The following video provides an overview of the radical prostatectomy with the daVinci System from www.intuitivesurgical.com. Dr. J.H. Witt www.pznw.de St. Antonius Hospital Gronau, Germany.
Showing posts with label Video. Show all posts
Showing posts with label Video. Show all posts
Friday, 15 May 2009
Video: Da Vinci Prostatectomy
The following video provides an overview of the radical prostatectomy with the daVinci System from www.intuitivesurgical.com. Dr. J.H. Witt www.pznw.de St. Antonius Hospital Gronau, Germany.
Tuesday, 31 March 2009
The Man, the Gland, the Dilemmas
Article from Wall Street Journal
You've been getting annual blood tests to check for prostate cancer. But two big studies in the New England Journal of Medicine just found that screening for PSA -- prostate specific antigen -- doesn't save many lives. Should you keep checking it?
Your biopsy was negative for prostate cancer but your PSA keeps rising. Should you stop worrying -- or have another biopsy?
You've been diagnosed with early-stage prostate cancer. It's probably harmless, but it could turn lethal. Should you just watch it or treat it aggressively and run the risk of impotence or incontinence?
Prostate cancer poses some of the most vexing questions in medicine, and one out of every six men in the U.S. will confront them at some point in their lives. Today's Health Journal is the first of a two-part series that aims to provide some guidance. This article looks at new diagnostic techniques that may help to resolve some of these quandaries. Next week we'll examine the perplexing array of treatment options and weigh the pros and cons of each.
Should You Be Screened?
For all the uproar they created, the recent NEJM studies settled little in the long-running debate over whether prostate-cancer screening is worthwhile.
PSA testing revolutionized detection of the disease in the late 1980s. Before that, doctors relied on a digital-rectal exam, or DRE, and by the time tumors could be felt, some were fairly large. Now, about 90% of prostate cancers are found at an early and highly curable stage.
But PSA screening can flag tumors almost too early, leading to considerable unnecessary surgery or radiation. Most prostate cancers are so small and slow-growing that they don't need treatment. Of the 185,000 U.S. men diagnosed with the disease each year, an estimated 85% would likely die of something else long before their cancer caused problems.
On the other hand, some prostate cancers are aggressive, each year killing some 28,000 men in the U.S. -- and 288,000 worldwide -- who weren't treated in time. It's the second most deadly cancer in men, after lung cancer.
As of now, it's difficult to tell which patients have which kind of tumors in the early stages. Experts say many more men could safely opt for "watchful waiting" -- monitoring their cancers to see if they grow. But thousands of men each year opt to have their prostates removed surgically or treated with radiation to be on the safe side, and many live with urinary or erectile problems in the bargain.
"Right now we are treating people for anxiety, not cancer," says Faina Shtern, CEO of the AdMeTech Foundation, a nonprofit group that is lobbying Congress to increase federal funding for research into prostate imaging. "We do not know if they will benefit from treatment, but we know they will have complications," Dr. Shtern says.
Weighing all those factors, a U.S. government panel last year recommended that doctors stop screening men age 75 and over for prostate cancer, since the risk of treating it likely outweighed the benefits.
The recent NEJM studies seemed to extend that reasoning to younger men as well. One study of 77,000 North American men showed that regular PSA screening didn't save a significant number of lives over 10 years. A study of 182,000 European men showed a 20% reduction in deaths among those screened regularly. But in that study, 48 men had to be treated for every life saved.
Still, many cancer organizations issued statements defending PSA testing -- in the absence of something better -- and urging men to discuss it with their doctors.
Most doctors believe that men with a family history of prostate cancer should have annual PSA testing, along with African-American men, for whom the death rate from prostate cancer is twice as high as for whites. For others, "you probably don't have to get it tested every year," says Al Barqawi, a urologist at the University of Colorado Health Sciences Center. "If there's a change, then do it more often."
"Blind" Biopsies
A PSA level is cause for concern if it's higher than usual for the man's age or rising rapidly. If so, the next step is usually a biopsy. That's typically done in a urologist's office with an ultrasound probe and a spring-loaded needle gun inserted into the rectum, taking six to 12 samples at random.
The ultrasound can't see well into the prostate, so urologists are effectively sampling blindly. More than 1.2 million American men have such transrectal ultrasound, or TRUS, biopsies each year due to a suspicious PSA level. Less than 15% come back positive for cancer. But TRUS biopsies miss about 20% of cancers, so a negative biopsy isn't completely reassuring.
That's the situation Richard Edelman, president and chief executive of the Edelman public-relations firm, faced in 2007. His PSA had doubled over two years to four nanograms/milliliter, considered elevated for his age of 54. He also had three close relatives with prostate cancer. A standard TRUS biopsy was negative, but a few months later, his PSA had jumped to 7.5 ng/ml.
His doctor suspected a urinary-tract infection, one of several benign conditions that can increase the PSA level, and prescribed an antibiotic. But Mr. Edelman's PSA remained elevated, as did his anxiety.
To get more information, Mr. Edelman enrolled in a clinical trial at the National Cancer Institute, where doctors are hoping to improve tumor detection by scanning prostates with magnetic-resonance imaging. The MRI scans are then used to target biopsies at suspicious-looking areas. Mr. Edelman had a second biopsy, guided by MRI, which found cancer in two of 21 samples. "The value of the MRI was huge," he says.
Imaging of the prostate has lagged far behind imaging for breast cancer in women -- largely because the prostate is deep inside the pelvis and harder to access. "It's medieval and barbaric what we do to men without better imaging," says AdMeTech's Dr. Shtern, who helped advance the use of MRIs for breast cancer at the NCI in the 1990s. She notes that NCI today spends twice as much on research into breast cancer than prostate cancer research, even though prostate cancer is twice as prevalent. Mr. Edelman's firm is helping her group's efforts; as are some equipment manufacturers.
