Archive | January, 2012

Saturation Biopsy Detects More Cancers

According to a new report, analysis of 20 to 24 biopsy cores is superior to analysis of 12 to 14 cores for detecting prostate cancer in men who’ve had a normal prostate biopsy in the past.

J. Stephen Jones, M.D., from Cleveland Clinic, Ohio said, “We have shown that transrectal saturation biopsy is as easy and safe to perform as standard biopsy while detecting almost 1/3 more cancers. With these findings, we are confident that this approach offers benefit with negligible downside.”

Jones did however caution that it would be premature to suggest that this should be made universal for a number of reasons.  First, this has only been shown in one study.  Second, this must be balanced against the potential to detect clinically insignificant cancers that we might be better not knowing about even though saturation biopsy detected almost a third more cancers and had equivalence complication rates.

Jones and colleagues compared the results of extended and saturation prostate biopsy protocols in a first repeat prostate biopsy population of 1056 men (393 with a 12 to 14-core extended biopsy and 663 with a 20 to 24-core saturation biopsy.  The authors reported their findings in the Journal of Urology. The detection rate was significantly higher in the saturation biopsy group than in the extended biopsy group.  Over a third of the positive biopsies (37.8%), however, met predetermined criteria for clinical insignificance, and there was a trend toward increased detection of clinically insignificant cancer in saturation compared to extended biopsies (40.1 percent compared to 32.6 percent).

For higher-risk populations, detection rates were higher for saturation biopsy than for extended biopsy, but the differences did not reach statistical significance.  The increased detection with saturation biopsy was significant for men whose initial biopsy was completely normal.

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Study Finds Strong Association Between Smoking and Risk for Bladder Cancer

Data from a large cohort study showed that smoking’s contribution to bladder cancer risk increased over the past 25 years, and the attributable risk in women caught up with that of men.

Current smokers increased risk of bladder cancer by four times compared to people who never smoked.  The risk among former smokers two times that of people who never smoked.  Previous cohort studies had shown about a threefold increased risk of bladder cancer among current smokers.

According to a recent article published in JAMA, smoking accounted for about half of the population-attributable risk of bladder cancer in men and women alike.

This apparent association between smoking and bladder cancer could reflect changes in cigarette manufacturing.

From the 1980s, the rates of bladder cancer in the U.S. has remained stable, ranging from 123.8 to 142.2 cases per 100,000 person-years in men, and from 32.5 to 33.2 cases per 100,000 person-years in women.

The authors noted in their introduction that the prevalence of smoking and cigarette composition have changed considerably during the same period, which perhaps changes the nature of the association between smoking and bladder cancer.

Neal D. Freedman, PhD, of the National Cancer Institute in Bethesda, Md., and co-authors revisited risk estimates for smoking and bladder cancer by examining data from the National Institutes of Health-American Association of Retired Persons (NIH-AARP) Diet and Health Study.

The NIH-AARP cohort study had follow-up data through December 31, 2006.  The participants, who were ages 50 to 71 at enrollment, completed a lifestyle questionnaire during 1995 and 1996.  This follow-up continued until the end of the study, a diagnosis of bladder cancer, a move outside the study’s catchment area, or death.

State cancer registries provided bladder cancer diagnoses information.  The foma; analysis included 281,394 men and 186,134 women.  During 4,518,941 person-years of follow up, 3,896 men had new diagnoses of bladder cancer, resulting in an incidence of 144 per 100,000 person-years.  During this same follow-up period, 627 women had a new diagnosis of bladder cancer for an incidence of 34.5 per 100,000 person-years.  Rates among people who never smoked were 69.8 and 16.1 per 100,000 person-years in men and women, respectively.  These rates increased to 154.6 and 276.4 per 100,000 person-years among men who were former or current smokers. Corresponding rates in women were 40.7 and 73.6 per 100,000 person-years.

The research team performed a systematic review and meta-analysis of prospective cohort studies of current smoking and bladder cancer started between 1963 and 1987.

Limitations of the study included lack of information on the year smoking had started and lack of follow-up data on smoking after the baseline survey to know how many people may have quit.

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Stem Cell Injections Better than Collagen Injections in Treating Stress Urinary Incontinence

A new study from Austria has found that injections of stem cells and other cells obtained from a woman’s own body can treat stress urinary incontinence with dramatically better results than conventional collagen injections.

These results mimic those from U.S. research that is underway and might also be long-lasting.

The study appears in The Lancet. The Austrian researchers, led by Hannes Strasser, MD, from the Medical University of Innsbruck, compared the effects of the stem cell injections with conventional injections of collagen in 63 women with stress urinary incontinence.

The team first performed a small muscle biopsy on the upper arms of the 42 women assigned to get stem cell injections.  In the laboratory, the women received myoblasts, a type of muscle stem cell, and fibroblasts, cells which form the structural framework for many body tissues.  According to Strasser, both types of cells have been shown to be effective in reconstructing the lower urinary tract in animal studies.

