Archive | Prostate Health

Adverse Sexual Side Effects linked to popular BPH drug

Dutasteride is a common medication used for treatment of Benign Prostatic Hyperplasia (BPH).

The findings of a new observational study supports a link between long-term dutasteride (5 alpha reductase inhibitor or 5-ARI) use and adverse sexual side effects, including worsening ED and reduced testosterone levels.

According to the author Abdulmaged M. Traish, MBA, PhD, of Boston University School of Medicine told Renal & Urology News. “The increase in blood glucose and A1C may predispose men to diabetes and the increase in lipids may predispose them to NAFLD [non-alcoholic fatty liver disease]. Most importantly, this agent worsens sexual function and reduces quality of life.”

Based on collected data, Dr. Traish and his colleagues found that dutasteride significantly improved LUTS over 36 to 42 months, according to results published in Hormones Molecular Biology and Clinical Investigations. It reduced prostate volume, International Prostate Symptom Score, and PSA. However, its use was also associated with increased blood glucose, hemoglobin A1c, triglycerides, and low-density lipoprotein levels over the long term. In addition, dutasteride appeared to increase liver transaminase activity and Aging Male Symptom score, which indicates inflammation and reduced quality of life.

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No Significant Association Found Between Androgen Deprivation Therapy and Cardiovascular Death

Treatment with androgen deprivation therapy (ADT) does not significantly increase the risk of cardiovascular mortality according to evaluation of mortality data in a large registry of men treated for prostate cancer.

ADT is commonly used to treat prostate cancer.  Some studies have shown that it may increase the risk of cardiovascular disease, but other studies have not confirmed the association and it remains controversial.  The authors of the recent study tried to explore the evidence further by analyzing the patients registry CAPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor), which includes men with confirmed prostate cancer recruited from 40 mostly community-based US urological practices.

Men who are diagnosed with localized prostate cancer between 1995 and 2007 were included in the analysis, and in order to try to control for factors that may confound the relationship between ADT and cardiovascular death, patients who used and did not use ADT were matched by their propensity to receive ADT.  These patients were categorized into three groups: primary ADT monotherapy, local treatment plus ADT, and watchful waiting/active surveillance (WW/AS).  Initial outcomes were associations between treatment and cardiovascular cause, prostate cancer, and other causes.  Study investigators assessed cause of death using death certificates.

At the point of data capture, there were 13,887 men in the registry, of whom 7,248 were eligible for the analysis.  The majority (71.3%) received local treatment only, 6.7% received local treatment plus ADT, 15% received primary ADT, and 7 percent WW/AS.  It was found that 21.7% received AFT at some point.  Nine hundred seventy six of these men died during the study period, 1.4% from prostate cancer, 2.7% from cardiovascular disease, and 9.4 percent due to other causes.  Patients treated with ADT or WW/AS had a higher likelihood of death due to prostate cancer than those treated just with local therapy.

The largest risk of cardiovascular death was in those treated with WW/AS compared to those only receiving local therapy.  The difference for those treated with local therapy plus ADT was not significant.

The authors’ conclusion is that the increased rate of cardiovascular death in the WW/AS group compared to the ADT group suggests that there are possibly unmeasured variables that affect treatment selection and that confound the association between ADT and cardiovascular death.  The research team notes that when patients were match on propensity to receive ADT, there was no significant association.  The limitation so the study included the relatively small number of deaths in some groups, and the assignment of cause of death from death certificates.

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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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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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Surgery Improves Longevity and Quality of Life for cT3 Prostate Cancer Patients

Researchers at the Mayo Clinic, a leading nonprofit institution providing medical care, research and education for people from all walks of life based in Rochester, Minnesota, have found that long-term survival rates for patients with advanced prostate cancer suggest that they can be good candidates for surgery.  The research team found a twenty-year survival rate for 80 percent of patients diagnosed with cancer that has potentially spread locally from inside the prostate to immediately outside of it, known as cT3 prostate cancer, and who had been treated with radical prostatectomy, which is surgery to remove the prostate gland.  These findings were presented at the annual meeting of the American Urological Association in Washington.

Previously, patients who had cT3 prostate cancer were offered radiation or hormone treatment but not radical prostatectomy.

