9. PROSTATE CANCER TREATMENT Jennifer Lynn Reifel, MD
The core references for this chapter include the textbook CancerTreatment (Haskell, 1995), CancerNet PDQ Information for Health Care
Professionals (National Cancer Institute, 1996) on prostate cancer and recent
review articles. Recent review articles were selected from a MEDLINE search
identifying all English language review articles published on prostate cancer
since 1992 (Garnick, 1993; Garnick and Fair, 1996a; Garnick and Fair, 1996b;
Daneshgari and Crawford, 1993; Gibson, 1993; Perez et al., 1993). Where the
core references cited studies to support individual indicators, these have
been included in the references. Whenever possible, we have cited the results
of randomized controlled trials. However, a dearth of such studies in the
literature has necessitated that we rely heavily on case analyses and expert
opinion to develop quality indicators. IMPORTANCE
Prostate cancer (adenocarcinoma) is now the most common cancer in men.
In men age 75 and older, prostate cancer and benign prostatic hypertrophy
together account for about ten percent of office visits each year. In 1993,
the annual incidence of prostate cancer was estimated to be 165,000. Since
August 1994, when the FDA approved the use of prostate specific antigen (PSA)
testing in association with digital rectal examination for early detection of
prostate cancer, increasing numbers of tumors have been diagnosed and treated
before they were palpable. As a result, it is estimated that 317,000 new
cases will be diagnosed in the United States alone in 1996 (Parker et al.,
The natural history of prostate cancer is highly variable. One-third of
men older than 50 will have prostate cancer discovered incidentally at
autopsy; however, clinically apparent prostate cancer develops in only ten
percent of men during their lifetime (Epstein et al., 1986).
Because of the variability in its virulence, and the lack of controlled
trials for its treatment, the management of prostate cancer remains confusing
Screening for prostate cancer remains extremely controversial. Our
rationale for not developing quality indicators for prostate cancer screening,
including PSA and digital rectal exam, are discussed in Chapter 8.
However, in spite of a lack of consensus, screening for prostate cancer
with PSA is rapidly increasing and is expected to dramatically increase the
numbers of asymptomatic localized cancers diagnosed in the next few years. DIAGNOSIS
Symptoms of urinary obstruction (urgency, nocturia, frequency of
urination, and hesitancy) due to an enlarged prostate are the most common
presenting symptoms of prostate cancer. These symptoms also occur with benign
prostatic hypertrophy. Other less common presenting symptoms of prostate
cancer are new onset impotence and less firm penile erections. If the
physical exam in a man with symptoms of urinary obstruction is not suggestive
of prostate cancer, often the diagnosis will be made incidentally upon
pathological examination of tissue obtained during transurethral resection of
the prostate (TURP) performed to relieve obstructive symptoms. The quality
indicators for the evaluation of obstructive urinary symptoms is discussed in
Volume III of this series (see Chapter 4: Benign Prostatic Hyperplasia).
Occasionally, patients present with complaints related to distant
metastases, usually back pain from bony lesions, and rarely cord compression
or acute urinary retention. When a work-up for back or other bone pain
reveals metastatic lesions in a man, a diagnosis of prostate cancer should be
pursued because it is the most treatable of the metastatic adenocarcinomas.
Further evaluation should include a digital rectal examination of the prostate
and PSA (Indicator 1) (Leonard and Nystrom, 1993).
Staging of a cancer refers to the process of determining the presence or
absence of factors in a given patient in order to make predictions about the
patient's prognosis and make recommendations for treatment. Factors
considered useful for predicting prognosis in prostate cancer include the
stage and histologic grade of the tumor, the level of the PSA, as well as the
patient's age and comorbid conditions (Montie, 1996). Age and comorbidity are
important in treatment decisions in prostate cancer because untreated
localized prostate cancer has a prolonged course with ten year disease-
specific survival rates of approximately 85 percent and ten year overall
survival rates of approximately 60 percent (Johansson et al., 1996; Whitmore,
1990; Adolffson, 1993). Therefore, no treatment may be indicated for patients
who are not expected to live longer than ten years from the time of the
diagnosis of their localized prostate cancer. For this reason we have limited
the quality indicators for the treatment of localized prostate cancer with
curative intent to men who are expected to live ten years or longer. We have
done this by excluding men over 65, as well as men with known coronary artery
disease or a second cancer, except for skin cancer (Indicator 5).
The main purpose for staging evaluations when a diagnosis of prostate
cancer has been made is to determine if the disease is localized (and thus
potentially curable), regionally advanced (and therefore not amenable to
surgery with curative intent), or metastatic (not curable).
