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ABSTRACT: Digital rectal examination is widely performed for following patients with localized prostate cancer after definitive therapy. This examination has marginal efficacy for detecting initial prostate cancer and postoperative recurrence. To determine the efficacy of digital rectal examination in terms of new information provided after radiotherapy we analyzed the results of digital rectal examination in the followup of patients with prostate cancer after radiotherapy.
We performed a nonrandomized study in 235 consecutive patients with prostate cancer followed at a large tertiary care military hospital between January 1, 1995 and December 31, 1999. All patients had been treated with prostate radiotherapy and had no evidence of metastatic disease at the first visit within that interval. Digital rectal examination was done at followup and the main outcome measure was new information provided by that examination.
A total of 1,544 digital rectal examinations were performed in 1,627 visits. New information was provided by digital rectal examination in only 30% of 286 abnormal examinations, of which more than three-quarters were related to bleeding and would otherwise have been noted on routine examination by the primary care provider. All 8 persistent recurrent prostate nodules were noted in the context of increasing prostate specific antigen.
Routine digital rectal examination in patients with prostate cancer after radiotherapy may be omitted from followup protocols.
The Journal of Urology 12/2001; 166(5):1684-7. · 3.75 Impact Factor
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ABSTRACT: A retrospective outcomes review of radiotherapy for Bowen's disease was performed to analyze all patients treated with radiation therapy between 1993 and 1997 at the Naval Medical Center, San Diego.
Eleven patients with 16 lesions were treated with a median time-dose-fractionation value of 105 (range, 93-108).
All 11 patients were without evidence of disease within 1 to 2 months of completing treatment. Four of the 16 lesions (25%) were unhealed at time of last follow-up; the remainder healed with good cosmetic result. All unhealed lesions were on the lower extremity. Median follow-up was 27.5 months (range, 9-57 months).
Radiation remains a good therapeutic option in selected patients with Bowen's disease, but caution should be exercised before selection of patients with lesions in potentially poor healing areas, such as the lower extremity.
Journal of the American Academy of Dermatology 10/2001; 45(3):401-4. · 3.99 Impact Factor
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ABSTRACT: Patients with surgically staged localized prostate cancer treated with external beam radiation therapy were retrospectively analyzed for 15 and 20-year overall and cause specific survival. The need for additional therapy was also evaluated.
We analyzed 145 patients who received external beam radiotherapy after negative staging pelvic lymphadenectomy. Followup data were available for 129 patients. Overall and cause specific survival was calculated with the Kaplan-Meier method.
Median followup was 14.9 years. Actuarial overall survival at 15 and 20 years was 45.9% and 24.6%, respectively. Cause specific survival at 15 and 20 years was 64.5% and 37.7% for having all patients dying of unknown causes censored, and 54.4% and 30.1% for those dying of unknown causes categorized as having prostate cancer, respectively. Of the patients who survived 47% were on hormonal therapy.
Longer followup after external beam radiation therapy continues to demonstrate a decrease in cause specific survival. Many patients ultimately require hormonal therapy.
The Journal of Urology 08/2001; 166(1):116-8. · 3.75 Impact Factor
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ABSTRACT: Xerostomia is a frequent and potentially debilitating toxicity of radiotherapy (XRT) for cancers of the head and neck. This report describes the use of acupuncture as palliation for such patients.
Eighteen patients with xerostomia refractory to pilocarpine therapy after XRT for head and neck malignancy were offered acupuncture as palliation. All patients are without evidence of cancer recurrence at the primary site. Acupuncture was provided to three auricular points and one digital point bilaterally, with electrostimulation used variably. The Xerostomia Inventory (XI) was administered retrospectively to provide an objective measure of efficacy.
Acupuncture contributed to relief from xerostomia to varying degrees. Palliative effect as measured by the XI varied from nil to robust (pre- minus post- therapy values of over 20 points). Nine patients had benefit of over 10 points on the XI.
Acupuncture reduces xerostomia in some patients who are otherwise refractory to best current management.