Researchers at NCI and several major medical centers are currently using several kinds of advanced MRIs to scan the prostate for abnormalities that could signal cancer. MRIs with contrast agents can highlight areas of new blood-vessel growth. Other techniques include MR spectroscopy, which looks for telltale chemical changes, and diffusion-weighted MRIs, which measure changes in water flow around cells. Clinical trials are underway to assess whether biopsies guided by such images are better than standard TRUS biopsies at finding cancers.
"None of these tests will absolutely differentiate benign from malignant. They're pointers to areas that should be further biopsied or followed," says Peter Choyke, the NCI's chief of molecular imaging.
MRIs often identify abnormalities that aren't cancerous. They also add $1,000 or more to the cost of a biopsy, which itself runs about $2,000. But Dr. Shtern argues that scanning before performing a biopsy could save money in the long run if it helps to reduce the $2 billion spent annually on standard biopsies that don't find cancer.
"It sounds good, but the burden of proof is on us to show that this makes a difference in detecting cancers," says Peter Pinto, director of the fellowship program at NCI's urologic oncology branch.
Has it Spread?
Once a biopsy confirms cancer, many major medical centers now use MRIs to help determine whether it has spread beyond the prostate and invaded the nearby nerves and blood vessels involved in sexual function and urination. That information can be crucial if a patient is considering surgery, radiation or watchful waiting.
More often, doctors are playing probabilities to determine whether early-stage cancers have spread beyond the prostate. Some use mathematical formulas based on a combination of PSA levels, a DRE and what's known as a Gleason score, a measure of a cancer's aggressiveness based on the pattern of abnormal cells seen on the biopsy.
And doctors often disagree about what that information signifies. In Mr. Edelman's case, one counseled watchful waiting since his Gleason score was a moderate six. Another doctor suspected Mr. Edelman's cancer had already spread, based on his PSA, and urged radiation and hormone therapy. At Memorial Sloan-Kettering Cancer Center in New York, Mr. Edelman had a second MRI that revealed that his cancer was still confined to the prostate, but was on both sides of the gland and had grown since the first MRI scan.
He opted for a radical prostatectomy last fall -- and he thinks he caught the cancer just in time. "I'm told I have more than a 95% chance of being around for a long time," he says. His last PSA was down to zero.
Doctors who use MRIs caution they aren't always definitive and can't see very small cancers, but even that can be useful. "If I don't see anything on an MRI, it helps reassure me you probably don't have a large, life-threatening cancer." says Peter Scardino, chief of urology at Memorial Sloan-Kettering.
"We are all like the blind men feeling the elephant," Dr. Scardino adds. "I don't rely just on the DRE, the PSA, the biopsy results or the MRI. But if we put all that information together, we can get a pretty good idea of what's going on."
Playing 'Battleship'
Rather than rely on imaging, a small but growing group of urologists prefer to bombard the prostate with more extensive biopsies. A "3D-mapping biopsy" takes 50 or more samples, five millimeters apart, throughout the gland. The needles are inserted through a grid that allows doctors to pinpoint the size, shape and location of any cancers. Practitioners liken it to playing the game Battleship with the prostate. Unlike a standard biopsy done through the rectum, a mapping biopsy is performed through the skin behind the scrotum with the patient under anesthesia.
The cost of a 3D-mapping biopsy is $5,000 to $6,000, due to the extensive pathology needed. They're far too costly and cumbersome for routine screening. But the technique can provide valuable information for making treatment decisions, and is increasingly covered by insurance and Medicare.
In the last three years, Dr. Barqawi at the University of Colorado has performed two hundred 3D-mapping biopsies on patients after they had had TRUS biopsies. Of them, 96 learned that their cancers were more extensive than the first biopsy showed. But 33 patients were reassured that their cancers were small and could just be watched.
Dr. Barqawi says 60 of the patients getting mapping biopsies learned that their tumors were so localized that they opted for new treatments known as targeted focal therapies. With these, doctors are able to destroy just the tumor with cryosurgery or specialized ultrasound and leave the rest of the prostate alone.
"Knowledge is power and that's especially true when managing patients diagnosed with early-stage disease to avoid un-needed surgeries," Dr. Barqawi says.
Molecular Markers
Scientists are also making headway in finding new molecular markers that may be able to signify not just the presence of cancer, but what its lethal potential is.
Researchers at the University of Michigan have identified a molecular waste product of tumors, called sarcosine, that is elevated in the urine of men with advanced prostate cancers. Researchers at Memorial Sloan-Kettering and elsewhere are studying circulating tumor cells -- bits of cancer cells that break off and enter the blood stream -- that may be able to indicate whether cancer has the potential to metastasize.
Some patients have more than one kind of prostate cancer, and scientists are developing PET scans and radioactive dyes that may one day be able to make different kinds of tumors light up like colored Christmas lights -- yellow for benign, red for really lethal.
"We've got potentially game-changing biomarkers that could get us out of the dilemma we are in with PSA," says oncologist Jonathan Simons, president of the Prostate Cancer Foundation, which funds some of that research. With the recent NEJM studies, he says, "We've been reminded again of how much work we need to do."
You've been getting annual blood tests to check for prostate cancer. But two big studies in the New England Journal of Medicine just found that screening for PSA -- prostate specific antigen -- doesn't save many lives. Should you keep checking it?
Your biopsy was negative for prostate cancer but your PSA keeps rising. Should you stop worrying -- or have another biopsy?
You've been diagnosed with early-stage prostate cancer. It's probably harmless, but it could turn lethal. Should you just watch it or treat it aggressively and run the risk of impotence or incontinence?
Prostate cancer poses some of the most vexing questions in medicine, and one out of every six men in the U.S. will confront them at some point in their lives. Today's Health Journal is the first of a two-part series that aims to provide some guidance. This article looks at new diagnostic techniques that may help to resolve some of these quandaries. Next week we'll examine the perplexing array of treatment options and weigh the pros and cons of each.
Should You Be Screened?