Two staging systems exist for prostate cancer: the "conventional" or
Jewett system, and the American Joint Committee on Cancer/International Union
Against Cancer TNM system (see Table 9.1). Below, we review the evidence for
the various modalities that have been used to attempt to evaluate prostate
cancer stage. Radical prostatectomy with pelvic lymphadenectomy is generally
considered the gold standard against which other staging strategies are
Experts recommend obtaining a serum PSA level as part of a staging
evaluation for prostate cancer (Garnick and Fair, 1996; Montie, 1996;
Oesterling et al., 1993). PSA correlates well with the pathological stage of
the tumor: 70 to 80 percent of men with PSA less than 4 ng/ml have localized
prostate cancer, and most men with PSA greater than 50 ng/ml have positive
pelvic lymph nodes at surgery. However, 60 percent of men with localized
prostate cancer have a PSA between 4 and 50 ng/ml so it is not specific enough
to be used alone for staging but can be a useful adjunct to other staging
evaluations (Partin and Oesterling, 1994; Oeesterling et al., 1993) (Indicator
Digital rectal exam (DRE) is the primary means of determining if the
cancer appears to be organ confined (Stage A or B) or has spread locally
beyond the confines of the prostate gland (Stage C). However, the sensitivity
of DRE for detecting disease that has spread beyond the prostate is only
reported to be 10 to 30 percent (Hricak et al., 1987). While transrectal
ultrasound has a greater sensitivity for detecting cancer that has spread
beyond the confines of the prostate than DRE (66 percent), its specificity is
only 46 percent (Rifkin et al., 1990). CT Scan has been shown to have a
comparable sensitivity of 67 percent with a specificity of 60 percent for
detecting prostate cancer that has spread locally beyond the prostate (Platt
et al., 1987). MRI is only slightly better than CT scan at identifying
locally invasive prostate cancer, with a reported sensitivity of 75 percent
and reported specificity ranging from 57 percent to 88 percent (Rifkin et al.,
Identifying patients who have prostate cancer that has already spread to
pelvic lymph nodes (Stage IV/D) is even more problematic than identifying
locally invasive prostate cancer (Stage III/C). Neither physical exam nor
transrectal ultrasound are useful in evaluating pelvic lymph nodes. The
sensitivity of CT scan for identifying pelvic lymph nodes involved with
prostate cancer is zero percent (Platt, Bree, and Schwab, 1987). MRI has a
sensitivity of only four percent for identifying positive lymph nodes in
prostate cancer patients (Rifkin et al., 1990). Because of their poor
performance in predicting patients with cancer that has spread beyond the
prostate (Stage III/C and Stage IV/D), we do not recommend that DRE,
transrectal ultrasonography, CT scan, or MRI be included in a quality
indicator for the staging evaluation of prostate cancer.
A radionuclide bone scan is generally performed routinely to rule-out
bone metastases (Stage IV/D) prior to initiating treatment in most patients
with prostate cancer (Garnick, 1993; McGregor et al., 1978). A study
evaluating the relationship of the PSA level to bone scan findings in 852
patients with prostate cancer found that no patients with a PSA less than 8.0
ng/ml had bone scan evidence of metastases. Furthermore, 0.5 percent of
patients with a PSA less than 10 ng/ml had a positive bone scan, and 0.8
percent of patients with a PSA less than 20.0 ng/ml had a positive bone scan
(Oesterling et al., 1993). In accordance with these data and expert opinion
(Garnick and Fair 1996; Montie 1996; McGregor et al., 1978; Oesterling et al.,
1993), we recommend two quality indicators for the staging of prostate cancer.