International Journal of Radiation OncologyBiologyPhysics 07/2001; 50(2):353-7. · 4.11 Impact Factor
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ABSTRACT: Optimal means of modeling death rates of large populations with a specific disease have not been described in the literature.
Statistical modeling was used on archival data.
In the authors' prior publications describing the survival of untreated cancer patients, data that were adequately fitted by an exponential curve were found to be much better fitted by an inverse Gompertz curve (R(2) = 99.7% for untreated breast carcinoma, 99.9% for untreated cervical carcinoma). However, when data from treated patients are examined, fits show that successive stages begin at successive positions on the inverse Gompertz curve. Breast carcinoma data showed that treatment begun at an early stage raised survival to a linear decline; at an intermediate stage led to a modified inverse Gompertz, the earlier the stage at which therapy was begun, the greater the survival rate; and at a late stage exhibited an exponential decline showing a negligible effect of late treatment. Confidence in this approach was enhanced by its applicability using published data from the National Cancer Database for breast, pancreatic, bone, and skin cancers.
The use of data modeling allowed us to assess realistically the value of intervention in cancer populations and to optimize staging schemas. It strongly reinforced the concept that early detection provides a far greater impact on a population's subsequent survival than therapy of advanced disease.
Cancer 07/2001; 91(12):2469-75. · 4.77 Impact Factor
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ABSTRACT: An outcomes analysis study was performed to quantify the benefit of directed diagnostic imaging of selected very young women (defined as < or = 30 years of age) in our population. Summary results are presented.
Women's Imaging Services were queried for studies performed between April 1, 1997 and December 31, 1998 on women < or = 30 years of age. The authors' referral pathway mandates breast examination by a general surgeon or by the head of Women's Imaging before mammography in all such patients. Studies were excluded if there were reviews of scans performed at other sites. The resulting 142 mammograms were evaluated.
Ninety percent of the 142 studies were within normal limits. Only 11 mammograms indicated any required action (7.8%), and only 5 of these merited biopsy. All biopsies revealed benign disease. No carcinomas were detected by biopsy or on clinical follow-up in this cohort of women. These values are congruent with the scarce literature on mammography in this population.
The yield of mammography in the age < or = 30 years population is low.
Cancer 04/2001; 91(6):1075-8. · 4.77 Impact Factor
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ABSTRACT: Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine dermal neoplasm. Because of the limited number of cases described in the literature (approximately 600 to date), statistically significant data regarding treatment are difficult to obtain. The majority of MCC cases affect the head and neck and are thought to be caused by the actinic damage associated with sun exposure. This study evaluates cases of head and neck MCC at Naval Medical Center San Diego (NMCSD) and compares the treatment regimens and outcomes from multiple institutions. This study is a retrospective outcomes analysis of all cases of head and neck MCC seen at NMCSD, between January 1, 1988 and June 30, 1998. The records of the NMCSD Tumor Registry were searched for patients with that diagnosis, and supplemental information was retrieved from the Radiation Oncology and Head & Neck Surgery Clinic charts. Eight of nine patients in this study were treated with either wide-local excision or Mohs microsurgery. The surgical margins were free of disease in all eight patients. One patient presented with distant metastatic disease, and two others were subsequently found to have nodal involvement. Subsequent therapy varied among the patients. Survey of the available literature revealed inconsistency in terms of which treatment regimens are optimal. Tumor resections are recommended by most groups to include a 2-cm to 3-cm tumor-free margin around the primary lesion when possible, but this is often difficult to achieve in the head and neck. Data, which do not reach statistical significance, suggest improved outcomes with tumor-free margins. Treatment of the regional draining lymph nodes is also recommended in most series. Prophylactic lymph node dissection or radiation therapy to the nodal chain may decrease local recurrence but does not consistently affect overall survival. Adjuvant chemotherapy is advocated by most groups in the treatment of metastatic disease because MCC is pathologically similar to small-cell lung carcinoma. However, no chemotherapy protocol has been shown to improve survival. Head and neck MCC is a rare and aggressive dermal tumor of neuroendocrine origin that requires multimodality therapy, including surgery, radiation therapy, and possibly adjuvant chemotherapy. Multiinstitutional studies are crucial to obtain sufficiently large populations to investigate and optimize therapy in this disease.