R. Jeffrey Karnes, MD, an Assistant Professor at the Mayo Clinic’s Department of Urology said that the identification and expansion of candidates for surgery that results in improved and longer outcomes for patients has improved. Other study investigators from the Mayo Clinic include Christopher Mitchell, M.D., Eric Umbreit, M.D., Rachel Carlson and Laureano Rangel.

The 80 percent survival rate for cT3 diagnoses at 20 years is compared to 90 percent for cT2, which is cancer confined to the prostate.  The study included patients with cT3 diagnoses and who were operated on between 1987 and 1997.  Ongoing research will continue to examine the current data.  This long-term follow-up is an important advance in understanding the quality outcomes for these cT3 patients.

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Rectal Injuries During Treatment for Prostate Cancer Reduced by Tissue Spacers

Recent research has found that injecting a tissue space in the prostate-rectal inter-space is an effective way to reduce the rectal dose for prostate cancer patients receiving radiation therapy.  These results were presented at the Cancer Imaging and Radiation Therapy Symposium in Atlanta, sponsored by the American Society for Radiation Oncology (ASTRO) and Radiological Society of North America (RSNA).

Although prostate cancer is cured in over 90 percent of patients, reducing side effects from treatment complications remains an important concern.  A more common side effect is damaging the rectum during treatment.  For this reason, researchers wanted to determine if inserting an injectable tissue space would reduce the risks of radiation burns to the rectum.

Thirty-four prostate carcinoma patients were administered a tissue space compound to increase the separation between the prostate and the rectum in this study in addition to the radiation therapy they were receiving.  They were imaged by MRI pre-injection and every two weeks until the end of treatment to monitor changes.  The research tem found that the spacer produced an additional one centimeter on average separation between the prostate and rectum resulting in a significant reduction in the rectal dose administered, and it caused very little damage to the rectum.

Severe rectal radiation burns, the most serious risk of injury from the radiation were almost eliminated by injecting an absorbable material into the rectum.  This allows the radiation oncologist to increase the dose to the posterior prostate without concern of damaging the rectum.

Kenneth Tokita, MD, senior author of the study and the founder and medical director of Cancer Center of Irvine said that reducing the risk of rectal injury from the treatment makes radiation therapy the treatment of choice for prostate cancer.

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Brisk Walking Slows Down Prostate Cancer Progression

A recent study at the University of California, San Francisco (UCSF) and the Harvard School of Public Health found that an association between brisk walking and lowered risk of prostate cancer progression in a study of 1,455 men in the U.S. diagnosed with early-stage prostate cancer.

The research team found that men who walked briskly at least at three miles per hour for at least three hours each week after diagnosis were about sixty percent less likely to develop biochemical markers of cancer recurrence or less likely to need a second round of prostate cancer treatment.  The study was published in the journal Cancer Research.

This new finding complements an earlier study published by UCSF’s June Chan, ScD, and collaborators at the Harvard School of Public Health showing that physical activity after diagnosis could reduce disease-related mortality in a distinct population of men with prostate cancer.  The recent study by Erin Richman, ScD, a postdoctoral fellow at UCSF is the first to focus on the effect of physical activity after diagnosis on early indications of disease progression, such as rise in prostate-specific antigen (PSA) blood levels.

An advantage of this study is the focus on early recurrence of prostate cancer, which occurs before men may experience painful symptoms of prostate cancer metastases, a frequent cause for men to decrease their usual physical activity. Additionally, the researchers reported that the benefit of physical activity was independent of the participants’ age at diagnosis, type of treatment and clinical features.  This work was funded by the Department of Defense, the Prostate Cancer Foundation, Abbott Labs, and through a National Institutes of Health training grant.

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Alpha Blocker Improves Symptoms of Chronic Prostatitis

Recent findings show that treatment with a specific alpha blocker helps reduce symptoms and improve quality of life for men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).  This alpha-blocker, called silodosin, works by selectively relaxing the muscles in the neck of the urinary bladder and prostate.  It has been approved in Canada, the United States, the EU and Japan to treat symptoms of another prostate gland condition, benign prostatic hyperplasia, which is commonly referred to as an enlarged prostate.

Although CP/CPPS is the most common form of prostatitis, it is the most misunderstood and difficult to treat because the symptoms are very similar to other conditions and requires a significant amount of testing and screening to identify.

