simply not getting through to the gatekeeper. In fact, the authors estimated that screening continues among men with a high risk of mortality from other causes within 10 years. In speaking with patients they mention that they have been told a variety of things by their internists, ranging from “PSA has been found to be inaccurate” to “we are not supposed to worry about our prostate any longer.” A number of primary care physicians continue to screen aggressively in all men, while others obtain PSA but do not react unless extremely high numbers are noted. The mass confusion regarding interpretation of guidelines and application in practice is the result of a recommendation that is not particularly intuitive. How does one prevent prostate cancer death if one is not looking for prostate cancer? The U.S. Preventive Services Task Force owes it to the American public to clarify its recommendations and offer general practitioners a more clear and practical strategy for treatment of the aging male patient. In the meantime urologists must persist in presenting a clear message to our primary care colleaguesdPSA testing has value in decreasing mortality among men who will live long enough to be at risk for prostate cancer mortality. Samir S. Taneja, MD
Suggested Reading Bhindi B, Mamdani M, Kulkarni GS et al: Impact of the U.S. Preventive Services Task Force recommendations against prostate specific antigen screening on prostate biopsy and cancer detection rates. J Urol 2015; 193: 1519. Barocas DA, Mallin K, Graves AJ et al: The effect of the USPSTF grade D recommendation against screening for prostate cancer on incident prostate cancer diagnoses in the United States. J Urol 2015; 194: 1587. Banerji JS, Wolff EM, Massman JD III et al: Prostate needle biopsy outcomes in the era of the U.S. Preventive Services Task Force recommendation against prostate specific antigen based screening. J Urol 2016; 195: 66.
Re: Importance of Local Control in Early-Stage Prostate Cancer: Outcomes of Patients with Positive Post-Radiation Therapy Biopsy Results Treated in RTOG 9408 D. J. Krauss, C. Hu, J. P. Bahary, L. Souhami, E. M. Gore, S. M. Chafe, M. H. Leibenhaut, S. Narayan, J. Torres-Roca, J. Michalski, K. L. Zeitzer, V. Donavanik, H. Sandler, D. G. McGowan, C. U. Jones and W. U. Shipley Department of Radiation Oncology, Oakland University William Beaumont School of Medicine, Royal Oak and Michigan Cancer Research Consortium CCOP, Ann Arbor, Michigan, NRG Statistics and Data Management Center, Philadelphia, Pennsylvania, Medical College of Wisconsin, Milwaukee, Wisconsin, Sutter General Hospital, Sacramento and Cedars-Sinai Medical Center, Los Angeles, California, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, Washington University, St. Louis, Missouri, Albert Einstein Medical Center, Bronx, New York, Christiana Care Health Services Inc. CCOP, Newark, Delaware, Dana-Farber Cancer Institute, Boston, Massachusetts, and Centre Hospitalier de l’Universite´ de Montre´al-Notre Dame and McGill University, Montreal, Quebec and Cross Cancer Institute, Edmonton, Alberta, Canada Int J Radiat Oncol Biol Phys 2015; 92: 863e873. doi: 10.1016/j.ijrobp.2015.03.017
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26104939 Editorial Comment: In this study men undergoing radiotherapy as part of a prospective clinical trial of the Radiation Therapy Oncology Group were subjected to per protocol prostate biopsy 2 years after completion of radiotherapy if they were clinically free of disease recurrence. Men with evidence of cancer on repeat biopsy demonstrated inferior recurrence-free survival, disease specific survival and metastasis-free survival compared to those with a negative biopsy. Overall survival was also inferior in men with high grade disease and positive biopsy. This article caught my eye for several reasons. I have always believed that, given the poor outcomes observed following radiation failure, the use of empirical biopsy to allow early detection of
IMAGING
352
recurrence may be the best opportunity for salvage. Current methods of defining radiation failure may result in quite delayed recognition of disease recurrence. This article demonstrates the potential for biopsy to detect residual/recurrent disease in the absence of clinical indicators of recurrence. In addition, we have always been taught that positive biopsies following radiation, in the absence of clinical evidence of recurrence, may reflect an inadequate amount of time for radiation response. In many cases such biopsy outcomes might be ignored. In this instance 2-year outcomes of biopsy were highly predictive of clinical outcomes, suggesting that, at least at this interval, biopsy outcomes are meaningful. Samir S. Taneja, MD
Suggested Reading Jalloh M, Leapman MS, Cowan JE et al: Patterns of local failure following radiation therapy for prostate cancer. J Urol 2015; 194: 977. Kabalin JN, Hodge KK, McNeal JE et al: Identification of residual cancer in the prostate following radiation therapy: role of transrectal ultrasound guided biopsy and prostate specific antigen. J Urol 1989; 142: 326. Leach GE, Cooper JF, Kagan AR et al: Radiotherapy for prostatic carcinoma: post-irradiation prostatic biopsy and recurrence patterns with long-term followup. J Urol 1982; 128: 505. Dugan TC, Shipley WU, Young RH et al: Biopsy after external beam radiation therapy for adenocarcinoma of the prostate: correlation with original histological grade and current prostate specific antigen levels. J Urol 1991; 146: 1313.
