December, 2013

Pain drugs used in prostate gland removal linked to cancer outcome, study finds

The methods used to anesthetize prostate cancer patients and control pain when their prostate glands are surgically removed for adenocarcinoma may affect their long-term cancer outcomes, a study led by Mayo Clinic has found. Opioids, painkillers commonly given during and after surgery, may suppress the immune system’s ability to fight cancer cells. The research suggests that supplementing general anesthesia with a spinal or epidural painkiller before a radical prostatectomy reduces a patient’s need for opioids after surgery, and this finding was associated with a lower risk of cancer recurrence. The findings are published online in the British Journal of Anaesthesia. The immune system’s strength is especially important in cancer surgery because surgical manipulation of a tumor may spread cancer cells. The immune system can be impaired by general anesthesia, the overall stress surgery places on the body and by post-surgical systemic opioid use. The study found better outcomes in radical prostatectomy patients who had general anesthesia supplemented with spinal or epidural delivery of a long-acting opioid such as morphine, than in those who received general anesthesia only. “We found a significant association between this opioid-sparing technique, reduced progression of the prostate tumor and overall mortality,” says senior author Juraj Sprung, M.D., Ph.D., a Mayo Clinic anesthesiologist. Researchers used Mayo Clinic’s prostatectomy registry, anesthesia database and electronic medical records to identify patients who had prostate gland surgery for adenocarcinoma from January 1991 through December 2005. Reports of recurrence of cancer, cancer spread and death were confirmed with patients’ physicians. While promising, the findings must be tested in randomized trials, Dr. Sprung says: “Provided future studies confirm what we’ve found in this study, maybe down the line this would be a standard of care for pain management in patients undergoing cancer surgery.”...

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Better guidelines, coordination needed for prostate cancer specialists

With a deluge of promising new drug treatments for advanced prostate cancer on the market, a new model of care is needed that emphasizes collaboration between urologists and medical oncologists, according to UC Davis prostate cancer experts. In an article published online today in the journal Urologic Oncology, urologist Ralph de Vere White and medical oncologist Primo Lara, Jr. of the UC Davis Comprehensive Cancer Center describe a framework for urology and medical oncology interactions to enhance patient care, improve outcomes and yield clinical research advances. The physicians aim to address the general lack of collaboration between the two specialties when patients with prostate cancer develop resistance to drugs that block the hormone testosterone, which fuels prostate cancer growth. Until now, only a handful of medications, including chemotherapies, have been available for this group of patients. All of the new drugs on the market for prostate cancer are designed to treat these so-called “castrate-resistant” patients. “Patients with castrate-resistant prostate cancer (CRPC) will benefit if all caregivers buy into an integrated and comprehensive approach,” said de Vere White, who also directs the UC Davis Comprehensive Cancer Center. “When both specialties jointly manage the CRPC patient from the start, the artificial boundaries between specialties dissolve and transitions of care become seamless.” The UC Davis experts explain that castration-resistant prostate cancer patients are now often managed by either a medical oncologist (who specializes in chemotherapy treatment) or a urologist (who specializes in surgery to remove a cancerous prostate). Historically, urologists have referred patients to medical oncologists after their cancers become castrate resistant, and chemotherapy or other types of treatment are warranted. The new drugs, sipuleucel-T, radium 223, enzalutamide, abiraterone, and cabazitaxel, vary in their mechanism of action, but all target castrate-resistant disease, and some can be prescribed by either medical specialist. “There is an extra level of complication that this scenario engenders,” Lara said. “It has become blurry – who manages what, and when.” Clinical dilemmas have arisen in which clinicians are not clear on whether patients should be treated similarly or which drugs should be used and in what order to be most effective.  “With so many new drugs, how do you use them, and in what sequence?” Lara asks. “Is one better than the other? While we don’t have those answers, we can work on a framework to deliver patient-centered treatment.” Lara and de Vere White call for a urology-medical...

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ERG protein in prostate biopsies signals increased cancer risk

Researchers from Weill Cornell Medical College have shown that the presence of a particular protein in biopsied prostate tissue substantially increases the likelihood that cancer will develop in that organ. The discovery will likely help physicians decide how closely to monitor men potentially at risk for the cancer—among the most confusing and controversial dilemmas in health care. Their findings, reported in the Journal of Clinical Oncology, are the first to quantify, in the setting of a clinical trial, the increased risk of prostate cancer development from the protein ERG. Traditional means of determining risk of prostate cancer—blood tests for the protein prostate-specific antigen (PSA) and biopsies—do not always correlate well with the chances of dying from the disease. Decisions on what to do with the results of these tests can be unclear, leaving doctors and patients frustrated and unsure of how to proceed. Researchers at Weill Cornell Medical College are looking at specific changes within prostate cells, from an initial biopsy, to determine which men have a higher risk of prostate cancer development and need repeat biopsies or other types of monitoring. This study starts to fill in the picture for about 10 percent of prostate biopsies. Investigators found that 53 percent of men whose prostate biopsies showed expression of ERG protein developed invasive prostate cancer, compared to 35 percent of men whose biopsies were ERG-negative. All of the biopsies were classified as having high-grade prostatic intraepithelial neoplasia (HGPIN), which are lesions that may or may not morph into cancer. The findings mean that potentially thousands of men a year—those with ERG-positive HGPIN biopsies—may benefit from increased surveillance and early treatment of prostate cancer, while those whose HGPIN biopsies come back ERG-negative may be able to avoid unnecessary future biopsies, says the study’s senior investigator, Dr. Mark Rubin, the Homer T. Hirst Professor of Oncology in Pathology and professor of pathology and laboratory medicine. “This study is the largest ever conducted that focuses on looking at HGPIN and ERG in a systematic way. We found that more than half of patients with these biomarkers go on to develop prostate cancer, and that is a significant finding which we now want to test in a prospective clinical trial,” says Rubin, who is also director of the Institute for Precision Medicine at Weill Cornell and New York-Presbyterian Hospital and a professor of urology. “What this study shows is that not all...

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