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Sunday, July 27, 2008

Blog Updates for July 2008

July 1/08. In PSA Screening and Early Detection - Part 2. Key Points on PSA we added this item: [PMID: 18267334] has even suggested that it may be necessary to lower the cutpoints used to assess the presence of prostate cancer in the obese.

July 1. In Prostate Cancer Calculators we added this link to the info on subdivisions of the WHO BMI data.

July 1. Added to Free Monthly Prostate Cancer Magazines and Journals : The new web site of Our Voice magazine is now functioning: web site

July 3. In the Urinary Incontinence post added: A 2008 Norweigan study concluded that patients receiving physiotherapist-guided pelvic floor exercise training throughout the year following surgery reduced urinary incontinence significantly in comparison to self-guided patients. No difference was seen at 3 months but after 6 and 12 months the group with physiotherapist-guided training were more likely not to require pads. [PMID: 18448233] .

July 3. On the Case Histories page: Steve Kramer has provided one sentence summaries of some patients with advanced prostate cancer who participated in online group in this post.

July 5. In Bradford Hill Criteria of Causation we added the following regarding the biological plausibility of lycopene's anti-cancer effect: the 11 conjugated and two non-conjugated double bonds in lycopene make it highly reactive towards oxygen and free radicals, and this anti-oxidant activity probably contributes to its efficacy as a chemoprevention agent. The reactivity of lycopene also explains why it isomerizes rapidly in blood and tissues from the biosynthetic all-trans form to a mixture of cis-isomers. ... In addition to antioxidant activity, in vitro experiments indicate other mechanisms of chemoprevention by lycopene including induction of apoptosis and antiproliferation in cancer cells, anti-metastatic activity, and the upregulation of the antioxidant response element leading to the synthesis of cytoprotective enzymes. [PMID: 18585855]

July 8. In Free Downloadable Materials we have added a link to the updated and expanded Princess Margaret Hospital booklet -- Challenging Prostate Cancer: Nutrition, Exercise and You, undated but appears to be 2007 or 2008. 102 pages. This new patient-oriented booklet has been expanded to its current size from the earlier 22 page version published in 2000. The older material is included in expanded chapters on diet and nutrition in Chapter 1, Supplements in Chapter 2 and the cookbook in Chapter 4. New chapters cover nutrition during treatment in Chapter 3, exercise in Chapter 5 and motivation in Chapter 6. Authors include doctors and medical personnel in urology, oncology, psychology, physiology, nursing and nutrition: John Trachtenberg, Neil Fleshner, Kristin Currie, Daniel Santa Mina, Andrew Mathew, Barbie Casselman, Paul Ritvo, Jane Irvine, Carol Lancaster. The older 22 page 2000 version is also avaliable: John Trachtenberg, Neil Fleshner, Carol Lancaster, Barbie Casselman. Eating Right for Life: Prostate Cancer Nutrition & You, 2000, 22 pages. For patients who already have prostate cancer (as opposed to preventing prostate cancer in healhty patients.) Collaborative work by a urologist, oncologist, nurse and nutritionist from Princess Margaret Hospital in Toronto. Cookbook section at end. No references.

July 8. In the Links section in the right margin under Guidelines - Europe we have added a link to the guidelines on Strengthening the Reporting of Observational Studies in Epidemiology: [STROBE]. This link points to the publications page which in turn has links to the checklist and elaboration plus further links. Although intended for authors of observational studies it may be useful to those wishing to understand the elements of a good observational study, as well.

July 9. Marked Biochemical PSA Recurrence link under Key Posts in the right margin with a black dot denoting that it is Highly Accessed.

July 12. In How Healthy Men Can Reduce Their Risk we add this statistic: Out of 100 men, 12 will get prostate cancer in their lifetime. [PMID: 9332756].