Then, Strasser’s team injected the cells back into the women’s sphincter and surrounding area using the ultrasound.

Traditional collagen injections, which do not generally have a high success rate for incontinence, were given to the other 21 women. Collagen treatments work by bulking up the area to compress the urethra, helping to hold urine.

After 12 months, 38 of the 42 women given the stem cell and other cell injections were completely continent. The other four showed either slight or substantial improvement. Only two of the 21 who got collagen injections were continent; seven others showed either slight or substantial improvement.

From ultrasound exams after the injections, it could be seen that the thickness of the sphincter had increased 59 percent in the women given cell injections but just nine percent in the collagen-treated group.  Muscle contractibility increased much more in the cell group.  Increases in the sphincter thickness and muscle contractibility are thought to help improve symptoms.  The women who were treated with the injections of cells reported higher quality of life than the women treated with collagen.  No one in the study reported any adverse side effects.

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Sacral Neuromodulation Treats Refractory Idiopathic Urge Urinary Incontinence

According to Dutch researchers, sacral neuromodulation could be a safe, if impermanent, way to treat refractory idiopathic urge urinary incontinence.

Sacral neuromodulation, also known as sacral nerve stimulation, involves the implantation of a programmable stimulator subcutaneously which delivers low amplitude electrical stimulation through a lead to the sacral nerve, usually accessed via the S3 forament.

In a new study published in a recent issue of the Journal of Urology, Jan Groen, Ph.D., Bertil F.M. Blok, M.D., Ph.D., and J.L.H. Ruud Bosch, M.D., all from the Erasmus Medical Center in Rotterdam and University Medical Center Utrecht (JLHRB), Utrecht, The Netherlands, report on 60 women who had leads for sacral neuromodulation implanted by open surgery.

Eighty-seven percent of the women had at least a 50 percent decrease in incontinence episodes or the number of pads used daily at one month.

By five years, however, only 62 percent of the women were still reporting at least a 50 percent decrease from baseline.  Additionally, only 15 percent were completely continent.  Over half (32 patients) had 57 adverse events; most involved hardware or pain and discomfort. None were serious.

The study’s lead author Groen said that despite its decreasing effectiveness, neuromodulation “remains our first choice, especially in younger patients, as the technique is safe, does not need frequent re-treatment and is not accompanied by a possible need for self-catheterization.”

He does, however, acknowledge that the relative place of neuromodulation in the treatment algorithm and the role of its most important alternative option, botulinum toxin, are evolving.

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Pre-op Counseling For Prostate Surgery Not Effective

Researchers have found that over half of men undergoing radical prostatectomy have unrealistic expectations about some of the outcomes.

Daniela Wittmann, MSW, and colleagues at the University of Michigan Comprehensive Cancer Center in Ann Arbor, Michigan found that despite a pre-operative education program, 61 percent of men expected the same or better sexual function a year after surgery as they had before.  Sixty percent of men expected difficulties with urinary incontinence to be the same or better.  These findings were published in the Journal of Urology.

Wittmann and colleagues found that a substantial proportion of patients, 17 percent and 12 percent, respectively for both effects, expected better performance a year after surgery than before even though they had been told that such an outcome was improbable.  The researchers argued that this finding suggests that pre-op education should be followed up with post-surgery support for prostate cancer survivors.

The research team asked men undergoing radical prostatectomy to fill out the short form of the Expanded Prostate Index Composite questionnaire, both before and a year after surgery to get an idea of their urinary, bowel, hormonal, and sexual function.

The men were also asked, after pre-op counseling but before surgery, to fill out the Expanded Prostate Index Composite-Expectations questionnaire, which detailed what level of function they expected a year later.  Both questionnaires assess five domains: incontinence, urinary irritative symptoms, bowel function, hormonal function, and sexual function.

Analysis of the 152 participants showed that 36 percent and 40 percent expected the same function at one year as at baseline in urinary incontinence and sexual function, respectively, while 12 percent and 17 percent expected better function.  Forty-seven percent and 44 percent of patients had lower than expected function for urinary incontinence and sexual function, respectively.  Expectations matched or were better than outcomes for 78 percent of patients for urinary irritative symptoms.  Expectations of bowel and hormonal function largely matched outcomes, with 92 percent and 86 percent, respectively, having outcomes that were the same as or better than expected.

Wittmann said that these differences may arise from the way that the pre-op counseling is given.  The research tem cautioned that the study had a low response rate.  Out of 526 patients who signed consent forms, only 152 completed all the questionnaires.  This makes it difficult to generalize the findings.  Also, while the counseling on sexual matters was standardized, the information provided by surgeons on other outcomes was not.

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