For all the uproar they created, the recent NEJM studies settled little in the long-running debate over whether prostate-cancer screening is worthwhile.
PSA testing revolutionized detection of the disease in the late 1980s. Before that, doctors relied on a digital-rectal exam, or DRE, and by the time tumors could be felt, some were fairly large. Now, about 90% of prostate cancers are found at an early and highly curable stage.
But PSA screening can flag tumors almost too early, leading to considerable unnecessary surgery or radiation. Most prostate cancers are so small and slow-growing that they don't need treatment. Of the 185,000 U.S. men diagnosed with the disease each year, an estimated 85% would likely die of something else long before their cancer caused problems.
On the other hand, some prostate cancers are aggressive, each year killing some 28,000 men in the U.S. -- and 288,000 worldwide -- who weren't treated in time. It's the second most deadly cancer in men, after lung cancer.
As of now, it's difficult to tell which patients have which kind of tumors in the early stages. Experts say many more men could safely opt for "watchful waiting" -- monitoring their cancers to see if they grow. But thousands of men each year opt to have their prostates removed surgically or treated with radiation to be on the safe side, and many live with urinary or erectile problems in the bargain.
"Right now we are treating people for anxiety, not cancer," says Faina Shtern, CEO of the AdMeTech Foundation, a nonprofit group that is lobbying Congress to increase federal funding for research into prostate imaging. "We do not know if they will benefit from treatment, but we know they will have complications," Dr. Shtern says.
Weighing all those factors, a U.S. government panel last year recommended that doctors stop screening men age 75 and over for prostate cancer, since the risk of treating it likely outweighed the benefits.
The recent NEJM studies seemed to extend that reasoning to younger men as well. One study of 77,000 North American men showed that regular PSA screening didn't save a significant number of lives over 10 years. A study of 182,000 European men showed a 20% reduction in deaths among those screened regularly. But in that study, 48 men had to be treated for every life saved.
Still, many cancer organizations issued statements defending PSA testing -- in the absence of something better -- and urging men to discuss it with their doctors.
Most doctors believe that men with a family history of prostate cancer should have annual PSA testing, along with African-American men, for whom the death rate from prostate cancer is twice as high as for whites. For others, "you probably don't have to get it tested every year," says Al Barqawi, a urologist at the University of Colorado Health Sciences Center. "If there's a change, then do it more often."
"Blind" Biopsies
A PSA level is cause for concern if it's higher than usual for the man's age or rising rapidly. If so, the next step is usually a biopsy. That's typically done in a urologist's office with an ultrasound probe and a spring-loaded needle gun inserted into the rectum, taking six to 12 samples at random.
The ultrasound can't see well into the prostate, so urologists are effectively sampling blindly. More than 1.2 million American men have such transrectal ultrasound, or TRUS, biopsies each year due to a suspicious PSA level. Less than 15% come back positive for cancer. But TRUS biopsies miss about 20% of cancers, so a negative biopsy isn't completely reassuring.
That's the situation Richard Edelman, president and chief executive of the Edelman public-relations firm, faced in 2007. His PSA had doubled over two years to four nanograms/milliliter, considered elevated for his age of 54. He also had three close relatives with prostate cancer. A standard TRUS biopsy was negative, but a few months later, his PSA had jumped to 7.5 ng/ml.
His doctor suspected a urinary-tract infection, one of several benign conditions that can increase the PSA level, and prescribed an antibiotic. But Mr. Edelman's PSA remained elevated, as did his anxiety.
To get more information, Mr. Edelman enrolled in a clinical trial at the National Cancer Institute, where doctors are hoping to improve tumor detection by scanning prostates with magnetic-resonance imaging. The MRI scans are then used to target biopsies at suspicious-looking areas. Mr. Edelman had a second biopsy, guided by MRI, which found cancer in two of 21 samples. "The value of the MRI was huge," he says.
Imaging of the prostate has lagged far behind imaging for breast cancer in women -- largely because the prostate is deep inside the pelvis and harder to access. "It's medieval and barbaric what we do to men without better imaging," says AdMeTech's Dr. Shtern, who helped advance the use of MRIs for breast cancer at the NCI in the 1990s. She notes that NCI today spends twice as much on research into breast cancer than prostate cancer research, even though prostate cancer is twice as prevalent. Mr. Edelman's firm is helping her group's efforts; as are some equipment manufacturers.
Researchers at NCI and several major medical centers are currently using several kinds of advanced MRIs to scan the prostate for abnormalities that could signal cancer. MRIs with contrast agents can highlight areas of new blood-vessel growth. Other techniques include MR spectroscopy, which looks for telltale chemical changes, and diffusion-weighted MRIs, which measure changes in water flow around cells. Clinical trials are underway to assess whether biopsies guided by such images are better than standard TRUS biopsies at finding cancers.
"None of these tests will absolutely differentiate benign from malignant. They're pointers to areas that should be further biopsied or followed," says Peter Choyke, the NCI's chief of molecular imaging.
MRIs often identify abnormalities that aren't cancerous. They also add $1,000 or more to the cost of a biopsy, which itself runs about $2,000. But Dr. Shtern argues that scanning before performing a biopsy could save money in the long run if it helps to reduce the $2 billion spent annually on standard biopsies that don't find cancer.
"It sounds good, but the burden of proof is on us to show that this makes a difference in detecting cancers," says Peter Pinto, director of the fellowship program at NCI's urologic oncology branch.
Has it Spread?
Once a biopsy confirms cancer, many major medical centers now use MRIs to help determine whether it has spread beyond the prostate and invaded the nearby nerves and blood vessels involved in sexual function and urination. That information can be crucial if a patient is considering surgery, radiation or watchful waiting.
More often, doctors are playing probabilities to determine whether early-stage cancers have spread beyond the prostate. Some use mathematical formulas based on a combination of PSA levels, a DRE and what's known as a Gleason score, a measure of a cancer's aggressiveness based on the pattern of abnormal cells seen on the biopsy.
