Death From Other Causes
The mean age at metastatic prostate cancer diagnosis in the study was roughly 71 years. Most of the cohort was White and had a diagnosis of stage M1b metastatic prostate cancer , which means the cancer had spread to the bones.
Among men in the cohort, the rates of death from septicemia, suicide, accidents, COPD, and cerebrovascular diseases were significantly increased compared with the general US male population, the team observes.
Thus, the study authors were concerned with not only with death from metastatic prostate cancer, but death from other causes.
That concern is rooted in the established fact that there is now improved survival among patients with prostate cancer in the US, including among men with advanced disease. âPatients tend to live long enough after a prostate cancer diagnosis for noncancer-related comorbidities to be associated with their overall survival,â they write.
The editorialists agree: prostate cancer âhas a high long-term survival rate compared with almost all other cancer types and signals the need for greater holistic care for patients.â
As noted above, cardiovascular diseases were the most common cause of non-prostate cancer-related deaths in the new study.
As in the management of other cancers, there is concern among clinicians and researchers about the cardiotoxic effects of prostate cancer treatments.
The study had no specific funding. The study authors and editorialists have disclosed no relevant financial relationships.
Radiation Therapy And Radiopharmaceutical Therapy
External-beam radiation therapy
Candidates for definitive radiation therapy must have a confirmed pathologic diagnosis of cancer that is clinically confined to the prostate and/or surrounding tissues . Staging laparotomy and lymph node dissection are not required.
Radiation therapy may be a good option for patients who are considered poor medical candidates for radical prostatectomy. These patients can be treated with an acceptably low complication rate if care is given to the delivery technique.
Long-term results with radiation therapy are dependent on stage and are associated with dosimetry of the radiation.
Treatment Option Overview For Prostate Cancer
In This Section
Local treatment modalities are associated with prolonged disease-free survival for many patients with localized prostate cancer but are rarely curative in patients with locally extensive tumors. Because of clinical understaging using current diagnostic techniques, even when the cancer appears clinically localized to the prostate gland, some patients develop disseminated tumors after local therapy with surgery or radiation.
Treatment options for each stage of prostate cancer are presented in Table 6.
|Stage||Standard Treatment Options|
|EBRT = external-beam radiation therapy LH-RH = luteinizing hormone-releasing hormone PARP = poly polymerase TURP = transurethral resection of the prostate.|
|Stage I Prostate Cancer|
|PARP inhibitors for men with prostate cancer and BRCA1, BRCA2, and/or ATM mutations|
Side effects of each of the treatment approaches are covered in the relevant sections below. Patient-reported adverse effects differ substantially across the options for management of clinically localized disease, with few direct comparisons, and include watchful waiting/active surveillance/active monitoring, radical prostatectomy, and radiation therapy. The differences in adverse effects can play an important role in patient choice among treatment options. Detailed comparisons of these effects have been reported in population-based cohort studies, albeit with relatively short follow-up times of 2 to 3 years.
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Men With Incurable Prostate Cancer Living For Twice As Long As Decade Ago
Patients with advanced prostate cancer treated with the latest therapies are living on average for more than twice as long as a decade ago, a striking new analysis reveals.It showed that patients with incurable prostate cancer treated at leading cancer hospital The Royal Marsden NHS Foundation Trust now live for about two extra years on average than they did just 10 years ago.The research, conducted by The Institute of Cancer Research, London, and The Royal Marsden, found the introduction of a range of new drugs has had such an impact that the system doctors use to predict how long patients will live now needs to be revised.The research is published in European Urology and was conducted by researchers who are funded by Prostate Cancer UK, Cancer Research UK, the Medical Research Council and the Prostate Cancer Foundation, US.The team studied data from 442 UK patients across 32 clinical trials and two extended access drug programmes at The Royal Marsden since 2003.Some 78% of patients received docetaxel-based chemotherapy, which was approved for use on the NHS in 2005.
Half received abiraterone, a targeted prostate cancer drug discovered at The Institute of Cancer Research and approved for use on the NHS last year.
Importance Of Cancer Staging
Staging a cancer helps your doctor and your cancer care team understand how advanced the cancer is.
Knowing the stage is important for selecting the best treatments and therapy options. It also plays a role in your outlook for the future.
The for pancreatic cancer is the American Joint Committee on Cancer TNM system. It uses a scale of 0 to 4.
The AJCC stages and substages are determined by key information:
- the cancers proximity to lymph nodes
- whether the cancers spread, or metastasized, to distant locations
Cancers may also be described using one of the
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What Are Next Steps
Bone metastasis have a profound effect on the long-term outlook for prostate cancer. But its important to remember that the numbers are only statistics.
The good news is that life expectancy for advanced prostate cancer continues to increase. New treatments and therapies offer both longer life and better quality of life. Speak to your doctor about your treatment options and long-term outlook.
Everyones cancer experience is different. You may find support through sharing your treatment plan with friends and family. Or you can turn to local community groups or online forums like Male Care for advice and reassurance.
What Is Stage 4 Cancer
Stage 4 cancer is sometimes referred to as metastatic cancer, because it often means the cancer has spread from its origin to distant parts of the body. This stage may be diagnosed years after the initial cancer diagnosis and/or after the primary cancer has been treated or removed.
