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ABSTRACT: After a surge in the incidence of prostate carcinoma in the early 1990s, diminishing rates of mortality became apparent in 1993. This decrease in mortality is unlikely to be explained entirely by treatment with curative intent alone following screen-detected cases, because the time frame between detection and mortality remains relatively brief.
This study used incidence and initial treatment data from the Detroit area SEER registry between 1973 and 1998 in addition to mortality data covering the Metropolitan Detroit area obtained from the Michigan Department of Community Health. Data for Caucasian and African-American men were analyzed. The use of androgen-deprivation therapy, which evolved during the study period, was evaluated in conjunction with mortality and incidence trend data for consideration of etiologic contributions.
The incidence of prostate carcinoma, as noted previously in national data, increased sharply in 1988, peaking in 1992 in Southeast Michigan, whereas mortality rates began to decrease in approximately 1993, with a sustained decrease to the latest recorded data in 1998. These trends were identical in Caucasians and African Americans. A sharp increase in the use of androgen-deprivation therapy began in 1990. This use of androgen-deprivation therapy is high and sustained for patients with early-stage disease, increases for several years, and then diminishes for patients with regional disease. The use also diminished through the 1990s for patients with late-stage disease, paralleling the decrease in the incidence rate for late-stage disease.
The pattern of androgen-deprivation therapy usage was consistent with that for hormonal monotherapy and adjuvant and neoadjuvant therapy. These findings suggest that androgen-deprivation therapy may contribute, along with advances in diagnostic techniques and curative therapy with radiation or surgery, toward decreasing prostate carcinoma mortality rates in Southeast Michigan.
Cancer 12/2001; 92(9):2309-17. · 4.77 Impact Factor
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T Campbell,
J Blasko,
E D Crawford,
J Forman,
G Hanks,
D Kuban, J Montie,
J Moul,
A Pollack,
D Raghavan,
P Ray,
M Roach,
G Steinberg,
N Stone,
I Thompson,
N Vogelzang,
S Vijayakumar
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ABSTRACT: The American Joint Committee on Cancer (AJCC) staging system for prostate cancer adopted in 1992 is based on tumor-node-metastasis (TNM) designations. It has been widely accepted for use in local and advanced disease. The purpose of this study was to assess reproducibility of staging among observers and to help clarify staging issues. Twelve prostate cancer cases were sent to 20 physicians with special expertise in prostate cancer including eight urologists, eight radiation oncologists, and four medical oncologists. Physicians were asked to assign a stage based on the 1992 AJCC clinical staging. The most frequently reported stage assigned to each case was taken to be the consensus. Agreement was the percentage of physicians who reported that particular stage. Seventy-five percent of the physicians responded. The overall agreement for assignment of T stage was 63.9%. Differences were found by specialty for inclusion of available information in designating a T stage. The overall agreement for N stage was 73.8%. The most common designation was Nx regardless of availability of a computed tomography scan. The overall agreement for M stage was 76.6%. Without a bone scan the most common designation was Mx regardless of Gleason grade or prostate-specific antigen (PSA). A frequent comment was that PSA was more indicative of disease extent than current clinical staging. The reproducibility of the 1992 clinical AJCC staging is poor even among experts in the field. This problem arises primarily from disagreement regarding which studies are included in assigning a stage. Some of these difficulties are addressed in the 1997 revision. However, the clinical staging does not address the true biological significance of disease in many instances.
International Journal of Cancer 07/2001; 96(3):198-209. · 5.44 Impact Factor
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A Tewari,
M Issa,
R El-Galley,
H Stricker,
J Peabody,
J Pow-Sang,
A Shukla,
Z Wajsman,
M Rubin,
J Wei, [......],
R Demers,
C C Johnson,
L Lamerato,
G W Divine,
E D Crawford,
E J Gamito,
R Farah,
P Narayan,
G Carlson,
M Menon
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ABSTRACT: Despite many new procedures, radical prostatectomy remains one of the commonest methods of treating clinically localized prostate cancer. Both from the physician's and the patient's point of view, it is important to have objective estimation of the likelihood of recurrence, which forms the foundation for treatment selection for an individual patient. Currently, it is difficult to predict the probability of biochemical recurrence (rising serum prostate specific antigen [PSA] concentration) in an individual patient, and approximately 30% of the patients do experience recurrence. Tools predicting the recurrence will be of immense practical utility in the treatment selection and planning follow up. We have utilized preoperative parameters through a computer based genetic adaptive neural network model to predict recurrence in such patients, which can help primary care physicians and urologists in making management recommendations.
