Complications of radical prostatectomy.
Complications of radical prostatectomy are well-known and the most bothersome ones are impotence and incontinence. There is also a risk of mortality because this is a surgical procedure. For that interest I think radiation therapy will offer some alternatives. The complications are different for the two procedures. Surgery, as we said, has an immediate mortality; incontinence and impotence. Radiation therapy causes irritation to the rectum and bladder, which usually gets better over time, although you can have some scarring. Both of them can actually produce impotence and fatigue. Impotence following radiation therapy is usually more slow to develop. It develops gradually over time but it is there as a complication. Whereas in surgery it’s an immediate, one-time issue. There have been improvements in therapy, in both radiation and surgical areas. Surgeons are interested in so-called nerve-sparing prostatectomies, which lower the risks of impotence in these patients. Cryosurgery has been done in both modalities, neo-adjuvant hormonal therapy, which I will come to in a minute – has also been done. Radiation therapy has undergone improvements also. We now have better radiation planning and radiation implants for low stage patients with needles be put into the prostate, rather than external beam radiation.
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The optimal strategy then for localized disease remains somewhat controversial. I think that the data that we have so far suggests that radical prostatectomy is the best proven method for disease-free survival. However, I think neither of these techniques – again, very analogous to breast cancer where they are dealing with radiation or surgery – neither of them are going to have an optimal impact on overall mortality until you can get something to go in systemically for the patients who have microscopic metastases. Remember the slide I showed you earlier, it showed that upwards of 30-50% of these people are going to have occult lymph node involvement even with clinically localized disease. These people are not going to be salvaged by whatever you do for local therapy. There is some data and a great deal of interest now starting to emerge in using adjuvant or neo-adjuvant androgen depletion in these patients. This shows data from patients who underwent prostatectomy alone or prostatectomy with orchiectomy and you can see the improved survival in this group of patients. So we are now very interested in using somewhere between 6 and 9 months of anti-androgen therapy in addition to local treatment for patients who have high risk tumors. Female pink viagra
With regard to metastatic prostate cancer, in the last couple of slides, the major therapy is related to androgen depletion. This can be done by orchiectomy. This can be done by using estrogens, which are seldom used today because of the complications of estrogen. It’s done most popularly today by using gonadotropin releasing hormone analogs and these have all been shown to be of equal efficacy. There has been some interest in using flutamide, which is an androgen receptor blockade, to provide so-called total androgen blockade. The data with that has, I think, been somewhat controversial. This cartoon I think reflects the problem. This is of course the testicle and the testosterone being reduced by blocking the gonadotropin releasing hormone to cut down on testicular testosterone. You still have the adrenal gland _ which can convert it to 5-alpha reductase to DHT so by blocking this or by blocking the androgen receptor you can have more complete androgenic blockade. Despite the fact that this looks good theoretically and the fact that this early study did show a slight survival advantage for total androgenic blockade, it looks now that there is really minimal, you know, slim to none, none to minimal advantage of using both gonadotropin releasing hormone agonist, and probably gonadotropin releasing hormone agonist alone is adequate therapy for metastatic disease.
The final slide I will show you for prostatism is that there are chemoprevention efforts that are getting under way using the retinoids, using the 5-alpha reductase inhibitors and looking at low fat diets to see whether we can modify incidence of disease, not just deal with it from screening positivity. So thank you very much.