First, all patients with a new diagnosis of prostate cancer should have a PSA
checked within one month of diagnosis or prior to treatment, whichever comes
first (Indicator 2). Second, patients with a new diagnosis of prostate cancer
and a PSA greater than 10 ng/ml should have a radionuclide bone scan within
one month of diagnosis or prior to treatment (Indicator 3). TREATMENT Minimal Disease (Stage 0/A1)
No randomized controlled trials have been performed comparing treatment
with no treatment in patients with Stage 0/A1 prostate cancer. In case
series, rates of disease progression of 5 to 16 percent have been reported
with a mean time to progression of six to nine years. However, the survival
of men with Stage 0/A1 prostate cancer is comparable to the expected survival
of men of similar ages in the general population (Epstein et al., 1986; Lowe
and Listrom, 1988; Roy et al., 1990; Thompson and Zeidman, 1989; Zhang et al.,
1991). Because the treatments for localized prostate cancer are associated
with significant morbidity and survival does not appear to be affected in
Stage 0/A1 disease, our proposed quality indicator requires that no treatment
be offered to men age 60 and older with Stage 0/A1 disease (Catalona and
Basler, 1993; Fowler et al., 1993)(Indicator 4). Since disease progression
increases with time, some experts do recommend treating younger men (under age
60) with Stage 0/A1 disease (Catalona and Basler, 1993; Fowler et al., 1993;
Epstein et al., 1986). However, because there is no consensus regarding the
management of Stage 0/A1 disease in men younger than 60, we have limited our
quality indicator to men 60 and older. Localized Disease (Stage I & II / A2 & B)
Treatment of localized prostate cancer remains controversial. The
greatest hope for curing prostate cancer is with radical prostatectomy or
radiation therapy while it is still localized. The only randomized controlled
trial of radical prostatectomy with no treatment failed to demonstrate a
survival advantage with radical prostatectomy. However, the reliability of
this result is often questioned because the sample size was only 142, and only
111 of 142 patients included in the trial were available for analysis
(Graverson et al., 1990). Several non-randomized studies of expectant
management ("watchful waiting") of patients with localized prostate cancer
have demonstrated ten year disease-specific survival rates of approximately 85
percent and ten year overall survival rates of approximately 60 percent.
These results are comparable to those obtained with radical prostatectomy and
radiation therapy (Perez et al., 1996; Bagshaw et al., 1993; Johansson et al.,
1992; Whitmore, 1990; Adolffson, 1993). The only randomized controlled trial
comparing radical prostatectomy with radiation therapy used time to first
treatment failure as its primary endpoint and showed an advantage for radical
prostatectomy (Paulson et al., 1982). But the study has been criticized
because the patients treated with radiation were not surgically staged (Hanks,
1988). At the 1987 NIH Consensus Conference on Prostate Cancer, no consensus
regarding treatment was reached, and none has been reached since. Still, most
American experts recommend definitive treatment for localized prostate cancer
for men with a life-expectancy greater than ten years (Gibbons 1993; Bagshaw
et al., 1993; Paulson et al, 1982; Perex et al. 1993; Garnick 1993; National
Radical prostatectomy is usually performed via a retropubic approach and
newer surgical techniques allow sparing of the neurovascular bundle in order
to decrease the incidence of incontinence and impotence. Usually, a pelvic
lymphadenectomy is performed prior to the prostatectomy, and the surgeon only
proceeds if the lymph nodes are negative for metastatic disease on frozen
section. Post-operative complications include incontinence, urethral
stricture, rectal injury, impotence, and the morbidity and mortality
associated with general anesthesia and a major surgical procedure (30-day
mortality of two percent in one study of 10,600 radical prostatectomies).
Reports in the literature of complication rates after radical prostatectomy
are quite varied. In one large case study of men undergoing the nerve-sparing
radical prostatectomy, significant incontinence occurred in six percent of
men, while 35 to 60 percent of men who were sexually potent before surgery
became impotent following the procedure (Catalona and Basler, 1993). However,
in a national survey of Medicare patients who underwent radical prostatectomy
in 1988-1990, over 30 percent of men reported the need for pads or clamps for
incontinence, and about 60 percent reported having no erections since surgery,
with 90 percent reporting no erections sufficient for intercourse during the
month prior to the survey (Fowler et al., 1993).
While radioactive implants are used to treat prostate cancer, the most
common technique currently in use today is external beam radiation (Garnick,
1993; Bagshaw et al., 1993; Perex et al., 1993). Using a linear accelerator,
67 to 70 Gy is delivered to the prostatic bed and periprostatic tissues over
six to seven weeks, with the pelvic lymph nodes receiving approximately 50 Gy.
If radiation therapy is chosen as definitive treatment, lymphadenectomy is
usually not performed, resulting in those cases which are clinically Stage I
or II/A or B but pathologically Stage III or IV/ C or D not being identified.
This creates difficulties when trying to compare the outcomes of clinical
trials of patients treated with radiation therapy with those treated with
radical prostatectomy. The complications of radiation therapy, though
infrequent, include diarrhea, proctitis, cystitis, hematuria, rectal bleeding,
anal stricture, urethral stricture, rectal ulcer, bowel obstruction. These
complications are usually reversible and rarely become chronic (Bagshaw et
al., 1993; Garnick, 1993). Sexual potency is generally preserved in the
short-term with radiation therapy, but may diminish over time.