American Journal of Clinical Oncology 03/2001; 24(1):35-42. · 2.01 Impact Factor
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ABSTRACT: The records of the San Diego Gamma Knife Center were retrospectively reviewed for unprogrammed events as part of a risk management assessment.
Review was made of the physicist notes of the first 1,000 patients successfully treated at the center. This encompassed 1,020 stereotactic frame placement procedures, accompanied by Gamma Knife radiosurgery in 98.0% of intended cases. A total of 7,145 Gamma Knife shots were delivered to 1,509 lesions.
Of the 43 unprogrammed events documented, 8 were patient related and 14 were related to lesion growth or location; these were considered unavoidable. Further, one event was related to dose administration, 5 to diagnosis, 15 to technique; these were considered potentially avoidable. This yielded an avoidable error rate of 2.1% per patient, 1.4% per lesion treated, and 0.29% per shot. It was clear that more avoidable errors occurred early in the center's operation, consistent with a learning curve. Review of individual physician's cases revealed none appeared more likely to have an avoidable event.
Consistently high quality may be achieved at a community-based Gamma Knife center if sufficient multidisciplinary involvement is achieved.
Stereotactic and Functional Neurosurgery 02/2001; 76(2):106-14. · 1.85 Impact Factor
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Journal of Surgical Oncology 11/2000; 75(2):95-7. · 2.10 Impact Factor
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ABSTRACT: To analyze the frequency and clinical importance of proctitis and hematochezia after radiation therapy for prostate cancer.
Of 63 patients with prostate cancer treated with curative intent by a single radiation oncologist between July 1, 1993, and December 31, 1997, 30 were asymptomatic, but 33 had heme-positive digital rectal examination (DRE) results or hematochezia at routine follow-up. Twenty-six of these patients underwent endoscopy of the sigmoid colon or colon for evaluation of these symptoms. Median doses of 60.0 Gy at postoperative radiation therapy and 68.4 Gy at definitive radiation therapy were delivered to four fields daily by using blocking customized on the basis of computed tomographically documented evidence of disease. The Fisher exact test and the Kaplan-Meier method were used to analyze the results.
The frequency of rectal bleeding approached 80% at 3 years after radiation therapy in definitively treated patients. Only 14 patients had proctitis: eight as the only sign, and six in association with other disease. Six patients had other disease without proctitis, and four patients had normal examination findings. The frequency of rectal bleeding in the presence of proctitis was similar to that in the presence of other disease (Fisher exact test, P =.68).
Hematochezia or positive DRE findings are frequent sequelae of definitive radiation therapy for prostate cancer; however, causes other than proctitis are often documented at endoscopy. Symptomatic individuals warrant rigorous evaluation to rule out serious coexistent disease.
Radiology 11/2000; 217(1):215-8. · 5.73 Impact Factor
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ABSTRACT: To document the frequency of clinically important coexistent disease depicted at contrast material-enhanced abdominal and pelvic computed tomography (CT) in patients undergoing definitive radiation therapy for prostate carcinoma, as such lesions might be missed at limited nonenhanced treatment-planning CT.
Of 133 consecutive patients with prostate carcinoma who were referred to the radiation oncology division between January 1, 1994, and December 31, 1996, 77 underwent definitive radiation therapy that required either contrast-enhanced abdominal and pelvic CT (n = 67) or contrast-enhanced pelvic CT (n = 10). Results of these studies were reviewed and retrospectively categorized.
Forty-eight (62%) of the 77 patients had either negative studies or minor abnormalities that did not require further follow-up. Only two patients (3%) had major abnormalities that required intervention. Five patients (6%) had new findings of clinically important coexistent disease, but no intervention was required.