Fourteen hundred patients who underwent radical prostatectomy at participating institutions form the subjects of this study. Demographic data such as age, race, preoperative PSA, systemic biopsy based staging and Gleason scores were used to construct a neural network model. This model simulated the functioning of a trained human mind and learned from the database. Once trained, it was used to predict the outcomes in new patients.
The patients in this comprehensive database were representative of the average prostate cancer patients as seen in USA. Their mean age was 68.4 years, the mean PSA concentration before surgery was 11.6 ng/mL, and 67% patients had a Gleason sum of 5 to 7. The mean length of follow-up was 41.5 months. Eighty percent of the cancers were clinical stage T2 and 5% T3. In our series, 64% of patients had pathologically organ-confined cancer, 33% positive margins, and 14% had seminal vesicle invasion. Lymph node positive patients were not included in this series. Progression as judged by serum PSA was noted in 30.6%. With entry of a few routinely used parameters, the model could correctly predict recurrence in 76% of the patients in the validation set. The area under the curve was 0.831. The sensitivity was 85%, the specificity 74%, the positive predictive value 77%, and the negative predictive value of 83%.
It was possible to predict PSA recurrence with a high accuracy (76%). Physicians desiring objective treatment counseling can use this model, and significant cost savings are anticipated because of appropriate treatment selection and patient-specific follow-up protocols. This technology can be extended to other treatments such as watchful waiting, external-beam radiation, and brachytherapy.
Molecular Urology 02/2001; 5(4):163-9.
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E D Crawford,
J T Batuello,
P Snow,
E J Gamito,
D G McLeod,
A W Partin,
N Stone, J Montie,
R Stock,
J Lynch,
J Brandt
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ABSTRACT: The current study assesses artificial intelligence methods to identify prostate carcinoma patients at low risk for lymph node spread. If patients can be assigned accurately to a low risk group, unnecessary lymph node dissections can be avoided, thereby reducing morbidity and costs.
A rule-derivation technology for simple decision-tree analysis was trained and validated using patient data from a large database (4,133 patients) to derive low risk cutoff values for Gleason sum and prostate specific antigen (PSA) level. An empiric analysis was used to derive a low risk cutoff value for clinical TNM stage. These cutoff values then were applied to 2 additional, smaller databases (227 and 330 patients, respectively) from separate institutions.
The decision-tree protocol derived cutoff values of < or = 6 for Gleason sum and < or = 10.6 ng/mL for PSA. The empiric analysis yielded a clinical TNM stage low risk cutoff value of < or = T2a. When these cutoff values were applied to the larger database, 44% of patients were classified as being at low risk for lymph node metastases (0.8% false-negative rate). When the same cutoff values were applied to the smaller databases, between 11 and 43% of patients were classified as low risk with a false-negative rate of between 0.0 and 0.7%.
The results of the current study indicate that a population of prostate carcinoma patients at low risk for lymph node metastases can be identified accurately using a simple decision algorithm that considers preoperative PSA, Gleason sum, and clinical TNM stage. The risk of lymph node metastases in these patients is < or = 1%; therefore, pelvic lymph node dissection may be avoided safely. The implications of these findings in surgical and nonsurgical treatment are significant.
Cancer 06/2000; 88(9):2105-9. · 4.77 Impact Factor
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ABSTRACT: Several investigators have reported that African-American men with clinically localized prostate cancer have poorer survival than do white men. In addition, prostate cancer in African-American men is commonly diagnosed at a more advanced stage of disease. Is race or ethnicity predictive of outcome of clinically localized prostate cancer? It has been reported that the presence of positive surgical margins significantly influences time to progression independently of other prognostic factors. Therefore, we have elected to conduct a multivariate analysis of clinical factors including race as potential predictors of positive surgical margin outcome.
We studied 369 consecutive men (120 African-American and 249 white) who had radical prostatectomies at a single institution. Comparisons by race of Gleason score, stage, presence of positive surgical margins, and mean preoperative prostate-specific antigen (PSA) level were carried out.
Our data demonstrate that African-American men have more pathologically locally advanced prostate cancer than do white American men: 69% among blacks compared with 57% among whites. However, the difference in rate of positive surgical margins between blacks and whites is statistically significant: 58% among blacks versus 40% among whites (P = 0.002). Four factors were predictive of positive surgical margins: preoperative PSA level, race, clinical stage, and Gleason score.
We have demonstrated that race is an independent predictor of positive surgical margins among patients with clinically localized prostate cancer and should be included in treatment decisions. In addition, the risk of positive surgical margins increases noticeably when PSA is greater than 10 ng/mL.