And doctors often disagree about what that information signifies. In Mr. Edelman's case, one counseled watchful waiting since his Gleason score was a moderate six. Another doctor suspected Mr. Edelman's cancer had already spread, based on his PSA, and urged radiation and hormone therapy. At Memorial Sloan-Kettering Cancer Center in New York, Mr. Edelman had a second MRI that revealed that his cancer was still confined to the prostate, but was on both sides of the gland and had grown since the first MRI scan.
He opted for a radical prostatectomy last fall -- and he thinks he caught the cancer just in time. "I'm told I have more than a 95% chance of being around for a long time," he says. His last PSA was down to zero.
Doctors who use MRIs caution they aren't always definitive and can't see very small cancers, but even that can be useful. "If I don't see anything on an MRI, it helps reassure me you probably don't have a large, life-threatening cancer." says Peter Scardino, chief of urology at Memorial Sloan-Kettering.
"We are all like the blind men feeling the elephant," Dr. Scardino adds. "I don't rely just on the DRE, the PSA, the biopsy results or the MRI. But if we put all that information together, we can get a pretty good idea of what's going on."
Playing 'Battleship'
Rather than rely on imaging, a small but growing group of urologists prefer to bombard the prostate with more extensive biopsies. A "3D-mapping biopsy" takes 50 or more samples, five millimeters apart, throughout the gland. The needles are inserted through a grid that allows doctors to pinpoint the size, shape and location of any cancers. Practitioners liken it to playing the game Battleship with the prostate. Unlike a standard biopsy done through the rectum, a mapping biopsy is performed through the skin behind the scrotum with the patient under anesthesia.
The cost of a 3D-mapping biopsy is $5,000 to $6,000, due to the extensive pathology needed. They're far too costly and cumbersome for routine screening. But the technique can provide valuable information for making treatment decisions, and is increasingly covered by insurance and Medicare.
In the last three years, Dr. Barqawi at the University of Colorado has performed two hundred 3D-mapping biopsies on patients after they had had TRUS biopsies. Of them, 96 learned that their cancers were more extensive than the first biopsy showed. But 33 patients were reassured that their cancers were small and could just be watched.
Dr. Barqawi says 60 of the patients getting mapping biopsies learned that their tumors were so localized that they opted for new treatments known as targeted focal therapies. With these, doctors are able to destroy just the tumor with cryosurgery or specialized ultrasound and leave the rest of the prostate alone.
"Knowledge is power and that's especially true when managing patients diagnosed with early-stage disease to avoid un-needed surgeries," Dr. Barqawi says.
Molecular Markers
Scientists are also making headway in finding new molecular markers that may be able to signify not just the presence of cancer, but what its lethal potential is.
Researchers at the University of Michigan have identified a molecular waste product of tumors, called sarcosine, that is elevated in the urine of men with advanced prostate cancers. Researchers at Memorial Sloan-Kettering and elsewhere are studying circulating tumor cells -- bits of cancer cells that break off and enter the blood stream -- that may be able to indicate whether cancer has the potential to metastasize.
Some patients have more than one kind of prostate cancer, and scientists are developing PET scans and radioactive dyes that may one day be able to make different kinds of tumors light up like colored Christmas lights -- yellow for benign, red for really lethal.
"We've got potentially game-changing biomarkers that could get us out of the dilemma we are in with PSA," says oncologist Jonathan Simons, president of the Prostate Cancer Foundation, which funds some of that research. With the recent NEJM studies, he says, "We've been reminded again of how much work we need to do."
Friday, 20 March 2009
Choosing a Treatment for Prostate Cancer
Once a man is diagnosed with prostate cancer, he faces a myriad of treatment options, ranging from prostate removal to radioactive implants to no treatment at all. Unfortunately, science isn’t much help.
A recent report from the Agency for Healthcare Research and Quality concluded that no one treatment is superior.
As part of our regular health video series, The New York Times spoke with 59-year-old Mark Spindel about his treatment choice: surgical removal of the prostate. Click on the video link to hear his story.
A recent report from the Agency for Healthcare Research and Quality concluded that no one treatment is superior.
As part of our regular health video series, The New York Times spoke with 59-year-old Mark Spindel about his treatment choice: surgical removal of the prostate. Click on the video link to hear his story.
Monday, 7 April 2008
Prostate Cancer Staging
As stated in my most recent post, I was told today that my Prostate Cancer Staging was: 'T3N0M0'. In order to put this in some perspective, for our readers; I decided to post the following:
The following article is excerpted from PSA Rising - Prostate Cancer Survivor (News, Info & Support) I would encourage all our readers to visit the author's website.
What is Staging?
If prostate cancer has been found by any method, the next step is to see how much of the prostate it takes up and whether it has spread outside the prostate to nearby tissue, lymph nodes, organs and/or bones.
This is called staging the cancer. Your prostate cancer stage is key to your treatment options. Primarily, staging is based on your digital rectal exam (DRE).
Two different systems of staging have been used for prostate cancer.
Today the older ABCD system has largely been replaced by the TNM (Tumor, Nodes, Metastases) system. In addition, two levels of staging are used, clinical and pathologic.
Clinical staging is based on digital exam and any further non-invasive tests necessary to find the extent of the cancer. It affects primary treatment decisions.
Pathologic stage refers to examination of the prostate and any other tissue removed during surgery. Only patients who undergo surgery receive the second level of staging.
The TNM system of staging
Primary tumor (T)
TX: Tumor cannot be assessed.
T1: Doctor is unable to feel the tumor or see it with imaging such as transrectal ultrasound.
T1a: Cancer is found incidentally during a transurethral resection (TURP) for benign prostatic enlargement. Cancer is present in less than 5% of the tissue removed.
T1b: Cancer is found after TURP and is present in more than 5% of the tissue removed.
T1c: Cancer is found by needle biopsy done because of an elevated PSA.