The incidence of clinically important coexistent disease in patients with prostate carcinoma who are referred for definitive radiation therapy is low. Therefore, contrast-enhanced abdominal and pelvic CT in addition to treatment-planning CT is of limited value.
Radiology 05/2000; 215(1):41-4. · 5.73 Impact Factor
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ABSTRACT: Knowing the clinical prognosis of untreated breast cancer is useful in dealing with patients with neglected disease or in environments with poorly developed healthcare systems. This study analyzes historical survival data in two sets of untreated patients: (1) 250 patients followed until death (up to 12 years) for which autopsy results are available and (2) an amalgam of 1,022 patients from several papers. Data from nine published papers underwent actuarial analysis. Median survival time of the 250 patients followed to death was 2.7 years. Actuarial 5- and 10-year survival rates for these patients with untreated breast cancer was 18.4% and 3.6%, respectively. For the amalgamated 1,022 patients, median survival time was 2.3 years. Actuarial 5- and (partially fitted) 10-year survival rates for these patients with untreated breast cancer was 19.8% and 3.7%, respectively. Historical data of untreated breast cancer patients reveal a potential for long survival in some cases. The spectrum of clinical aggressiveness of breast cancer varies between virulence and chronic disease.
Journal of Surgical Oncology 05/2000; 73(4):273-7. · 2.10 Impact Factor
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ABSTRACT: To describe patient-reported quality of life using a validated survey in a cohort of patients who are long-term survivors of definitive radiotherapy for T1-3N0 prostate cancer.
Survivors of a previously reported cohort of prostate cancer patients treated with staging pelvic lymphadenectomy and definitive radiotherapy between November 1974 and August 1988 were queried using a questionnaire incorporating the RAND 36-Item Health Survey and the University of California, Los Angeles Prostate Cancer Index. Responses were reviewed and analyzed. Of the 146 N0 patients, 88 have survived for 10 years postdiagnosis. Fifty-six (64%) of these patients were still alive with valid addresses and were mailed copies of the questionnaires, of which 46 (82%) responded. Median potential follow-up from date of diagnosis was 13.9 years, with a median age of responders of 80 years.
The mean sexual function score was 15.4, with a bother score of 42. The mean urinary function score was 65, with a bother score of 61. The mean bowel function score was 72.6, with a bother score of 64.8. The amount of patient bother reported in the sexual category is similar to that previously reported for cohorts of prostate cancer patients undergoing radiotherapy or observation. This is despite the fact that sexual function was similar to that previously reported for patients postprostatectomy. Patient-reported function and bother scores in urinary and bowel categories were somewhat more severe than a previously reported radiotherapy cohort with shorter follow-up.
With long follow-up, most patients who underwent radiotherapy for prostate cancer in the era described exhibit somewhat worse bladder, bowel, and erectile function than recently published controls without prostate cancer. In this cohort of older men with long follow-up, erectile function is similar to reported prostatectomy series. However, patient bother related to erectile function is similar to that of controls in earlier published radiotherapy series. Worse urinary and bowel function may be due to progressive symptoms with aging and longer follow-up, or to the radiotherapy techniques performed during the era in question.
International Journal of Radiation OncologyBiologyPhysics 04/2000; 46(4):833-8. · 4.11 Impact Factor
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ABSTRACT: The purpose of this study was to discuss the experience of one tumor registry with performing tonsillectomy in the diagnostic approach to unknown head and neck primary tumors. It also describes the importance of including tonsillectomy in this evaluation algorithm.
A retrospective chart review was done of 68 patients with either tonsillar or unknown primary squamous cell carcinoma culled from 829 patients seen from 1956 to 1996 at the head and neck tumor registry at the Naval Medical Center San Diego.
Records from the head and neck tumor registry, radiation oncology service, and pathology department were reviewed with attention to presenting symptom, initial examination, diagnostic studies performed, and type and result of biopsies performed.