Urology 06/1997; 49(5):726-31. · 2.43 Impact Factor
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ABSTRACT: Determination of the risk of invasive bladder tumors progressing is still imprecise due to the heterogeneous biological behavior of this neoplasm. The goals of this study were to evaluate the patterns of expression of the epidermal growth factor (EGF) system in invasive bladder cancer and to assess its prognostic value.
This immunohistochemical study was performed using fresh frozen tumor samples and a panel of monoclonal antibodies on a series of 43 invasive bladder cancers treated by cystectomy.
EGF was detected in 45% of the tumors and did not correlate with survival from bladder cancer. Transforming growth factor alpha (TGF alpha) was expressed by 60% of the tumors and correlated strongly with death from bladder cancer. Epidermal growth factor receptor (EGF-R) expression was seen in 86% of cases and had no prognostic significance. c-erbB2 was expressed in 50% of cases and was inversely related to a poor prognosis. When EGF and TGF alpha were both expressed, there was little or no expression of c-erbB2.
The accumulation of several growth factors and the relevant receptor are necessary for the progression of invasive bladder cancers. They could be used as indicators of tumor aggressiveness.
Urological Research 02/1997; 25(1):9-17. · 1.23 Impact Factor
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Urology 11/1996; 48(4):519-33; discussion 533-4. · 2.43 Impact Factor
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ABSTRACT: A prospective evaluation of neoadjuvant hormonal downsizing in patients with localized carcinoma of the prostate was undertaken to assess its effect on normal tissue irradiation. Twenty patients with stage T1 or T2 (A, B) carcinoma of the prostate received 3 months of Lupron prior to definitive radiotherapy. The volumes of the prostate, seminal vesicles, bladder, and rectum from both the pre- and posthormone treatment planning CT were entered onto a 3-D treatment-planning system. The treatment planning parameters were standardized to facilitate comparison of the pre- and posthormonal volumes. Following the three monthly injections of Lupron, the average volume of the prostate was reduced by 37%. As a consequence, the volume of the bladder receiving at least 40, 52, and 64 Gy was reduced by an average of 15, 18, and 20%, respectively. In addition, the volume of the rectum receiving at least 40, 52, and 64 Gy was reduced by an average of 13, 20, and 34%, respectively. In conclusion, in patients with localized prostate cancer, downsizing of the prostate resulted in a reduction in the volume of bladder and rectum receiving high radiation doses. This approach may result in an improvement in the therapeutic ratio by reducing the morbidity of treatment.
Cancer Investigation 02/1995; 13(1):8-15. · 1.85 Impact Factor
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ABSTRACT: Cryotherapy of the prostate has been reintroduced clinically due to improved ultrasound guidance and cryotechnology. The purpose of this canine feasibility study was to assess the accuracy of transrectal ultrasound (TRUS) in monitoring iceball progression with histologic correlation.
Six mongrel dogs received cryotherapy to the entire prostate and were observed for selected periods of 1 day to 12 weeks with TRUS follow-up. Some technical limitations of the canine model prohibited complete comparison with techniques currently used in humans.
TRUS monitoring of posterior iceball progression proved to be highly accurate and correlated with subtotal necrosis of the rectal wall, sparing the mucosal layer with millimeter accuracy. The prostate was completely necrotic in three of six dogs. Scattered residual glands remained at the distal apex in one dog and in the posterolateral periphery of a larger-volume prostate. Cryotherapy missed the prostate in one dog due to pelvic hematoma formation and poor TRUS visualization. Without adequate urethral warming, central sloughing was noted in chronic animals. Histologic examination demonstrated hemorrhagic infarction with subsequent ingrowth of transitional epithelium from the urethra producing re-epithelialization of glandular spaces along the residual collagenous architecture.
Accurate TRUS monitoring of prostate cryotherapy allows thorough yet careful extension of the iceball through the posterior aspect of the prostate. Unique histologic changes may account for the unremarkable TRUS appearance following cryotherapy, as well as some of the benign, "atypical" glands seen on follow-up biopsies in humans.
Urology 09/1994; 44(2):175-83; discussion 183-4. · 2.43 Impact Factor
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ABSTRACT: Extragonadal germ cell tumors (EGGCT) are uncommon, occur primarily in the mediastinum and retroperitoneum, and have been noted to have variable response rates to cisplatin-based chemotherapy regimens.
The Southwest Oncology Group (SWOG) has completed a prospective trial of combination chemotherapy followed by surgical removal of residual disease in patients with this type of germ cell neoplasm. Chemotherapy consisted of alternating cycles of vinblastine, bleomycin, and cisplatin with etoposide, bleomycin, doxorubicin, and cisplatin. Four cycles of therapy were given followed by surgical removal of residual disease where appropriate.