T2: Doctor can feel the tumor when a digital rectal exam (DRE) is performed but the tumor still appears to be confined to the prostate.
T2a: Cancer is found in one half or less of only one side (left or right) of the prostate.
T2b: Cancer is found in more than half of only one side (left or right) of the prostate.
T2c: Cancer is found in both sides of the prostate.
T3: Cancer has begun to spread outside the prostate and may involve the seminal vesicles.
T3a: Cancer extends outside the prostate but not to the seminal vesicles.
T3b: Cancer has spread to the seminal vesicles.
T4: Cancer has spread to tissues next to the prostate (other than the seminal vesicles), such as the sphincter, rectum and/or wall of the pelvis.
T4a: Invades bladder neck, external sphincter, or rectum.
T4b: Invades muscles and/or pelvic wall.
Regional Lymph Nodes (N)
To see if the cancer has spread to the lymph nodes or bones, the doctor may order a CT scan or an MRI of the pelvis and a bone scan.
What is Staging?
If prostate cancer has been found by any method, the next step is to see how much of the prostate it takes up and whether it has spread outside the prostate to nearby tissue, lymph nodes, organs and/or bones.
This is called staging the cancer. Your prostate cancer stage is key to your treatment options. Primarily, staging is based on your digital rectal exam (DRE).
Two different systems of staging have been used for prostate cancer.Today the older ABCD system has largely been replaced by the TNM (Tumor, Nodes, Metastases) system. In addition, two levels of staging are used, clinical and pathologic.
Clinical staging is based on digital exam and any further non-invasive tests necessary to find the extent of the cancer. It affects primary treatment decisions.
Pathologic stage refers to examination of the prostate and any other tissue removed during surgery. Only patients who undergo surgery receive the second level of staging.
The TNM system of staging
Primary tumor (T)
TX: Tumor cannot be assessed.
T1: Doctor is unable to feel the tumor or see it with imaging such as transrectal ultrasound.
T1a: Cancer is found incidentally during a transurethral resection (TURP) for benign prostatic enlargement. Cancer is present in less than 5% of the tissue removed.
T1b: Cancer is found after TURP and is present in more than 5% of the tissue removed.
T1c: Cancer is found by needle biopsy done because of an elevated PSA.
T2: Doctor can feel the tumor when a digital rectal exam (DRE) is performed but the tumor still appears to be confined to the prostate.
T2a: Cancer is found in one half or less of only one side (left or right) of the prostate.
T2b: Cancer is found in more than half of only one side (left or right) of the prostate.
T2c: Cancer is found in both sides of the prostate.
T3: Cancer has begun to spread outside the prostate and may involve the seminal vesicles.
T3a: Cancer extends outside the prostate but not to the seminal vesicles.
T3b: Cancer has spread to the seminal vesicles.
T4: Cancer has spread to tissues next to the prostate (other than the seminal vesicles), such as the sphincter, rectum and/or wall of the pelvis.
T4a: Invades bladder neck, external sphincter, or rectum.
T4b: Invades muscles and/or pelvic wall.
Regional Lymph Nodes (N)
To see if the cancer has spread to the lymph nodes or bones, the doctor may order a CT scan or an MRI of the pelvis and a bone scan.
Sentinel lymph nodes in the pelvis that look suspicious on CT scan or MRI can be examined by fine needle aspiration biopsy method. This is done commonly in breast cancer staging.
NX: Nodes cannot be assessed
N0: No regional node metastasis
N1: Single node metastasis, 2 centimeters (cm) or less at largest point
N2: Single node metastasis, 2 cm to 5 cm at largest point, or multiple nodes, no larger than 5 cm at largest point
N3: Metastasis larger than 5 cm in any node
Distant Metastasis (M)
MX: Metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis
M1a: Distant lymph node(s) involved
M1b: Bone(s) involved
M1c: Other site(s) involved (e.g. liver, lung)
Note on stages that "cannot be assessed."
Patients in whom abnormal digital rectal examinations (DREs) do not match up with their prostate biopsy findings are "clinically unstageable."
To find out what unstageable prostate cancer involves, Wisconsin researchers looked at post-op pathology reports of some 100 patients who were unstageable.
"For these patients pathological staging revealed pT2a cancers in 26%, pT2b in 53%, pT3a in 19%, pT3b and pT0 in 1% of patients." The authors conclude: "Thus, the prevalence of unstageable prostate cancer is low but significant and it can be accurately classified into clinical stage T1c. "Clinical and pathological characteristics of unstageable prostate cancer: analysis of the CaPSURE database. Langenstroer P et al. Medical College of Wisconsin. J Urol. 2005 Jul;174(1):118-20.
NX: Nodes cannot be assessed
N0: No regional node metastasis
N1: Single node metastasis, 2 centimeters (cm) or less at largest point
N2: Single node metastasis, 2 cm to 5 cm at largest point, or multiple nodes, no larger than 5 cm at largest point
N3: Metastasis larger than 5 cm in any node
Distant Metastasis (M)
MX: Metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis
M1a: Distant lymph node(s) involved
M1b: Bone(s) involved
M1c: Other site(s) involved (e.g. liver, lung)
Note on stages that "cannot be assessed."
Patients in whom abnormal digital rectal examinations (DREs) do not match up with their prostate biopsy findings are "clinically unstageable."
To find out what unstageable prostate cancer involves, Wisconsin researchers looked at post-op pathology reports of some 100 patients who were unstageable.
"For these patients pathological staging revealed pT2a cancers in 26%, pT2b in 53%, pT3a in 19%, pT3b and pT0 in 1% of patients." The authors conclude: "Thus, the prevalence of unstageable prostate cancer is low but significant and it can be accurately classified into clinical stage T1c. "Clinical and pathological characteristics of unstageable prostate cancer: analysis of the CaPSURE database. Langenstroer P et al. Medical College of Wisconsin. J Urol. 2005 Jul;174(1):118-20.