When a cancer metastasizes to a different part of the body, it is still defined by its original location. For instance, if breast cancer metastasizes to the brain, it is still considered breast cancer, not brain cancer. Many stage 4 cancers have subcategories, such as stage 4A or stage 4B, which are often determined by the degree to which the cancer has spread throughout the body. Similarly, stage 4 cancers that are adenocarcinomas are often referred to as metastatic adenocarcinomas.
Liquid cancers, or blood cancers, such as leukemia, lymphoma or multiple myeloma, are staged differently than most other cancers because they may not always form solid tumors. Liquid cancers may be staged by a variety of factors, including:
- The ratio of healthy blood cells to cancerous cells
- The degree to which lymph nodes, the liver or spleen may be swollen
- Whether the cancer has resulted in blood disorders such as anemia
Stage 4 cancer is determined in the five most common cancers this way:
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Do You See A Urologist For Prostate Cancer
Often, if a physician suspects their patient has prostate cancer, they will refer them to a urologist for further evaluation. Urologists specialize in diagnosing and treating diseases of the urinary system, including prostate cancer. A urologist can conduct a biopsy to confirm a prostate cancer diagnosis. During the biopsy, a thin, hollow needle will be inserted into the prostate to collect a sample of prostate tissue. The needle may be inserted multiple times to collect several samples.
Within a few days, the urologist should have the diagnosis. If the biopsy is positive for prostate cancer, he or she will then stage the cancer and discuss the patients treatment options. Some patients with early-stage prostate cancer may be eligible for an active surveillance approach in which their condition will be monitored regularly. Treatment may be considered if the cancer begins to spread or cause symptoms.
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Watchful Waiting Or Active Surveillance/active Monitoring
Asymptomatic patients of advanced age or with concomitant illness may warrantconsideration of careful observation without immediate active treatment. Watch and wait, observation, expectant management, and active surveillance/active monitoring are terms indicating a strategy that does not employ immediate therapy with curative intent.
Watchful waiting and active surveillance/active monitoring are the most commonly used terms, and the literature does not always clearly distinguish them, making the interpretation of results difficult. The general concept of watchful waiting is patient follow-up with the application of palliative care as needed to alleviate symptoms of tumor progression. There is no planned attempt at curative therapy at any point in follow-up. For example, transurethral resection of the prostate or hormonal therapy may be used to alleviate tumor-related urethral obstruction should there be local tumor growth hormonal therapy or bone radiation might be used to alleviate pain from metastases. Radical prostatectomy has been compared with watchful waiting or active surveillance/active monitoring in men with early-stage disease .
- Regular patient visits.
- Transrectal ultrasound .
- Transrectal needle biopsies .
Patient selection, testing intervals, and specific tests, as well as criteria for intervention, are arbitrary and not established in controlled trials.
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Does Overdiagnosis Lead To Overtreatment Of Older Men
The widespread use of PSA screening has led to an increase in the diagnosis and treatment of early localized prostate cancer. Data from the US Cancer of the Prostate Strategic Urological Research Endeavor database suggest a significant decrease in risk in the last 2 decades in the United States, with more patients being identified with low-risk disease at diagnosis,29 but the role of active treatment of low- and intermediate-risk disease in elderly men remains controversial.
The median time from diagnosis to death from prostate cancer for men with nonpalpable disease is approximately 17 years.30,31 Considering that the US male life expectancy at the age of 65 years is 16 years, aggressive therapy will hardly extend life expectancy of older men with no palpable prostate cancer at the time of diagnosis.32 Twenty to 30% of prostate cancers detected by PSA screening programs show Gleason scores of 6 or lower and, thus, are not poorly differentiated and have volumes smaller than 0.5 cm3.3335
Histologic evaluation of radical prostatectomy specimens demonstrated that about 20% to 30% of cancers are small volume, show low Gleason scores, and are consequently clinically harmless.35,36 Many of these cancers pose little threat to life, especially for older men. Has PSA screening resulted in prostate cancer overdiagnosis?
How We Treat Prostate Cancer
The prognosis for metastatic prostate cancer can be discouraging, but some treatment centerslike the Johns Hopkins Precision Medicine Center of Excellence for Prostate Cancerspecialize in innovative, individualized therapy with the potential to improve outcomes.
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Stage 2 Prostate Cancer
In stage 2, the tumor is still confined to your prostate and hasnt spread to lymph nodes or other parts of your body. A doctor may or may not be able to feel the tumor during a prostate exam, and it may appear on ultrasound imaging. The survival rate is still .
The PSA score for stage 2 is less than 20 ng/mL.
Stage 2 cancer is further divided into three phases depending on the grade group and Gleason scores:
- Gleason score: 6 or less
What Is Inoperable Lung Cancer
Inoperable lung cancer is a tumor that surgery canât treat. This might be because the cancer is in a hard-to-reach spot or for other reasons, like if itâs spread outside your lungs. Itâs also called unresectable lung cancer.