Given the lack of clear evidence in favor of a particular treatment for
localized prostate cancer, the variable complication rates after radical
prostatectomy and radiation therapy, and the need for patients to have the
option of a curative treatment when presenting with cancer at a curative
stage, we propose a quality indicator specifying that men under age 65 with
Stage II/A2&B should have been offered radical prostatectomy or radiation
Locally Advanced Disease (Stage III/C)
The optimal treatment for patients with locally advanced prostate cancer
is even less clear than that for localized disease. The results of radical
prostatectomy in Stage III/C patients are greatly inferior to the results in
localized disease (Gibbons, 1993). As surgical removal of the gland is often
difficult in Stage III/C prostate cancer, radiation therapy is generally
selected for patients with clinical Stage C prostate cancer. The ten year
overall survival with both radical prostatectomy and radiation therapy for
Stage III/C prostate cancer is about 35 percent. Neoadjuvant androgen
ablation therapy has had some success in "downstaging" patients so that PSA
levels become undetectable and the remaining cancer is organ confined in more
patients at surgery (Labrie et al., 1994; Fair et al., 1993; Gleave et al.,
1996). And while one randomized study of radiation therapy with and without
androgen ablation showed an advantage in progression-free survival at five
years for the arm that received androgen ablation, to date, neoadjuvant
androgen ablation has not been shown to provide an advantage in overall
survival (Pilepich et al., 1995). Another treatment option for Stage III/C is
early androgen ablation therapy (which will be discussed in the Advanced
Disease section); but there is no evidence that it prolongs survival. Still
another option is expectant management and treatment when necessary to relieve
Given the poor ten year survival with locally advanced disease, many
experts would recommend more aggressive treatment in younger men (less than
age 60) (Haskell, 1995; National Cancer Institute, 1996; Garnick and Fair,
1996a; Gibbons, 1993; Bagshaw et al., 1993). If pathologic staging confirmed
Stage III/C disease, many experts would recommend radical prostatectomy, if
technically feasible, or radiation therapy with curative intent.
As there is little consensus on how to treat asymptomatic patients with
Stage III/C prostate cancer, we do not recommend a quality indicator for the
treatment of this group of patients. Advanced Disease (Stage IV/D)
The most common symptoms of advanced prostate cancer originate from the
urinary tract or from bone metastasis. Historically, more than 50 percent of
patients present with bone metastases (prior to the advent of PSA screening)
(Huggins and Hodges, 1941). Patients with bone pain, visceral involvement,
impending cord compression, obstructive urinary symptoms or hydronephrosis
should receive androgen ablation therapy for palliation. Experts also
generally recommend treating patients with asymptomatic advanced prostate
cancer with androgen ablation therapy; however, the data for this are not
conclusive. In randomized controlled trials, androgen ablation therapy
appears to slow disease progression in Stage IV/D prostate cancer, and may
improve overall survival; however, it is not clear if starting androgen
ablation therapy early, while patients are still asymptomatic, has an
advantage over waiting until patients develop symptoms.
There are multiple approaches to androgen ablation therapy including
orchiectomy alone, monotherapy with an luteinizing hormone-releasing hormone
(LHRH) analogue,1 monotherapy with non-steroidal antiandrogen therapy,2 or
maximal androgen blockade (either orchiectomy or an LHRH analogue and
The major side-effects of all androgen ablation treatments include
impotence (almost universally), breast tenderness, and hot flashes. In
addition, with LHRH analogues, many patients experience a flare of bone pain
and other symptoms after initiating treatment. Since 1941, orchiectomy has
been considered the standard ablation treatment for advanced prostate cancer;
however, it has not been compared to no treatment in a randomized trial, nor
has it been shown to prolong survival (Huggins and Hodges, 1941). The only
randomized placebo-controlled trial of androgen ablation compared DES with
placebo. The VACURG study showed a slowing of disease progression in Stage
IV/D patients treated with DES 5 mg/day compared with placebo, but overall
survival was worse in the group treated with DES (diethylstilbestrol), largely
due to an increase in cardiovascular mortality (Veterans Administration,
1967). As treatment with DES in this study was associated with an increase in
cardiovascular complications and cardiac mortality, DES has been largely been
replaced by the newer drugs (LHRH analogues and antiandrogens). Randomized
controlled trials of bilateral orchiectomy, the LHRH analogue goserelin, and
DES have shown them all to be equally effective in terms of slowing disease
progression (Peeling, 1989; Vogelzang et al., 1995; Kaisary et al., 1991).
However, none of these studies answer the specific question of whether
immediate therapy has a survival advantage over deferred therapy with androgen
blockade for advanced prostate cancer. A randomized trial is currently in
progress to try to answer this question (EORTC protocol 30846, 1986).
