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Posts Tagged ‘Biopsy’

PROSTABLOG NZ:  HERE are four key issues the NZ Parliamentary inquiry into the detection and treatment of prostate cancer ought now to be focusing on:

  • Mass screening…or not: Not. The evidence in favour of mass screening of all middle-aged men for prostate cancer is not sufficiently strong in statistical terms to overcome the counter-arguments concerning needless and over-treatment and high likelihood of after effects that will blight quality of life.

But…it’s not strong enough yet. That may change as more studies are done and closer analysis of the large random trials is completed. PSA testing may also improve, or be replaced with something better, a test that defines the actual risk to the patient.

  • Guidelines to GPs must be revised. Currently, GPs are forbidden by the Ministry of Health to routinely offer PSA tests and/or rectal examinations for prostate cancer unless a man asks, or mentions symptoms. Since this can be a symptomless disease (until it’s too late), that is unacceptable. It also presumes that people don’t move around, change doctors, lose track of medical records, or simply have little idea of the implications of dad dying of prostate cancer.

If the Ministry of Health wants to avoid high-risk treatment being offered unnecessarily, it needs to move the initial gatekeeping further up the food chain to the specialists.

  • Specialists’ advice needs to be delivered via a more balanced and less costly method. At present, the system works well enough up to the point the pathologist finds signs of cancer in biopsy samples.

But after that, men are left to fend for themselves when it comes to seeking advice from a range of authorities. Some don’t bother, and just go with what the urologist offers. Some can’t afford the $1600 charged by a cancer specialist (oncologist), who may be the most neutral source of advice available.

In the US, the first specialists in the hierarchy, urologists, earned themselves the unenviable moniker of “prostate snatchers” because of the lucrative, medical insurance-backed business of prostate surgery.

How about panels of doctors representing the main treatment options in NZ (surgery, robotic surgery, external beam radiation, brachytherapy, watchful waiting) reviewing the case notes and offering clearly explained options to patients?

  • The public needs to be kept up to date – in layman’s terms – with diagnostic and treatment developments. This is not happening at present. The Ministry and its satellite committees do not have readily available, up-to-date information on the web to help men with newly diagnosed prostate cancer become fully informed before making one of the biggest decisions of their lives.

As wealthy male baby boomers hit the danger zone, enormous amounts of US, European and Asian money are going into researching and developing new drugs, methods of surgery and radiation, diagnostic tools and a bewildering range of related methdologies.

That’s the point – it’s bewildering to the average Kiwi, who must hope his medics are keeping up to date and that the government is adequately funding new treatments.

For example, there is Provenge, a new $100,000+ drug regime that will extend life for a few months, and which is now selling big in the US. When will we see it here?

Communicating the relevance of the overseas prostate industry boom to Kiwis cannot be left solely to the news media here: that’s worse than leaving it to chance and the public relations industry.

Few, if any, journalists in NZ take an abiding interest in prostate cancer (why would they – it’s one of many diseases), and what they do write is sometimes ill-informed, incomplete, inaccurate and out of date.

Finally, the Health Select Committee would be wise to keep its files open on this inquiry. It would be a mistake to shut the doors on a tsunami of prostate cancer information that emerges daily on the web.

Developments are moving so quickly, the committee should require the Ministry of Health to report regularly about what’s happening. The inquiry report, when it finally emerges, should be an interim one that can be updated over time.

The committee is wrestling with questions that are far from settled.

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NEW PROSTATE CANCER INFOLINK:  Is more better when it comes to the number of samples taken in a prostate biopsy? Not according to new research. READ MORE>

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URO TODAY: Men having a biopsy for prostate cancer need to be warned that it will temporarily affect urination and may also have an impact on erectile function, a German study says. READ MORE>

Prostate biopsy causes impaired voiding (of the bladder).

Saturation (20-core) prostate biopsy and periprostatic nerve block seem to have a lasting impact on voiding function.

Erectile function is transiently affected by prostate biopsy regardless of periprostatic nerve block and the number of cores.

Patients who undergo prostate biopsy must be informed about these side effects.

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URO TODAY: Current standard prostate biopsy protocols have limited accuracy in identifying candidates for less drastic focal therapy for prostate cancer (as opposed to total removal or treatment). READ MORE>

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URO TODAY: The greater number of positive samples in a prostate cancer biopsy (usually 12 samples), the greater the chance the disease has spread to the lymph system. READ MORE>

The percentage of positive cores involved with prostate cancer is the most reliable predictor of lymph node metastases and indicates the need for extended pelvic lymphadenectomy.