Fifty patients were entered into the trial, and 41 were eligible, with 4 patients excluded by pathology review. Of the 41 eligible patients, 24 had mediastinal tumors, 15 had retroperitoneal tumors, and 2 had unknown primary sites. Complete response rates (chemotherapy +/- surgery) for the various sites were as follows: mediastinum, 18 of 24 (75%); retroperitoneum, 10 of 15 (67%); and unknown primary, 2 of 2 (100%). At 2 years, the disease-free survival rate for all patients was 87%. At a median follow-up of 6.8 years, 26 of 41 patients (63%) are alive. The toxicity of the chemotherapy regimen was substantial, with neutropenic fever developing in 17 of 41 patients (41%) during treatment. Additional side effects included nausea and vomiting (76%), mucositis (27%), and pulmonary toxicity (5%).
This prospective trial of chemotherapy in patients with EGGCT demonstrates a significant response in patients with either mediastinal or retroperitoneal tumors and a 4-year survival rate of more than 60% and 70%, respectively.
Cancer 05/1993; 71(8):2631-8. · 4.77 Impact Factor
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ABSTRACT: Salvage surgery was done in 43 patients who did not respond to radiation therapy of prostate cancer between 1982-1991. Thirty-five patients underwent salvage prostatectomy and 8, cystoprostatectomy.
The complications were significant; four patients had rectal injuries (all closed primarily), one had a ureteral injury, and there was one perioperative death. Urinary incontinence occurred in 10 of 35 patients (30%). Pathologic step sections of the prostate showed that only 13 of 43 patients (30%) had negative surgical margins. Follow-up (range, 1-10 years) revealed that 34 patients were alive, and 9 had died. Eleven of 20 patients were alive who were followed more than 5 years. Ten patients were considered to have no evidence of disease (undetectable prostate specific antigen levels).
In selected patients, salvage surgery has a place in the treatment of prostate cancer after radiation therapy failure.
Cancer 03/1993; 71(3 Suppl):976-80. · 4.77 Impact Factor
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ABSTRACT: The incidence of residual neoplastic cells on prostatic biopsy following conventional external beam radiotherapy is reported to range from 40-90%. As a result, it has been stated that current modalities of radiotherapy may carry an unacceptable local failure rate even in patients irradiated for low stage disease. In order to assess the potential benefits of three-dimensional (3-D) treatment planning, an unselected, consecutive group of patients with localized adenocarcinoma of the prostate was evaluated. This study was designed to determine the frequency of residual cancer in the prostate two years following definitive external beam radiotherapy designed, using a 3-D planning system. Between February 1988 and February 1989, 30 consecutive patients with localized (Stage T1-T3NxMo) adenocarcinoma of the prostate received definitive external beam radiotherapy. All treatment fields were designed with a computed tomography (CT)-based 3-D treatment planning system, resulting in a static conformal radiotherapy plan. The minimum dose delivered to the target volume, which included the prostate, periprostatic tissues, and a 1 cm margin, was between 65 and 69 cGy. Twenty-six patients had Stage T1, T2NxMo primary tumors and four were T3NxMo. Two years following the completion of treatment, all patients underwent digital rectal examination, transrectal ultrasound examination of the prostate with multiple biopsies, bone scan, and serum prostate specific antigen (PSA) determinations. Residual prostate cancer was proven by biopsy in six of 30 patients (20%). Four of 26 (15%) with Stage T1 and T2 tumors had a positive biopsy. However, two of the four Stage T3 tumors had postradiation biopsies positive for cancer (50%). Only one patient with a positive biopsy had an abnormal rectal examination. Five of the eight patients with elevated serum PSA levels after two years had residual neoplasia identified on biopsy. One of six patients with an abnormal postradiation ultrasound had residual tumor. Only one of the 22 patients (5%) with a normal serum PSA at two years had a positive postradiation biopsy. In patients with localized prostate cancer, the use of 3-D static conformal radiotherapy followed by multiple ultrasound guided biopsies confirmed the efficacy of external beam radiotherapy in low stage disease. We believe that the low incidence of positive biopsies in this study resulted from the benefits of 3-D treatment planning as well as the fact that all patients were evaluated, whereas past studies have been in selected patient groups when suspicion of residual disease existed prior to biopsy.(ABSTRACT TRUNCATED AT 400 WORDS)
The Prostate 02/1993; 23(3):235-43. · 3.48 Impact Factor
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ABSTRACT: Six patients with localized prostatic carcinoma undergoing radical prostatectomy were studied by serial sample collection from the time of surgical removal of the prostate up to one week in the postoperative period. Of the three markers studied (PAP, PSA, LASA), half-life of specific prostatic markers were calculated. Half-life of PAP was found to be 7.25 hours +/- SE of 0.7 hours. For PSA the half-life could be obtained in 4 of 6 patients and was found to be 45.5 hours +/- SE 4.9 hours. In 2 patients PSA did not fall in a regular fashion and half-life could not be obtained. In both patients metastatic disease has developed within six months of surgery. LASA demonstrated progressive increase following surgery, most likely due to associated inflammatory reaction. These studies confirm previous observations that PSA is a more sensitive marker than PAP, and that the presence of an elevated PSA after radical prostatectomy denotes the presence of residual disease.