1 Chronic administration of LHRH analogues causes an inhibition of luteinizing
hormone and follicle stimulating hormone release and subsequently a suppression oftesticular testosterone secretion similar to that obtained by surgical castration. The commonly used LHRH analogues in the United States are:
leuprolide (Lupron) 1 mg subcutaneous injection daily or 7.5 mgintramuscular injection monthly or 22.3 mg intamuscular injection every 3months
b. goserelin acetate (Zoladex) 3.6 mg depot injection monthly or 10.8 mg
2The antiandrogens block the effect of androgens at the receptor level in the
prostatic tissue. The antiandrogens commonly used in the United States include:
flutamide (Eulexin) 250 mg by mouth three times a day
bicalutamide (Casodex) 50 mg by mouth daily
nilutamide (Anandron) 300 mg by mouth daily for the first month oftreatment followed by 150 mg by mouth daily thereafter.
Some experts advocate maximal androgen blockade therapy with the addition
of an antiandrogen to either orchiectomy or an LHRH analogue alone (Labrie et
al., 1993). Maximal androgen blockade is thought to be of benefit because,
even in the face of medical or surgical castration, adrenal production of
testosterone is able to maintain dihydrotesterone levels in the testes of up
to 40 percent of normal. The antiandrogens act on the prostate tissue to
counter the effect of dihydrotestosterone at the receptor level. Several
randomized controlled trials have shown increased progression free survival of
three to six months and a survival benefit of approximately six months in
patients treated with maximal androgen blockade as compared with monotherapy
with an LHRH analogue or orchiectomy, though it only reached statistical
significance in two of the studies (Crawford et al., 1989; Keuppens et al.,
1990; Beland, 1990; Navaratil, 1987; Janknegt et al., 1993). A subgroup of
patients with good performance status and minimal disease (lymph node
involvement only) in the NCI randomized trial comparing leuprolide with and
without flutamide had a pronounced survival advantage of 20 months (61 versus
41.5 months) when treated with maximal androgen blockade"(Labrie et al.,
1993). However, overall the results overall are mixed, and two meta-analyses
of monotherapy with LHRH analogues or castration compared with maximal
androgen blockade showed no survival advantage for maximal androgen blockade
(Bertagna et al., 1994; Prostate Cancer Trialists’ Collaborative Group, 1995).
Therefore, our quality indicator does not state a preference for maximal
androgen blockade over other methods of androgen ablation.
Monotherapy with an antiandrogen is another approach that has been
advocated by some experts because it is associated with fewer side-effects
(Soloway and Matzkin, 1993). While breast tenderness often still occurs with
the antiandrogens, along with occasional nausea and diarrhea, libido and
potency, when present before therapy, are generally maintained. Randomized
controlled trials comparing monotherapy with an antiandrogen to standard
androgen blockade approaches are lacking. In several small randomized trials,
flutamide and cyproterone acetate have produced objective responses equal to
or greater than DES; yet, no studies have compared patients' survival with
these agents (Pavone-Macaluso et al., 1986; Lund and Rasmussen, 1988). Given
the absence of data, monotherapy with antiandrogens cannot be considered a
standard therapeutic approach for advanced prostatic cancer; however,
individual patient preferences may make it the treatment of choice in specific
In summary, since patients with Stage IV/D prostate cancer may have a
benefit to both progression free survival and overall survival from treatment
with androgen ablation, but the evidence in the literature does not clearly
support one treatment over the others, we propose as a quality indicator that
all men with Stage IV/D prostate cancer be offered at least one of the
androgen ablative therapies -- orchiectomy, LHRH analogues, or antiandrogens
The advantages of orchiectomy over medical androgen ablation include
better patient compliance and lower cost. The disadvantages are the surgical
morbidity, the irreversibility of the hormone ablation (and therefore
permanence of the associated side-effects), and the psychological effect on
the patient of losing his testes. Because it is important for patients to
have a choice of treatments, especially when one of them may be
psychologically distressing to the patient and equally efficacious
alternatives exist, we have developed a quality indicator to ensure that
patients who undergo orchiectomy were given a choice. The proposed indicator
requires documentation in the patient’s chart that he was offered medical
androgen ablation as an alternative therapy (Indicator 7). Hormone Refractory Prostate Cancer
Prostate cancer that progresses while on androgen ablation therapy is
termed hormone refractory prostate cancer. Once this occurs, treatment
options are limited. A patient being treated with monotherapy when evidence
of progression is noted (be it orchiectomy, LHRH analogues, antiandrogens, or
DES), especially if symptoms are present, should be given a trial of the
maximal androgen blockade. Even when patients progress on maximal androgen
blockade, many physicians continue androgen ablation therapy because