Thirty-four patients sought treatment for a neck lymph node metastasis of squamous cell carcinoma without an identifiable primary tumor site. Six of these (18%) had the primary site diagnosed by performing tonsillectomy ipsilateral to the presenting neck mass. Six of 14 T1 tonsillar carcinomas in this series had the primary site identified by tonsillectomy.
Despite a diligent search, a primary tumor site may not be found in the head and neck cancer patient. The tonsil may harbor an occult squamous cell carcinoma. The patient benefits from identification of the initial tumor site because postoperative irradiation ports may be reduced and because surveillance for recurrence may be improved. For these reasons, tonsillectomy should be performed ipsilateral to the presenting cervical metastasis if no other primary tumor site is identified.
Otolaryngology Head and Neck Surgery 02/2000; 122(1):52-5. · 1.72 Impact Factor
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ABSTRACT: The purpose of this study was to evaluate free-to-total prostate-specific antigen (PSA) ratios after definitive external beam radiation therapy for men with adenocarcinoma of the prostate (CaP).
A prospective evaluation of percent free PSA in men following definitive external beam radiation therapy for CaP was compared to men with untreated CaP and men at very low risk for CaP. Statistical comparison of clinical and pathologic parameters was performed.
There was no statistically significant difference in free-to-total PSA ratios for men with newly diagnosed CaP and men with detectable PSA who were treated with external beam radiation therapy.
Free-to-total PSA ratios after definitive external beam radiation therapy for CaP are consistent with percent free PSA in patients with newly diagnosed CaP. This supports the theory that PSA from in situ prostate tissue following external beam radiation therapy is produced by malignant cells.
Journal of Surgical Oncology 03/1999; 70(2):91-4. · 2.10 Impact Factor
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ABSTRACT: A program was implemented in the Radiation Oncology Division at Naval Medical Center San Diego to document baselines for process improvement and fairly assess physician supervisory performance for recredentialing. This program was based on criteria established by the American College of Radiology (ACR). In addition to weekly chart rounds with peer review of films and charts while patients are on treatment, a new mechanism of peer review post-therapy was instituted. All patients completing therapy have this peer review prior to final disposition of their charts. Data are now readily available for physician recredentialing. Further, several points of inconsistent chart documentation have been identified and remedied. This mechanism is a simple and efficient way to ensure continuing patient care within ACR standards.
Quality management in health care 02/1999; 8(1):22-8.
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ABSTRACT: Delayed breast cellulitis is an infrequently reported entity after conservation therapy for breast cancer. We describe our experience with this entity at Naval Medical Center, San Diego.
Eight patients who presented with delayed cellulitis after wide local excision/axillary dissection and breast radiotherapy (RT) are presented. Their clinical characteristics and therapy are described and possible causative factors are analyzed.
The latency of breast cellulitis is variable after breast conservation therapy, although most cases in our experience and in the literature occur within a year post-RT. These infections are frequently refractory to a single course of antibiotics (n = 4 cases in our experience). Some patients suffer multiple episodes separated by months.
Breast cancer patients are at risk for delayed cellulitis after conservative surgery and RT. The mechanism of such events probably involves lymph stasis, however, therapy is no different from the more frequently occurring cases of cellulitis presenting perioperatively.
Journal of Surgical Oncology 05/1998; 67(4):242-5. · 2.10 Impact Factor
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ABSTRACT: The risk of patients with prostate cancer to have second primary malignancies is unclear. Population and autopsy based studies have shown no increased risk, which is at variance with several institutional analyses. A retrospective review was performed with comparison to expected cancer data from the Connecticut Tumor Registry.
Records of a cohort of prostate cancer patients treated with staging pelvic lymphadenectomy and definitive radiotherapy between November 1, 1974 and July 7, 1987 were reviewed. Median potential followup from date of diagnosis was 10.9 years.