Curtis Nickel, a professor in the Department of Urology, practicing urologist at Kingston General Hospital and Canada Research Chair in Urologic Pain and Inflammation, emphasized that antibiotics are commonly used as a treatment, but they are not typically effective.  This could be because CP/CPPS does not seem to be caused by a bacterial infection.

CP/CPPS is a debilitating condition; patients with this condition suffer from discomfort in the lower pelvic area including the bladder area, testicles, and penis.  Symptoms may be severe and can include painful and frequent urination and difficult or painful ejaculation.  The cause of CP/CPPS is not known.

In Dr. Nickel’s study, about 60 percent of men reported feeling better after treatment with silodosin as opposed to 30 percent of participants who were given a placebo.  These results for patients feeling better is higher than a similar study he conducted several years ago that tested the effects of a different alpha blocker.

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No Relationship Between Small Prostate Size and High Grade Cancer

Previously, radical prostatectomy series have shown an inverse relationship between prostate size and high grade cancer.  It was suggested that smaller sized prostates arise in a low androgen environment, which enables development of more aggressive cancer.  A recent study by a team of authors from Stanford University School of Medicine in the Journal of Urology, however, shows that small prostate size is not associated with high grade cancer.  The authors argue that previous observations are the result of ascertainment bias driven by prostate specific antigen performance.

The study’s authors analyzed 1,404 patients from the Stanford Radical Prostatectomy Database with clinical stage T1c (723) and T2 (681) disease who had surgery between 1988 and 2002 and underwent detailed morphommetric mapping by a single pathologist.  They used multivariate linear regression to analyze the effects of age, prostate weight and prostate specific antigen on total and high grade cancer volume and percentage of high grade disease.

Patients who underwent biopsy due to abnormal prostate specific antigen (stage T1c had a prostate weight that was negatively associated with total cancer volume, which is the volume of high grade disease and percentage of high grade disease.  For patients who underwent biopsy based on abnormal rectal examination (stage T2), these relationships were not present.

The authors conclude that improved prostate specific antigen performance for high grade disease results in ascertainment bias in patients with T1c disease.  For this reason, the relationship between prostate size and high grade disease may be a result of grade dependent performance of prostate specific antigen rather than true tumor biology.

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New Technology May Encourage Doctors to Recommend Prostate Surgery

A new study finds that after hospitals in Wisconsin received robotic surgery technology, the number of prostate removals there doubled within three months.  In contrast, the number of prostate surgeries remained the same at hospitals that did not purchase this new two-million dollar technology.

This finding was published in the peer-reviewed journal Cancer. It comes just months after a Johns Hopkins report showing that hospital websites often hype robotic surgery without considering the risks and play up the benefits leading the study authors to worry that the new technology is encouraging doctors to recommend surgery to patients.

Each robot, in addition to the initial cost of nearly $2 million, requires more than $100,000 per year for maintenance.  Jim Hu, MD, director of urologic robotic surgery at Brigham and Women’s Hospital in Boston, who was not involved in the new study, suggested that hospitals that acquire this expensive technology might feel pressure to cover its costs by performing more surgeries.    The new technology is now used in almost three-quarters of all prostate removals nationwide.  Yair Lotan, MD, from the University of Texas Southwestern Medical Center at Dallas, who was not involved in the study, said that The bulk of evidence, however, does not show it to be more effective in saving lives than traditional surgery.

Joan Neuner, MD, MPh, of the Medical College of Wisconsin and colleagues found that between 2002 and 2008, Wisconsin hospitals performed more than 10,000 prostate removal surgeries. Almost one in four hospitals purchased surgical robots in that period.  Although fewer men had prostate cancer in 2007, there were 1,760 prostatectomies in 2007 compared to 1,400 in 2002.

Dr. Neuner and colleagues attribute these findings partly to patient demand, driven by aggressive marketing by manufacturers and hospitals.  Dr. Lotan reports that patients often request the robotic surgery without knowing the risks involved.  While shorter recovery times, less blood loss, and smaller scars are benefits of the robotic system, the technology extends the operation time. Dr. Hu emphasizes that the safety of surgeries depends more on the skills of the surgeon than on the technology involved.

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