susceptible cancer cells may still be affected. Other treatment options that
exist for hormone refractory prostate cancer include: stopping the
antiandrogen (which occasionally produces disease remission), suppression of
adrenal androgen production with high dose ketoconazole or aminoglutethamide,
estramustine, suramin, or low dose steroids. If patients are asymptomatic and
have hormone refractory prostate cancer, the aforementioned approaches can be
tried; however, there is no evidence that they delay progression or prolong
survival. Thus, many physicians wait until patients have symptoms before
instituting any further treatment. If patients have symptoms from prostate
cancer that is hormone refractory, any of the above approaches may be used for
palliation as well as for trying to slow disease progression. There is
insufficient evidence for us to recommend a quality indicator for the
treatment of hormone refractory prostate cancer. Pain from Bone Metastases
Patients with prostate cancer that has metastasized to the bone often
suffer from excruciating pain. A primary focus in the care of patients with
metastatic prostate cancer is pain control. It is not uncommon for patients
to require substantial narcotic analgesia. While narcotics generally provide
pain relief, it is often at a cost to quality of life by inducing somnolence,
dysphoria, or constipation. Pain may also be relieved, and narcotic
requirements reduced, by treatment with androgen blockade or the other
systemic therapies discussed in the hormone refractory prostate cancer
section. Palliative radiation therapy directed at sites of bony metastases
and strontium-89 have been shown to decrease pain and reduce narcotic
analgesia requirements in approximately 80 percent of patients. Quality
indicators related to pain management are covered in Chapter 11. Cord Compression
Spinal cord compression develops in approximately seven percent of men
with prostate cancer (Osborn et al., 1995). If a patient with prostate cancer
develops new or worsening back pain, or neurologic symptoms, spinal cord
compression by tumor should be considered. Back pain is the initial symptom
in 75 to 100 percent of patients with cord compression. A normal neurologic
exam in a patient with back pain does not rule out spinal cord compression.
In a study of patients with known malignancy, back pain, and a normal
neurologic exam, 36 percent had spinal epidural metastases on myelogram
(Rodichok et al., 1981). Plain films of the spine have a sensitivity of 91
percent and a specificity of 86 percent for predicting epidural metastases
(Grant et al., 1994). Bone scan has a sensitivity of 91 percent as well, but
a specificity of only 53 percent. The positive predictive value of neurologic
exam and plain films together varies between studies. False negative rates
for ruling-out cord compression with a normal neurologic exam and normal plain
film range between zero and 17 percent (Rodichok et al., 1981). The gold
standard for diagnosis of spinal cord compression is CT myelogram, and MRI
scanning has been shown to have comparable sensitivity and specificity.
Experts recommend that any patient with underlying prostate cancer who
develops new or worsening back pain and either has an abnormal neurological
exam or abnormal plain films of the spine or an abnormal bone scan undergo
either MRI or CT myelogram to rule-out cord compression (Rodichok et al.,
1981). As patients with new or worsening back pain who have a normal
neurologic exam with normal plain films or bone scan still may have up to a 17
percent risk of cord compression, experts recommend either proceeding on with
a MRI and CT myelogram as well or, alternatively, applying a more sensitive
test to rule-out metastatic bone disease, a CT scan of the spine (Rodichok et
al., 1981). If the CT scan of the spine does not show bony metastases, then
spinal cord compression is unlikely. However, if the CT scan of the spine
demonstrates metastases, then MRI or CT myelogram are required to evaluate for
We recommend that the quality indicator for the evaluation for spinal
cord compression include documentation of a normal CT scan of the spine or
performance of an MRI or CT myelogram (Indicator 8). No data exist in the
literature regarding the time frame in which these tests should be obtained
nor how long their results are still valid should new symptoms develop in the
future. The evaluation of cord compression is generally considered an
emergency, especially if neurologic deficits are present on exam, because the
most significant prognostic variables for recovery of function are the
severity of weakness at presentation and the duration of paraplegia before
treatment is initiated. Therefore, we have selected 24 hours as a
conservative maximum allowed time for obtaining an emergent diagnostic study
to rule-out cord compression. Given that the median survival for men with
hormone refractory prostate cancer is less than ten months (Garnick, 1993),
and 57 to 82 percent of men with prostate cancer who develop cord compression
are on hormone therapy (suggesting that they have become hormone
refractory)(Lund and Rasmussen, 1988), we have allowed for diagnostic tests
for cord compression that were obtained up to three months prior to the
presenting complaint to satisfy the indicator requirements.