Of the 164 patients 150 (91.5%) had followup to death or to August 1995, with data available in part on 4 of the remaining patients. In 43 patients 51 second primary malignancies developed. Increased frequency of lymphomas, and kidney, bladder and rectal lesions (all p < 0.001) was observed concurrently with diagnosis of prostate cancer, although this may be due to bias since full staging for the prostate cancer may have led to their diagnosis. An increased frequency of renal lesions in the 1 to 4-year followup period (p = 0.032) also was observed. Two sarcomas and a leukemia were putatively radiation induced but their frequency was not significantly different from the comparison baseline.
Much of the apparent increase in second primary malignancies associated with prostate cancer noted by some authors may be attributed to bias in the staging process. Renal cancers may occur more frequently in patients with prostate cancer but the distribution of these lesions is inconsistent with a field defect mechanism of cancer induction.
The Journal of Urology 03/1998; 159(3):946-9. · 3.75 Impact Factor
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ABSTRACT: We recently reported the outcome of 168 patients treated with pelvic lymphadenectomy and definitive radiation therapy. This report is a subanalysis of those patients (pts) who were clinically without evidence of disease (NED) 10 years after a negative staging pelvic lymphadenectomy and definitive radiation therapy for prostate cancer. One hundred of our original cohort of 168 patients had at least ten year follow-up. 76 patients had pathologically negative lymph nodes and had not received hormonal therapy. Forty-two N0 patients with sufficient follow-up were alive and clinically NED 10 years post-operatively. Distribution by disease stage at diagnosis was: Stage A2: 12 pts; Stage B: 19 pts; Stage B2/C: 6 pts; Stage C: 5 pts. Median follow-up was 13.3 years, with a minimum follow-up of 10 years. Of the 42 patients clinically NED at 10 years, 5 pts died subsequently without PSA data, remaining clinically NED a median of 13 y 3 m postoperatively; 37 patients were alive and without evidence of disease off all therapy at 10 years post-operatively. Bone scans were performed on 8 of the 9 patients with PSA over 4.0 ng/ml or on hormonal therapy. These revealed a single patient with diffuse but asymptomatic bone metastases. Ultrasound-guided sextant biopsies were performed on one 78-year-old patient with elevated PSA 19 years post-operatively, revealing an asymptomatic local recurrence. Patients who survive clinically NED for 10 years have a low likelihood of clinical failure, even in the presence of PSA values between 4.0 and 10 ng/ml. In these patients, PSA trends are of greater utility than absolute values.
Radiation Oncology Investigations 01/1998; 6(2):103-8.
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ABSTRACT: A retrospective analysis was performed on patients with surgically staged localized prostate cancer treated with external beam radiation therapy for 10-year overall, cause specific and disease-free survivals based on lack of clinical recurrence and 2 separate prostate specific antigen criteria for cure.
We analyzed 145 patients who received external beam radiation therapy after a negative staging pelvic lymphadenectomy for prostate cancer. Followup data were available for 129 patients (90%). Disease was stage A in 29 patients (22.5%), stage B in 64 (49.6%), stage B2/C in 2 (17%) and stage C in 14 (10.9%). Average potential followup from date of diagnosis was 11.5 years (minimum 7.2). Of the patients 87 potentially can be followed for longer than 10 years. Disease-free survival was based on a normal digital rectal examination, lack of symptoms suspicious for metastasis and application of 2 separate prostate specific antigen criteria of 4 ng./ml. or less (group 1), or 1.5 ng./ml. or less (group 2). Survival was analyzed with the Kaplan-Meier actuarial method.
Actuarial overall survival at 10 and 15 years was 63.7 and 49.6, respectively, and cause specific survival was 84.2 and 80%, respectively. Disease-free survival was 54.5 and 32.4%, respectively, for group 1, and 42.3 and 9.6%, respectively, for group 2.
The improved patient selection inherent in surgical staging before definitive external beam radiation therapy provides for improved overall and cause specific survival over that of patients without surgical staging. Biochemical disease-free survival also appears to be improved.
The Journal of Urology 06/1997; 157(5):1754-9. · 3.75 Impact Factor