July 13. In Biochemical PSA Recurrence we added this chart showing the probability of recurrence at 1 and 3 years given the PSA after Surgery based on those patients with high PSA after surgery:

July 14. In Advice to the Newly Diagnosed we added this bar chart of diagnostic imaging radiation levels:

July 14. In PSA Screening and Early Detection - Part 2. Key Points on PSA we added these bar chart: PSA Cutoff Levels

July 15. In How Long Can Prostate Cancer Treatment be Delayed After Treatment we added the two charts in this passage depicting the probability of a Gleason Score upgrade:
  • probability of GS upgrade is 62% if the pre-surgery PSA is 12 or more (vs. 18% if the pre-surgery PSA was less than 12)

    Probability of Gleason Score Upgrade vs. PSA
  • probability of a GS upgrade is 22.6% when the greatest percent of cancer in a biospsy core was higher than 5% (vs. a risk of 10.5%% when the greatest percent of cancer in a biopsy core was 5% or lower).

    Probability of Gleason Score Upgrade vs. Percent Cancer

July 16. In Advice to the Newly Diagnosed we add: A June 2008 epidemiological study based on 431 young-onset prostate cancer cases and matched controls found risks of 2x, 5x and 14x between the development of prostate cancer and X-ray exposure 5, 10 and 20 years earlier and also found a 2x risk for barium enenmas 5 years prior. The study author cautioned that "Although these results show some increase in the risk of developing prostate cancer in men who had previously had certain radiological medical tests we want to reassure men that the absolute risks are small and there is no proof that the radiological tests actually caused any of the cancers." [Science Daily] [PMID: 18506189].

July 19. In the Urinary Incontinence post added this reference: An excellent one page review by Committee 13 at the ICI 2088 conference in Paris presented on July 17, 2008 is available [here]. We have also added the Committee 13 Guidelines to the European Guidelines in the right margin of this site for easy reference under the tag [UI].

July 19. The material on radiation risks that was previously part of Advice to the Newly Diagnosed was expanded and placed onto a separate page: Radation Risks Associated with Prostate Cancer

July 19. On the Treatment Comparison: Line under Links in the right margin we added this comparison of Proton Beams vs. IMRT [link].

July 19. In ED After Prostatectomy. Part 2 - Rehabilitation we add: Preoperative Administration. In a Medscape article [Penile Rehabilitation Following Radical Prostatectomy] (see section entitled Structure of Rehabilitation) and a 2006 Urology Times interview John Mulhall (papers) indicates that there is animal evidence for daily administration (every other day for Cialis) preoperatively as well as post operatively and so uses the following protocol for his patients (quote is from Medscape link):
I encourage presurgical patients to use low-dose PDE-5 inhibitors on a nightly basis for 2 weeks before their operation. This strategy is based on the animal data supporting pretreatment. These patients are then told that with the catheter in place they should continue to use low-dose PDE-5 inhibitors on a regular basis (sildenafil and vardenafil nightly, tadalafil 3 times a week). When they are given the go-ahead to resume attempts at obtaining erections, they are switched to a low-dose PDE-5 inhibitor 6 nights a week and a maximum dose 1 night a week. The maximum-dose pill needs to be used in an appropriate fashion with sexual stimulation. The patients are encouraged to return to the office 6 weeks after surgery, which will allow them approximately 4 weeks to try maximum-dose medication.
After 6 weeks the protocol is as follows. In the exceptional case that this is successful in restoring sexual function within 6 weeks, they can continue with PDE-5 inhibitors. In the more likely case that they are not successful within 6 weeks then therapy is switched to intracavenosal penile injections twice a week (with appropriate training) and low dose PDE-5 inhibitors on non-injection nights. Because of its longer half life Cialis is not appropriate for this phase of the therapy. After a year they try maximum PDE-5 dosage once a month and if successful on that can stop injections. He normally expects some improvement within 10-14 months and optimal functionality in 18 to 24 months and notes that failure to respond to PDE-5 inhibitors in the first year does not necessarily preclude an excellent response after two years. The link cited above also gives a variation of this protocol in the case that it is started post-operatively.

July 20. In Prostate Cancer Calculators we added a link to the Han online calculator and updated the other links in this passage: An older 2003 recurrence table was published by Han et al [online calculator] [Full Text] [PMID: 12544300]. That table was based on a single surgeon at a single institution.