If the radiologic studies are consistent with cord compression, treatment
with a minimum dose of dexamethasone (4 mg IV or PO every six hours) should be
instituted immediately, followed by palliative radiation therapy or
decompressive laminectomy (Lund and Rasmussen, 1988). Randomized controlled
trials of higher doses of dexamethasone have not shown an improvement in
neurologic recovery (Lund and Rasmussen, 1988). Experts recommend 72 hours of
dexamethasone therapy and then a rapid taper (Lund and Rasmussen, 1988).
Several retrospective studies comparing decompressive laminectomy alone with
decompressive laminectomy followed by radiation therapy have demonstrated a
benefit for the latter (Rodichok et al., 1981). When decompressive
laminectomy was compared with radiation therapy alone, no differences in
functional outcomes were observed; although, in a series of 22 patients with
rapidly progressing neurologic signs, 54 percent of those treated with
radiation therapy improved and none of those who underwent surgery improved
(Lund and Rasmussen, 1988). In general, radiation therapy is considered first
line therapy, though in selected cases, such as spinal instability,
decompressive laminectomy may be indicated. The dose of radiation in the
treatment of cord compression is not well established. Spinal cord toxicity
can occur at doses greater than 4500 cGy. No dose-response relationship has
been identified in the treatment of spinal cord compression secondary to
prostate cancer, but 3000 to 4000 cGy fractionated over two to four weeks is
commonly given. We propose that the quality indicator for the treatment of
cord compression in prostate cancer include treatment with a minimum dose of 4
mg dexamethasone orally or intravenously every six hours for at least 72
hours, and either radiation therapy (total dose between 3000 cGy and 4500 cGy)
or decompressive laminectomy within 24 hours (Indicator 9 and 10). FOLLOW-UP
Some experts recommend follow-up with DRE and PSA testing for patients
with Stage I to III prostate cancer every three months for one year, and every
six months thereafter (Garnick, 1993). In addition, prostate biopsy has been
recommended 18 to 24 months after completing radiation therapy or if the
findings on DRE change (Garnick, 1993). For patients with Stage IV prostate
cancer, experts recommend DRE and PSA testing every three months as well as a
bone scan, if clinically indicated (Garnick, 1993). However, these
frequencies are based upon the follow-up of patients in clinical trials and
may not be applicable in a clinical setting where the need to measure
treatment outcome at regular intervals does not exist. To date, no studies
have evaluated what constitutes necessary and appropriate follow-up of
patients with prostate cancer. In addition, there are no data to suggest that
diagnosing recurrence earlier leads to prolonged survival or better quality of
life asymptomatic patients. As such, follow-up for prostate cancer should be
tailored to a patient’s symptoms and needs. Therefore, we do not recommend a
quality indicator for the follow-up of patients with prostate cancer. Table 9.1 Definition of Stages of Prostate Cancer Definitions of Stage for Quality Indicators
incidentally found in _ 5 percent of tissue
resected by TURP and well-differentiated.
found at TURP in _ 5 percent of tissueresected with a Gleason sum score _ 4 ordescribed as well-differentiated.
incidentally found in >5 percent of tissue
prostate cancer localized to the prostate
resected by TURP and well-differentiated.
either:• found at TURP in >5 percent of tissue;
• found at TURP in >5 percent of tissue
incidentally found in >5 percent of tissue
Patient with prostate cancer confined to
the prostate palpable on physical exam.
Patient with prostate cancer that extends
including but not limited to the bones.
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The following criteria apply to men age 18 and older. Quality of Indicator Evidence Literature Benefits Comments Diagnosis
A patient without any previously known
50% of patients with prostate cancer present
lytic lesions, or with a notation that the
within the 12 months prior or the 3 weeksfollowing the date of the x-ray or bonescan:
Patients with a new diagnosis of prostate
Provides prognostic information and if <10ng/ml,
obviates need for bone scan. Only 0.5% of men
with PSA less than 10ng/ml had a positive bone
after diagnosis or prior to any treatment,
Patients with a new diagnosis of prostate
Identify patients with metastatic disease. 50% of
patients with prostate cancer present with bone
scan within 1 month or prior to initiation
of any treatment, whichever is first. Quality of Indicator Evidence Literature Benefits Comments Treatment
Men over 60 with minimal prostate
Case series demonstrate survival comparable to
cancer (Stage O/A1) should not be
b. LHRH analogue; 1 2c. antiandrogen;3d. radical prostatectomy;e. radiation therapy.