Just because you can’t have surgery doesn’t mean you can’t do anything about the cancer. Treatments like radiation, chemotherapy, targeted therapy, and immunotherapy can fight it, even when an operation isn’t an option.
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Possible Changes In Body Function
- Profound weakness usually the patient cant get out of bed and has trouble moving around in bed
- Needs help with nearly everything
- Less and less interest in food, often with very little food and fluid intake for days
- Trouble swallowing pills and medicines
- More drowsiness the patient may doze or sleep much of the time if pain is relieved, and may be hard to rouse or wake
- Lips may appear to droop
- Short attention span, may not be able to focus on whats happening
- Confusion about time, place, or people
- Limited ability to cooperate with caregivers
- Sudden movement of any muscle, jerking of hands, arms, legs, or face
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Quality Of Life With Advanced Stage Prostate Cancer
Since Huggins and Hodges won a Nobel Prize in 1966 for their work describing the relationship between testosterone and prostate cancer, androgen deprivation has continued to be an important component in the treatment of advanced prostate cancer. It is associated, however, with significant cost in terms of morbidity as well as economics. Side effects of androgen deprivation therapy include hot flashes, osteoporosis, loss of libido or impotence, and psychological effects such as depression, memory difficulties, or emotional lability. Recently Harle and colleagues55 reported insulin resistance, hyperglycemia, metabolic syndrome, and metabolic complications being associated with castration and thus being responsible for increased cardiovascular mortality in this population.
Because of the palliative nature of androgen ablation, quality of life is an important component of evaluating competing therapies. Intermittent androgen deprivation is one approach to hormonal therapy that has been developed with the aim of minimizing the negative effects of therapy while maximizing clinical benefits and the patients quality of life. It can be used in any clinical situation where continuous androgen deprivation treatment could be applied.56
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Hormonal Therapy And Its Complications
Several different hormonal approaches are used in the management of various stages of prostate cancer.
These approaches include the following:
- Abiraterone acetate .
Abiraterone acetate has been shown to improve OS when added to ADT in men with advanced prostate cancer who have castration-sensitive disease. Abiraterone acetate is generally well-tolerated however, it is associated with an increase in the mineralocorticoid effects of grade 3 or 4 hypertension and hypokalemia compared with ADT alone. It may also be associated with a small increase in respiratory disorders.
Benefits of bilateral orchiectomy include the following:
- Ease of the procedure.
- Immediacy in lowering testosterone levels.
- Low cost relative to the other forms of ADT.
Disadvantages of bilateral orchiectomy include the following:
- Psychological effects.
Bilateral orchiectomy has also been associated with an elevated risk of coronary heart disease and myocardial infarction.
Estrogens at a dose of 3 mg qd ofdiethylstilbestrol will achieve castrate levels of testosterone. Likeorchiectomy, estrogens may cause loss of libido and impotence. Estrogens also cause gynecomastia, and prophylactic low-dose radiation therapy to the breasts is given to prevent this complication.
Luteinizing hormone-releasing hormone agonist therapy
Religious And Spiritual Beliefs
Awareness of the importance of religious beliefs and spiritual concerns within medical care has increased substantially over the last decade. National consensus guidelines, published in 2018, recommended the following:
- That all patients receive a screening assessment for religious and spiritual concerns, followed by a more complete spiritual history.
- That all patients receive a formal assessment by a certified chaplain.
- That such information is placed in patient records, with follow-up at all appropriate times, including hospitalization at the EOL.
An interprofessional approach is recommended: medical personnel, including physicians, nurses, and other professionals such as social workers and psychologists, are trained to address these issues and link with chaplains, as available, to evaluate and engage patients. A survey of nurses and physicians revealed that most nurses and physicians desire to provide spiritual care, which was defined as care that supports a patients spiritual health. The more commonly cited barriers associated with the estimated amount of spiritual care provided to patients included inadequate training and the belief that providing spiritual care is not part of the medical professionals role. Most nurses desired training in spiritual care fewer physicians did.
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Treatment Of Invasive Bladder Cancer In The Elderly And Frail Patient
I think this is a very contemporary topic because we are living in an aging society. If you look here, and you know if you really want to look at the life expectancy you should look at charts of the insurance company and governmental agencies rather than medical reports. And this is the life expectancy nowadays where in North America. So, you can see that if you are at the octogenarians, octogenarians for the sake of this talk is 80 years old, 80 to 90, and nonagenarians are 90 and plus. And you see so when you hit 80 you still have at least seven years as a male, and nine years or more as a female. So, we are actually talking about increased population that, and Ill show you data, has more bladder cancer, and theyre actually destined to live quite long if they are in the average risk. So, if you live for example to 90 years old youre expected to live about four years if youre a male and four and a half or five years if youre a female. So, we have to bear these figures in mind.
But once its diagnosed we have a very poor, we poorly address that. This is a paper by Gore et al, and it shows that only 21% of muscle invasive bladder cancer patients over the age of 65 here actually received radical cystectomy. He shows also that there was a better overall survival, but obviously this is biased by selection.
Partial cystectomy there is very few data, none in octogenarian. This is just a series from Wes Kassouf, so I will omit that because we really dont have enough data.