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URO TODAY: Knowing exactly where in the prostate a biopsy sample has come from is a problem for those diagnosing the disease, but scientists may have found a way to improve that by combining MRI scans with needle biopsy. READ MORE>

It is feasible to document the location of transrectal ultrasonography (TRUS)-guided prostate biopsies on pre-procedure MRI by fusing the pre-procedure TRUS to an endorectal coil MRI using electromagnetic needle tracking.

This procedure may be useful in documenting the location of prior biopsies, improving quality control and thereby avoiding under-sampling of the prostate, as well as directing subsequent biopsies to regions of the prostate not previously sampled.

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URO TODAY: Benign prostatic hyperplasia patients in whom prostate cancer is suspected and who have urination problems, with a previously negative biopsy result, can undergo transurethral resection of the prostate, which treats bladder outlet obstruction and gives early diagnosis of prostate cancer. READ MORE>

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PROSTABLOG: When can we expect a report from the NZ parliamentary inquiry into the early detection and treatment of prostate cancer, which was launched a little over a year ago?

No word on that from the committee, but perhaps two of the most powerful “words” in the debate on screening were submitted to the committee just before last Christmas (unreported in the news media, so far as I can tell).

They came from eminent pro-screening urologist Robin Smart and from the Ministry of Health’s expert panel, the NZ Guidelines Group, which has been strongly anti-screening (population-based).

Here’s a couple of quotes from Smart’s submission, which discussed the inconclusive results of the two large international screening trials published in March last year:

The conclusion is that it is now very difficult if not impossible to conduct trials of controls having no testing versus screened having PSA/DRE (PSA tests/digital rectal examinations) testing with endpoints of death or metastases in advanced countries especially the United States.

This is largely due to the international improvements in these aspects because of PSA/DRE testing and consequent reluctance of men to remain in control groups.

This in turn means that it is going to continue to be difficult for authorities and governments responsible for making decisions concerning setting up national prostate cancer screening programmes who are waiting for more information before doing so.

These decisions will have to be made largely on current information from existing trials, studies and experience…

The weight of evidence in favour of PSA/DRE testing is now irrefutable after almost two decades of international experience.

To go back to the time before PSA testing would now be unthinkable.

Of course we hope for the perfect tests, perfect treatment and continue to look for improvements. But men today need the benefit of current technology which the evidence shows is saving between a third to a half of those who would otherwise die of prostate cancer where it is applied.

In its final submission (dated the same day as Smart’s, December 16), the guidelines group gave a contrary view.

It looked at nearly 10,000 research abstracts and chose 166 it says were relevant to the brief given to it by the Ministry of Health.

Its analysis concluded that the potential harm from population-based screening outweighs benefits.

The best case scenario it could find estimated that a screening programme conducted on all men aged 50 to 74 for nine years would save about 40 lives a year (from the 600 who die from the disease in NZ each year).

Those 360 lives saved over nearly a decade had to be weighed against the following “harm” that could be done:

  • An estimated 41 men would suffer significant treatment complications for every one life saved.
  • Of the additional 1953 men per year requiring prostate cancer treatment (presumably on top of the 2500 now), 43% to 88% would have sexual dysfunction, 10% to 35% urinary dysfunction and 8% to 43% bowel dysfunction (the range depending on whose research is consulted)
  • Each year, there would be the following additional complications – 838 to 1677 cases of sexual dysfunction; 156 to 838 cases of bowel dysfunction; and 195 to 682 cases of urinary dysfunction.

Meantime, international debate on screening continues.

HERE> is a report on a pro v con panel discussion at the recent American Urological Association annual conference.

And, Mike Scott, sitemaster of the New Prostate Cancer Info-Link in the US, says he agrees with an April article in the Australian Medical Journal that said population-based screening (that is, screening of all men) cannot be sanctioned until something more accurate than the PSA test is developed. READ MORE>

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URO TODAY: Screening for prostate cancer decreases the incidence of advanced prostate cancer, according to a Finnish year-long study of 80,000 men. READ MORE>

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URO TODAY: 5-Alpha reductase inhibitors, such as finasteride and dutasteride, may increase the accuracy of PSA tests in men with elevated or fluctuating PSA levels and previous negative biopsy, according to new data from researchers. READ MORE>

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