Imaging Re: Anterior Prostate Cancer: Diagnostic Performance of T2-Weighted MRI and an Apparent Diffusion Coefficient Map H. Shinmoto, C. Tamura, S. Soga, T. Okamura, A. Horiguchi, T. Asano and T. Kaji Departments of Radiology and Urology, National Defense Medical College, Saitama, Japan AJR Am J Roentgenol 2015; 205: W185eW192. doi: 10.2214/AJR.14.13392
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26204306 Editorial Comment: This is a retrospective review of 87 patients who underwent 3 T magnetic resonance imaging of the prostate and subsequent radical prostatectomy. The prostate gland was divided into anterior and posterior segments, and the radiologist interpreted T2-weighted images alone for the presence of prostate cancer and T2-weighted images in conjunction with apparent diffusion coefficient (ADC) imaging. Anterior prostate cancer was defined as cancer located anterior to the urethra in either the transition zone, the anterior fibromuscular stroma or the anterior horns of the peripheral zone. Anterior prostate is a challenging area for radiologists and often is not included in prostate biopsies. Anterior prostate cancers account for approximately 20% of prostate cancers and may be located deep in the anterior apex (another problem area). Focused attention to the anterior gland and search for tumors in this location is valuable. The interobserver agreement was improved when T2-weighted images and ADC maps were reviewed together. T2-weighted imaging with the ADC imaging showed improved accuracy for the detection of anterior gland tumors. Cary Siegel, MD
351
2010 to 2014 owing to the extremely low rate of screening noted to begin with. Screening rates were greatest in the 60 to 74 years age range (43.6%), and approximately 37% of men older than 75 were screened, while only a quarter of those in the 50 to 59 age group underwent PSA testing. The message that the benefit of screening is greatest in men with sufficient longevity to allow mortality reduction is simply not getting through to the gatekeeper. In fact, the authors estimated that screening continues among men with a high risk of mortality from other causes within 10 years. In speaking with patients they mention that they have been told a variety of things by their internists, ranging from “PSA has been found to be inaccurate” to “we are not supposed to worry about our prostate any longer.” A number of primary care physicians continue to screen aggressively in all men, while others obtain PSA but do not react unless extremely high numbers are noted. The mass confusion regarding interpretation of guidelines and application in practice is the result of a recommendation that is not particularly intuitive. How does one prevent prostate cancer death if one is not looking for prostate cancer? The U.S. Preventive Services Task Force owes it to the American public to clarify its recommendations and offer general practitioners a more clear and practical strategy for treatment of the aging male patient. In the meantime urologists must persist in presenting a clear message to our primary care colleaguesdPSA testing has value in decreasing mortality among men who will live long enough to be at risk for prostate cancer mortality. Samir S. Taneja, MD
Suggested Reading Bhindi B, Mamdani M, Kulkarni GS et al: Impact of the U.S. Preventive Services Task Force recommendations against prostate specific antigen screening on prostate biopsy and cancer detection rates. J Urol 2015; 193: 1519. Barocas DA, Mallin K, Graves AJ et al: The effect of the USPSTF grade D recommendation against screening for prostate cancer on incident prostate cancer diagnoses in the United States. J Urol 2015; 194: 1587. Banerji JS, Wolff EM, Massman JD III et al: Prostate needle biopsy outcomes in the era of the U.S. Preventive Services Task Force recommendation against prostate specific antigen based screening. J Urol 2016; 195: 66.