Case series suggest similar 10 year survival
(85%) for radical prostatectomy, radiation
therapy, and observation. While data from
or radiation therapy for localized prostate
randomized controlled trials showing a definite
cancer (Stage I & II/A2 & B) within 3
survival benefit for radical prostatectomy or
radiation therapy is lacking, most experts would
recommend offering such treatment to men with
a life expectancy greater than 10 years toprovide an option for potential curative therapy. Quality of Indicator Evidence Literature Benefits Comments
Randomized controlled trials of bilateral
orchiectomy and LHRH analogues have shown
them to be equally effective at slowing disease
progression. Results are mixed on whether
“maximal androgen blockade” with an LHRH
analogue and an antiandrogen has a survival
benefit over treatment with an LHRH analogue
antiadrogens is lacking; however, as they have
fewer side-effects, they may be appropriate for
1993; Crawford etal., 1989;Keuppens et al.,1990; Beland etal., 1990;Navaratil,1987; Janknegt etal., 1993;Bertagna et al.,1994; ProstateCancer Trialists'CollaborativeGroup, 1995;Soloway andMatzkin 1993;Pavone-Macalusoet al., 1986; Lund,1988
Quality of Indicator Evidence Literature Benefits Comments
Randomized controlled trials of bilateral
orchiectomy and LHRH analogues have shown
them to be equally effective at slowing disease
Vogelzang et al.,1995; Kaisary etal., 1991; EORTC,1986; Kirk, 1984;Labrie et al.,1993;Crawford etal., 1989;Keuppens et al.,1994; Beland etal., 1990;Navaratil, 1987;Janknegt et al.,1994; PCTCG,1995; Soloway,1993;Pavone-Macaluso et al.,1986; Lund, 1988
compression improves functional outcome. 17%
false negative rate for cord compression with a
normal neurologic exam and normal plain films of
• a CT scan of the spine without
blastic or lytic lesions orcompression fractures;
• a CT myelogram;• an MRI of the spine. Quality of Indicator Evidence Literature Benefits Comments
Prostate cancer patients with evidence of
followed by radiation therapy over laminectomy
alone and no difference between laminectomy
at a total dose between 3000cGy and 4500 cGy over 2-4weeks;
Prostate cancer patients with evidence of
RCTs of higher doses of dexamethasone have
offered at least4 mg dexamethazone IV
prior to the radiologic study or within 1
dexamethasone 4 mg IV or PO q sixhours for at least 72 hours.
1 LHRH Analogue: The commonly used LHRH analogues in the United States are:
a. leuprolide (Lupron) 1mg subcutaneous injection daily or 7.5 mg intramuscular injection monthly or 22.3 mg intamuscular injection every 3 monthsb. goserelin acetate (Zoladex) 3.6 mg depot injection monthly or 10.8 mg depot injection every 3 months
2 Antiandrogen: The antiandrogens commonly used in the United States include
a. flutamide (Eulexin) 250 mg by mouth three times a dayb. bicalutamide (Casodex) 50 mg by mouth dailyc.
nilutamide (Anandron) 300 mg by mouth daily for the first month of treatment followed by 150 mg by mouth daily thereafter
3 Coronary Artery Disease: A person shall be considered to have coronary artery disease if he has any of the following documented in the chart in progress notes,problem lists, or as discharge diagnoses:
d. coronary artery bypass graft surgerye. PTCAf.
g. a coronary angiogram with at least one vessel with an occlusion >70%
4 Second Cancer: A person shall be considered to have a second cancer if he has any of the following documented in the chart in progress notes, problem lists, oras discharge diagnoses:
a. any cancer other than prostate cancer except for basal cell and squamous cell skin cancersb. treatment with chemotherapy
6 Acute low back pain: No record of chronic low back pain pre-dating the prostate cancer diagnosis.
Dynamiskt Hcp – principen Grunden för det dynamiska handicapet är prestation. Prestation mäts med de rankingpoäng spelaren tar. För att få rankingpoäng måsta man under samma förutsättningar prestera bättre än andra spelare i match eller tävling. Rankingpoängen är därför oberoende av siffernivån. En spelare som presterar får mycket rankingpoäng och därför lägre hcp.
UC Center Program Courses - Fall 2011 PCC 117. Media in France and the European Union Prof. Joav Toker email: firstname.lastname@example.org Office Hours By appointment COURSE DESCRIPTION The course will explore and critically analyse major institutions, actors and trends in contemporary French Media and attempt to situate them in the larger contexts of “unifying” Europe and “global