July 20. In the Urinary Incontinence post added this chart: Incontinence After Surgery with and without Training

July 21. In How Healthy Men Can Reduce Their Risk we found a more comprehensive list of labs providing the PCA3 test:

July 22. In Testosterone Metabolism we add: This suggests that such testosterone is advantageous to the cancer cells (bad for patient). In fact, Cougar Biotechnology is in Phase III clinical trials: NCT00485303 of a drug, abiraterone, whose mechanism of action includes preventing prostate cancers from manuacturing their own androgens inhibiting androgen production in the testis, adrenals and prostate by blocking CYP17 (P450c17). See [Medical News Today] [BBC News and audio interview] [Times News and Video] [Abstract] ASCO presentation and Urotoday ASCO summary [PCF Video].

July 22. Added new section to Radiation risks associated with Prostate Cancer:

Contrast-induced nephropathy, i.e. kidney damage due to the use of contrast agents taken by the patient to improve the images from diagnostic radiation (this is distinct from the radiation itself) is a possible complication of diagnostic imaging. "The risk of contrast-induced nephropathy is less than 10% in patients with normal baseline renal function. In patients with a creatinine clearance of 10 to 20 mL/min, the incidence of adverse renal effects is 80% to 90%." [Goldfarb, 2005] Risk assessment prior to such administration is performed. A brief overview of contrast-induced nephropathy be found in this article by George Herbert. More details can be found in [Rudnicki, 2006] and [Medscape review]. A 2008 meta-analysis of prevention methods concluded that "N-Acetylcysteine is more renoprotective than hydration alone. Theophylline may also reduce risk for contrast-induced nephropathy, although the detected association was not significant. Our data support the administration of N-acetylcysteine prophylaxis, particularly in high-risk patients, given its low cost, availability, and few side effects." [Annals of Internal Medicine, 2008].

July 22. In Questions to Ask Doctor added this link to advice from ASCO on dealing with doctors and the health care system:

July 25. In the Urinary Incontinence post added: Imipramine. Although anticholinergic drugs, and drugs in general, are normally thought of as addressing urge incontinence rather than stress incontinence, Bob Southard has had good experience with imipramine (also see [wikipedia] and particularly note [cautions]) for stress incontinence. It acts on the bladder neck muscles. (Note that typically the effect of drugs is on the bladder muscles themselves rather than the bladder neck muscles which is why drugs are normally associated with urge, rather than stress incontinence.) The following is quoted with permission:
Quick story... Had my RRP in 1994 at Johns Hopkins, and have had minor incontinence since, usually 1 pad per day. Last year I had a medical procedure that required a catheter. Apparently my bladder was quite unhappy with this, and my incontinence got significantly worse afterward (yes, I warned them). I was starting to get surprised by full pads, leaking pads. I needed 3 and sometimes 4 pads per day.
In December I went to a new urologist, and he prescribed imipramine Hcl 25mg, twice per day. It worked. I went back to 1 pad per day with LESS leakage than before the medical procedure. Note that this is an off label use for this relatively inexpensive generic drug.

I thought, maybe something else was going on, like I had an infection, or some irritation, or whatever. So to be sure, I tried going off the imipramine a few weeks ago. Yep, back the incontinence came. I went back on the imipramine, and it's gone again.

This is the 6th uro I've seen since my RRP, and the first to mention this drug. I ask myself, why are uros not bringing this to patients' attention? There have been many times in the past where it would have been useful to me in circumstances of dealing with a lot of stress incontinence.

I believe that my incontinence is MOSTLY stress incontinence. Typically, my leakage is MUCH worse when I am walking or working on my feet all day, much less when sitting and standing, and nil when sitting. I use no pad at night while sleeping.

So it's mostly stress incontinence, but I do occasionally feel bladder spasms; rarely, but they do occur. I never have sudden onset of the urge to urinate, or other symptoms of urge incontinence.

July 26. In Questions to Ask Doctor added this link: The answers to many questions on medical tests can be found on the Lab Tests Online site. Also put a link to it in Advice to the Newly Diagnosed and in the right margin in the Links section on the Medical/Uro line.

July 26. In the post on Testosterone Metabolism we add: In a July 2008 review [PMID: 18638000] the authors conclude that "In the few available case series describing testosterone replacement after treatment for PCa, no case of clinical or biochemical progression was observed. ... Although further studies are necessary before definitive conclusions can be drawn, the available evidence suggests that TRT can be cautiously considered in selected hypogonadal men treated with curative intent for PCa and without evidence of active disease."

July 26. Added in Links section of right margin on Webcasts line: [Youtube]

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