Urology 12/1990; 36(5):415-9. · 2.43 Impact Factor
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ABSTRACT: Seven patients with complicated pelviureteric junction (PUJ) obstruction underwent reconstruction by means of ureterocalicostomy; 5 had undergone previous surgery and 2 had primary obstruction. Radiographic studies showed resolution or improvement of the obstruction in 5 patients, who remain asymptomatic 15 to 47 months (mean 30) post-operatively. Obstruction persists in 1 patient and the other developed renal artery thrombosis with subsequent loss of the kidney. It was concluded that ureterocalicostomy can provide long-term, successful reconstruction of a complicated PUJ obstruction, but significant complications may be associated with the procedure.
British Journal of Urology 05/1990; 65(4):322-5.
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Progress in clinical and biological research 02/1990; 353:153-61.
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ABSTRACT: The long-term results of regional chemotherapy plus intra-arterial cisplatin with or without doxorubicin as an adjuvant before cystectomy and urinary diversion in patients with invasive transitional cell carcinoma of the bladder were evaluated. A total of 27 patients with T3aNxMo (8), T3bNxMo (14) and T4NxMo (5) disease participated in a phase II trial completed in 1985. Of the patients 19 received cisplatin and doxorubicin intra-arterially, and cyclophosphamide intravenously, and the remaining 8 received 70 to 100 mg. per m.2 cisplatin intra-arterially. A total of 19 patients underwent cystectomy after chemotherapy. Patients in this group had a pathological complete response (no evidence of disease after surgical restaging) or the presence of residual disease at operation that could (surgical complete response) or could not (pathological partial response) be completely resected. Of the 19 patients undergoing cystectomy surgical complete response was observed in 47.4%, pathological complete response in 26.3% and pathological partial response in 26.3%. At a median followup of 27 months for the group 66% of the patients with a surgical complete response, 100% with a pathological complete response and 40% with a pathological partial response were alive with no evidence of disease. The over-all survival for patients with a pathological or surgical complete response is 76.9%. In the patients not operated upon because of persistent or advanced disease after chemotherapy survival was brief (less than 4 months). Prolonged survival in patients achieving a pathological or surgical complete response with neoadjuvant chemotherapy occurs, and this modality may have a role in patients with invasive tumors.
The Journal of Urology 12/1989; 142(5):1211-4; discussion 1214-5. · 3.75 Impact Factor
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Progress in clinical and biological research 02/1989; 310:263-70.
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ABSTRACT: Complete surgical excision of solitary metastatic lesions in renal cell carcinoma has been reported to be associated with improved survival. An analysis of 65 outpatients undergoing excision of metastatic renal cell carcinoma is reviewed. In our series there was no significant difference among patients with solitary versus those with multiple metastasis. The overall 5-year survival was considerably lower than previously reported. We recommend that only patients with good performance status, who are participating in protocols with biological response modifiers, could potentially benefit from surgical removal of metastatic lesions.
Seminars in Surgical Oncology 02/1989; 5(4):282-5.
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Annals of the New York Academy of Sciences 02/1988; 532:387-94. · 3.15 Impact Factor
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ABSTRACT: Six patients with localized prostatic carcinoma undergoing radical prostatectomywere studied by serial sample collection from the time of surgical removal of the prostate up to one week in the postoperative period. Of the three markers studied (PAP, PSA, LASA), half-life of specific prostatic markers were calculated. Half-life of PAP was found to be 7.25 hours ± SE of 0.7 hours. For PSA the half-life could be obtained in 4 of 6 patients and was found to be 45.5 hours ± SE 4.9 hours. In 2 patients PSA did not fall in a regular fashion and half-life could not be obtained. In both patients metastatic disease has developed within six months of surgery. LASA demonstrated progressive increase following surgery, most likely due to associated inflammatory reaction. These studies confirm previous observations that PSA is a more sensitive marker than PAP, and that the presence of an elevated PSA after radical prostatectomy denotes the presence of residual disease.
Urology.