Re: Importance of Local Control in Early-Stage Prostate Cancer: Outcomes of Patients with Positive Post-Radiation Therapy Biopsy Results Treated in RTOG 9408 D. J. Krauss, C. Hu, J. P. Bahary, L. Souhami, E. M. Gore, S. M. Chafe, M. H. Leibenhaut, S. Narayan, J. Torres-Roca, J. Michalski, K. L. Zeitzer, V. Donavanik, H. Sandler, D. G. McGowan, C. U. Jones and W. U. Shipley Department of Radiation Oncology, Oakland University William Beaumont School of Medicine, Royal Oak and Michigan Cancer Research Consortium CCOP, Ann Arbor, Michigan, NRG Statistics and Data Management Center, Philadelphia, Pennsylvania, Medical College of Wisconsin, Milwaukee, Wisconsin, Sutter General Hospital, Sacramento and Cedars-Sinai Medical Center, Los Angeles, California, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, Washington University, St. Louis, Missouri, Albert Einstein Medical Center, Bronx, New York, Christiana Care Health Services Inc. CCOP, Newark, Delaware, Dana-Farber Cancer Institute, Boston, Massachusetts, and Centre Hospitalier de l’Universite´ de Montre´al-Notre Dame and McGill University, Montreal, Quebec and Cross Cancer Institute, Edmonton, Alberta, Canada Int J Radiat Oncol Biol Phys 2015; 92: 863e873. doi: 10.1016/j.ijrobp.2015.03.017
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26104939 Editorial Comment: In this study men undergoing radiotherapy as part of a prospective clinical trial of the Radiation Therapy Oncology Group were subjected to per protocol prostate biopsy 2 years after completion of radiotherapy if they were clinically free of disease recurrence. Men with evidence of cancer on repeat biopsy demonstrated inferior recurrence-free survival, disease specific survival and metastasis-free survival compared to those with a negative biopsy. Overall survival was also inferior in men with high grade disease and positive biopsy. This article caught my eye for several reasons. I have always believed that, given the poor outcomes observed following radiation failure, the use of empirical biopsy to allow early detection of
IMAGING
352
recurrence may be the best opportunity for salvage. Current methods of defining radiation failure may result in quite delayed recognition of disease recurrence. This article demonstrates the potential for biopsy to detect residual/recurrent disease in the absence of clinical indicators of recurrence. In addition, we have always been taught that positive biopsies following radiation, in the absence of clinical evidence of recurrence, may reflect an inadequate amount of time for radiation response. In many cases such biopsy outcomes might be ignored. In this instance 2-year outcomes of biopsy were highly predictive of clinical outcomes, suggesting that, at least at this interval, biopsy outcomes are meaningful. Samir S. Taneja, MD
Suggested Reading Jalloh M, Leapman MS, Cowan JE et al: Patterns of local failure following radiation therapy for prostate cancer. J Urol 2015; 194: 977. Kabalin JN, Hodge KK, McNeal JE et al: Identification of residual cancer in the prostate following radiation therapy: role of transrectal ultrasound guided biopsy and prostate specific antigen. J Urol 1989; 142: 326. Leach GE, Cooper JF, Kagan AR et al: Radiotherapy for prostatic carcinoma: post-irradiation prostatic biopsy and recurrence patterns with long-term followup. J Urol 1982; 128: 505. Dugan TC, Shipley WU, Young RH et al: Biopsy after external beam radiation therapy for adenocarcinoma of the prostate: correlation with original histological grade and current prostate specific antigen levels. J Urol 1991; 146: 1313.
Imaging Re: Anterior Prostate Cancer: Diagnostic Performance of T2-Weighted MRI and an Apparent Diffusion Coefficient Map H. Shinmoto, C. Tamura, S. Soga, T. Okamura, A. Horiguchi, T. Asano and T. Kaji Departments of Radiology and Urology, National Defense Medical College, Saitama, Japan AJR Am J Roentgenol 2015; 205: W185eW192. doi: 10.2214/AJR.14.13392
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26204306 Editorial Comment: This is a retrospective review of 87 patients who underwent 3 T magnetic resonance imaging of the prostate and subsequent radical prostatectomy. The prostate gland was divided into anterior and posterior segments, and the radiologist interpreted T2-weighted images alone for the presence of prostate cancer and T2-weighted images in conjunction with apparent diffusion coefficient (ADC) imaging. Anterior prostate cancer was defined as cancer located anterior to the urethra in either the transition zone, the anterior fibromuscular stroma or the anterior horns of the peripheral zone. Anterior prostate is a challenging area for radiologists and often is not included in prostate biopsies. Anterior prostate cancers account for approximately 20% of prostate cancers and may be located deep in the anterior apex (another problem area). Focused attention to the anterior gland and search for tumors in this location is valuable. The interobserver agreement was improved when T2-weighted images and ADC maps were reviewed together. T2-weighted imaging with the ADC imaging showed improved accuracy for the detection of anterior gland tumors. Cary Siegel, MD