Tuesday, 15 January 2008
Robotic Surgery
Further Research
I thought since I have already jumped ahead a few months by beginning to explore the various methods of 'radiotherapy'; that I may as well 'jump' to the next step, following that: i.e. 'Removal of the Prostate'. My surgeon intends to use the 'laporascopic method', rather than the more common 'open surgery' method. Whilst exploring these various options, I came across a radical, new technique now being used in Australia (and elsewhere).
The da Vinci PROSTATECTOMY Method
Da Vinci Robotic prostatectomy is the newest and most advanced surgical option for patients. This method gives a surgeon greater visualization, enhanced dexterity, precision, control and superior ergonomics. This very precise surgery only requires 5 small incisions (1cm) in the abdomen.
About the da Vinci Robotic System
The da Vinci Surgical System is powered by state-of-the-art robotic technology. The System allows your surgeon's hand movements to be scaled, filtered and translated into precise movements of micro-instruments within the operative site. The magnified, three-dimensional view the surgeon experiences enables him to perform precise surgery in complex procedures through small surgical incisions.
I thought since I have already jumped ahead a few months by beginning to explore the various methods of 'radiotherapy'; that I may as well 'jump' to the next step, following that: i.e. 'Removal of the Prostate'. My surgeon intends to use the 'laporascopic method', rather than the more common 'open surgery' method. Whilst exploring these various options, I came across a radical, new technique now being used in Australia (and elsewhere).
The da Vinci PROSTATECTOMY Method
Da Vinci Robotic prostatectomy is the newest and most advanced surgical option for patients. This method gives a surgeon greater visualization, enhanced dexterity, precision, control and superior ergonomics. This very precise surgery only requires 5 small incisions (1cm) in the abdomen.
About the da Vinci Robotic System
The da Vinci Surgical System is powered by state-of-the-art robotic technology. The System allows your surgeon's hand movements to be scaled, filtered and translated into precise movements of micro-instruments within the operative site. The magnified, three-dimensional view the surgeon experiences enables him to perform precise surgery in complex procedures through small surgical incisions.
The da Vinci System enhances surgical capabilities by enabling the performance of complex surgeries through tiny surgical openings. The System cannot be programmed nor can it make decisions on its own. The da Vinci System requires that every surgical maneuver be performed with direct input from your surgeon. The da Vinci Surgical System has been successfully used in thousands of prostate cancer procedures world-wide.
For patients, there are numerous potential benefits including:
- Shorter hospital stay
- Less pain and less pain medication
- Less risk of infection
- Less blood loss
- Less scarring
- Faster and more complete recovery
- Quicker return to normal activities
Surgical Benefits:
- 3-D visualization provides the surgeon with a true 3-dimensional view of the operating field. This direct and natural hand-eye instrument alignment is similar to open surgery with all-around vision and the ability to zoom-in and zoom-out.
- Dexterity: the da Vinci Robotic System provides the surgeon with intuitive operative controls that allows the experienced surgeon to use his open surgery skills rather than having to use counter-intuitive motions typically required by a laparoscopic approach.
- Surgical Precision: permits the surgeon to manipulate instruments with such accuracy that the current definition of surgical precision is exceeded.
- Range of Motion: the robotic instruments offer the surgeon full range of motion and ability to rotate the instruments through tiny incisions.
- Ergonomics: the surgeon can sit in a comfortable position, allowing him to concentrate fully on the surgery.
- Improved Access: Surgeons perform complex surgical maneuvers through 1-cm ports, eliminating the need for large traumatic incisions.
Source: St Vincent's Clinic
Wednesday, 19 December 2007
Keyhole Surgery?
I have been thinking lately about the procedure that (hopefully) awaits me sometime in the new year - i.e. 'Keyhole Surgery'!
I say hopefully because the early results (PSA, Gleason Score, Biopsy and CT Scan) seemed to rule out this option. Let me explain.
All of the tests mentioned above, indicated that the cancer had spread beyond the 'capsule' of the prostate. This meant that 'cure' by removal of the tumour was not an option. The best case scenario, meant that I would undergo 'hormone therapy' and could look forward to 3-5 years of life!
Well ... something amazing occured from the time of the Bone Scan which followed only days after the CT Scan. No evidence of the cancer spreading beyond the capsule was found! This meant that a 'cure' became a possibility.
A subsequent blood test showed a 71% reduction in my PSA level even though the treatment was only a few weeks old!
If all goes well and according to plan; the hormone therapy will continue to reduce the size of the tumour and force it into remission. At some subsequent stage, a course of radiotherapy will be introduced to 'kill' the cancer and make surgery a viable option for a cure!
Given that my Urologist prefers to utilise a 'laproscopic surgical procedure' I reasoned that I should conduct some research on this technique. What follows is a video depicting the procedure itself and the benefits it entails. Prostate Cancer - Video
Saturday, 8 December 2007
My PSA Reading
Updated: Now includes a video presentation on PSA Readings. Click on the video link below; also visit the host site for more educational videos.
On Friday 30th November, I attended our local GP's surgery for another blood test. Specifically, this blood test was to:
On Friday 30th November, I attended our local GP's surgery for another blood test. Specifically, this blood test was to:
- Determine whether my PSA reading [previously 84.8] had begun to drop. Thus showing that the hormonal therapy I had been undergoing for a little over 4 weeks, had in fact begun to have the desired affect; and
- Determine whether my cholesterol readings had improved as a result of my [now] 'extremely healthy' diet.
I was told that it is quite normal for the PSA to rise after a trans-rectal biopsy. I was also told to bear in mind, that I had only begun the hormone therapy 4 weeks prior to the blood test. [Orally for the first two weeks (i.e. Androcur - anti-agonist), followed by an LHRH implant and continuing the oral regime until two weeks after the implant procedure].
Well ... the results are in! And, as often happens, there is good news and bad news. The bad news relates to the fact that one of my readings had not altered at all!
My 'cholesterol level' has refused to budge!!
The good news ... well my PSA levels have gone down - very significantly! My previous PSA was 84.8. It is now 12 [only one month after receiving the LHRH implant]!!
For more on the significance of a PSA test I invite you to watch the following video, 'Prostate Cancer Predictors - PSA Test'. Other educational videos in the series are available at: Sutter Health.
Thursday, 6 December 2007
Latest Australian Cancer Statistics Released
Cancer in Australia: an overview, 2006 presents comprehensive national data on cancer incidence and mortality in Australia, and hospitalisation trend data from 2000-01 to 2004-05.
The report provides 2006 projections on incidence and 2003 data for cancers by site, age and sex, with summary data for each state and territory. Prostate cancer and cancer differentials for rural areas analysed.
The information in this report is supported by more detailed information in cancer incidence and mortality data cubes and workbooks on the AIHW's website. Cancer in Australia: an overview, 2006 is an important reference from the Cancer series for all those interested in the health of Australians. Authored by AIHW.
Full publication (1020KB PDF)
Preliminary material (180KB PDF)
- Half title and verso pages
- Title and verso pages
- Contents
- Contributors
- Summary
Sections
Introduction (96KB PDF)
- What is cancer?
- Cancer surveillance in Australia
- National Cancer Statistics Clearing House
- Cancer data on the AIHW website
Incidence and mortality (318KB PDF)
- Introduction Estimates of cancer incidence and mortality in 2006
- Incidence in 2003
- Incidence of lymphoid and haematopoietic neoplasms
- Cancer incidence in the states and territories, 1999-2003
- Incidence trends 1983-2003
- Mortality in 2003
- Mortality trends 1983-2003
- Cancers attributed to smoking and excessive alcohol consumption
Hospitalisation (158KB PDF)
- Introduction
- Main findings
Prostate cancer in profile (213KB PDF)
- Introduction
- Incidence and mortality
- Drivers of growth in new cases diagnosed
- Implications for projected incidence of prostate cancer
- International comparison
- Key statistics on prostate cancer
Regional cancer differentials (179KB PDF)
- Introduction
- Incidence differentials
- Mortality differentials
End matter (265KB PDF)
- Appendixes
- WHO classification of lymphoid and haematopoietic neoplasms
- Methods
- Population data
- Cancer registration in Australia
- Cancer registries contact list
- Data sources
- Abbreviations and glossary
- References
- Related state and territory cancer registry publications
- List of tables
- List of figures
Tuesday, 20 November 2007
Injection of LHRH Implant
Attended the Urologist's Surgery in St Leonards to receive an injection of a luteinising hormone-releasing hormone (LHRH)- specifically a 'Goserelin acetate implant' (the generic name) or Zoladex (the product name).
For a video demonstration of the proper technique for administering Zoladex please click here.
What is hormonal therapy?
Hormonal therapy treats prostate cancer by decreasing the supply or blocking the action of male hormones (androgens) such as testosterone that encourage prostate cancer growth. Hormonal therapy can slow the growth of the cancer and reduce the size of the tumour(s).
The following are the main types of hormonal therapy which may be used in prostate cancer:
Orchidectomy or surgical castration
Orchidectomy is the surgical removal of the testes, which are the organs that produce 95% of the body’s testosterone. Since the testes are the major source of testosterone in the body, this procedure is classified as hormonal therapy rather than surgical treatment. The aim is to deprive the prostate cancer cells of testosterone, thereby causing the cancer to shrink and/or to prevent further growth of the tumour. The testicles are removed through a small incision in the scrotum.
Figure 1: Orchidectomy
Most men who undergo surgical castration will experience a loss of sexual desire and impotence. In addition, hot flushes frequently occur. Surgery is permanent and the effects cannot be reversed.
Medical castration
Medical castration is achieved by using luteinizing hormone-releasing hormone agonists (LHRHa’s) (e.g. goserelin - ‘Zoladex’, leuprolide). They work by ‘switching off’ the production of male hormones from the testicles by reducing the levels of a hormone called luteinizing hormone. This hormone, is produced by the pituitary gland (a pea-sized gland located at the base of the brain which regulates and controls the release of hormones which directly or indirectly affect most basic bodily functions).
LHRH implants work just as well as orchidectomy in advanced diseasebut do not involve surgery. They are also used in combination withradiotherapy as adjuvant therapy for earlier disease.They are given by injection either under the skin (subcutaneous) or into the muscle (intra-muscular). The injections are generally given every month or every 3 months.
Most men who undergo medical castration will experience a loss of sexual desire and impotence. In addition, hot flushes frequently occur. However, medical castration is potentially reversible. If treatment is stopped, testosterone is produced once again.
LHRH Agonists
The 'original' 3.6mg formulation of Zoladex has been available since 1989 as a monthly implant. The new formation, 10.8 mg goserelin acetate implant given every three months, offers greater convenience to subjects choosing treatment with a luteinizing-hormone-releasing hormone (LHRH) analogue.
The 'original' 3.6mg formulation of Zoladex was shown to be as effective as orchiectomy (surgical castration) in controlling the spread of prostate cancer, thus offering men a choice between medical treatment and surgery.
This 12-13 week formulation of Zoladex is, a white to cream coloured, cylindrical implant with a 1.5 mm diameter that contains 10.8 mg of goserelin. Given by subcutaneous injection, into the anterior abdominal wall, the biodegradable implant slowly dissolves, delivering therapeutic levels of the drug continuously over a period of 12 weeks. This means an injection will be required every 12 to 13 weeks.
Ongoing Treatment
The success of this treatment (in my case Goserelin 10.8mg every 3 months) will be monitored by regular blood tests which look specifically at the Prostate Specific Antigen (PSA) readings. A lower PSA indicates that the treatment is working.
Subsequent to this treatment and dependent upon how my body reacts to the LHRH, radiotherapy will then be considered.
As with most things, there is a down side to this treatment. Men receiving Hormone therapy may have side effects from the withdrawal of testosterone. This could include: increased tiredness, erection problems, reduced sex drive, weight gain, hot flushes, breast tenderness, depression, and loss of bone strength (osteoporosis).
These side effects can significantly affect the way a man functions, however there are treatments that can minimise the impact of the side effects.
In order to monitor the progress of the Hormone Treatment, I have been scheduled to have two further blood tests (December and February) with the expectation that my PSA readings will go down. At present my PSA is 84.8. Normal readings for someone my age would be between 0 and 3.5 - still a way to go!
Monday, 12 November 2007
Making Decisions at Time of Diagnosis
The following article is excerpted from PSA Rising - Prostate Cancer Survivor (News, Info & Support) in the hope readers may become more informed. I would encourage all our readers to visit the author's website.
Slow down and take a breath before making any decisions about treatment. Prostate cancer can develop into a deadly disease. But for most men at time of diagnosis today, prostate cancer is not usually in need of immediate, emergency treatment. Most likely, you'll have time -- days, weeks and in some cases months -- to gather information and to decide among several treatment options.
Even so, a recent study found that men with stage T2 prostate cancer who had to wait nine weeks or more before receiving treatment by radiotherapy had a higher rate of recurrence unless they received a higher dose of radiation.
Your first task, with your doctors' help, is to get information about your Gleason grade and stage of prostate cancer and your PSA velocity.
Your second task is learn about which treatments offer you best outcomes in long-term survival and side effects.
Medical information about prostate cancer may be new to you. Your body is on the line, and new information may be hard to absorb. This may be the most complex decision you've ever made. Do what you can to make it easier on yourself.
A few practical steps will help you to get organized and on track:
Slow down and take a breath before making any decisions about treatment. Prostate cancer can develop into a deadly disease. But for most men at time of diagnosis today, prostate cancer is not usually in need of immediate, emergency treatment. Most likely, you'll have time -- days, weeks and in some cases months -- to gather information and to decide among several treatment options.
Even so, a recent study found that men with stage T2 prostate cancer who had to wait nine weeks or more before receiving treatment by radiotherapy had a higher rate of recurrence unless they received a higher dose of radiation.
Your first task, with your doctors' help, is to get information about your Gleason grade and stage of prostate cancer and your PSA velocity.
Your second task is learn about which treatments offer you best outcomes in long-term survival and side effects.
Medical information about prostate cancer may be new to you. Your body is on the line, and new information may be hard to absorb. This may be the most complex decision you've ever made. Do what you can to make it easier on yourself.
A few practical steps will help you to get organized and on track:
* Bring someone with you to your appointments.
* Bring a notepad and tape recorder to the appointments.
* At home, set up a calendar, a phone number book and a file box (or file drawer) and a loose-leaf ring binder.
* Use the file for your new medical records, medical bills and health insurance papers, and for print-outs from reliable sources like medical journals.
* Use the binder to list your own questions and to jot down your doctors' replies. If you prefer to use a small notebook in the doctor's office, tape your notes into the binder when you get home.
* If you wish, jot down or clip and paste in info from sources like books, pamphlets and computer print outs. Family, friends and support group members may be able to help you gather and sift information.
* Select the most important points that may affect you. These are points you want to discuss with your doctors.
* Nothing is too dumb (or too clever) to ask.
* If you need privacy to talk to your doctor about impact of various treatments on sexual desire, lovemaking and erections, or bladder and bowel control, say so.
* Expect any doctor you would care to allow to treat you to be interested in your overall health and well being and to see you as an individual with cancer not as a statistic or person of a certain age.
* Don't underestimate the value of statistics and "cancer numerology." Graphs and studies tell a story about human beings.
*Seek a second opinion about your biopsy.
*Seek second opinions and, if needed, third opinions or more about your treatment options.
*If you're considering either surgery or radiotherapy (external beam or brachytherapy), find a practitioner who has done the procedure many times. Usually, this means going to a major hospital recognized as a national cancer center. Prostate cancer has no single best treatment. But evidence has shown that some practitioners are "artists" and quantity of experience also counts. Quality of equipment used (especially for external beam radiation) is key. Urologists (surgeons) and radiologists who are leaders in their field and who have treated the most patients do a better job.
* Take some time to consider the information you have been given before you make a final decision.
In many situations in life we don't make optimal choices, "we choose the first reasonable option, a strategy known as satisficing." Satisficing is OK if there's no big penalty for choosing wrong.
In life and death situations, many people do not carefully gather all available information and come to a rational decision. A study of fire commanders found that they "took the first reasonable plan that came to mind and did a quick mental test for problems. If they didn't find any, they had their plan of action."
Some of the best cancer doctors are trained to be able to "take the first reasonable plan," do the quick mental test for problems and, if none jump out, to sell that plan of action to the patient.
But these people already know most of the available information.
Reflection
After you've gathered and studied a full range of good information, it's fine to sleep on it and let the decision come naturally.
A Dutch study has found that people can think unconsciously and -- surprisingly -- that for complex decisions unconscious thought is actually superior.
Lead researcher Dr Ap Dijksterhuis told the BBC: "The take-home message is that when you have to make a decision, the first step should be to get all the information necessary for the decision.
"Once you have the information, you have to decide, and this is best done with conscious thought for simple decisions, but left to unconscious thought - to 'sleep on it' - when the decision is complex."
It's your body and your life. You want to stay healthy, productive and active for as long as you can. More than one type of treatment might work equally well for you. For some men, no immediate treatment may be the best decision. But don't lose sight of the fact that you probably have just one good chance of a cure. It's worth bucking the urge to "satisfice" too soon. Keep reading and asking questions. Do the best that you can to make the right choice for yourself. Don't sell yourself short. Then, when you wake up with the decision "made" by your gut, or your unconscious mind, you can accept that and go forward without looking back.
The following video may prove useful in trying to understand the range of options available for treating Prostate Cancer today.
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