Lifebuoy Issue 1 - 2010 - St Vincents Prostate Cancer Centre

the
St Vincent’s Hospital
Prostate Cancer Support Group
affiliated with the
Prostate Cancer Foundation of Australia
LIFEBUOY
ISSUE 1 2010
Dear Readers
As advertised in our last newsletter Dr Charles “Snuffy” Myers visited Australia in February.
During his visit he gave talks in Sydney, Brisbane and Melbourne. I had the opportunity to
hear him speak at the Garvan Institute, where there was a sellout crowd of over 300 people.
A/Prof. Stricker has written a summary of Dr Myers’ talk which you can find inside, as well as
the details of how to purchase the talk Dr Myers’ gave at the Garvan Institue.
Jaime Fronzek – an accredited practicing dietician and nutritionist will be a regular contributor
to Lifebuoy. She has always had a passion for food and its effect on health. She is particularly
interested in the effects that specific dietary and lifestyle factors can have on men suffering
with prostate cancer. Jamie follows the recommendations of Dr Charles ‘Snuffy’ Myers due to
the success he has had with his patients. In each issue she will bring you updates on healthy
eating with a recipe for you to try. Now there will be no excuses not to eat delicious food that is
good for you.
Our research updates will now also introduce you to the talented researchers working
behind the scenes at the Garvan Institute and the St Vincent’s Prostate Cancer Centre. Each
newsletter will give you an opportunity to find out about them and their work.
On March 18th I attended the PCFA ‘Thank You’ function at Kirribilli House. I had the privilege
of being one of five recipients of the Max Gardner award for distinguished service. This award
is given by the PCFA to those who have made an outstanding and significant contribution to
the cause of prostate cancer in Australia. The other recipients were John Allen, Ron Schmarr,
Robert Slade and Con Casey. It was a wonderful evening and I felt very honoured.
prostate cancer
centre
Mr David Sandoe OAM with the Max Gardner Award recipients
Jayne Matthews - Coordinator
www.prostate.com.au
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Dr Charles ‘Snuffy’
Myers
The talk given
at the Garvan
Institute to over
300 people.
by A/Prof Phillip Stricker
The St Vincents Prostate Cancer Centre and the Prostate Cancer
Foundation of Australia were honoured to welcome Dr Myers to
Australia in February. Dr Myers (USA) is a medical oncologist,
scientist, nutrition expert and prostate cancer survivor. He
has over 250 research papers published and over 30 years of
experience with this disease. He opened the Institute for Diseases
of the Prostate in 2001 to provide men with the comprehensive
care that saved his life.
Understanding principles of cancer.
1. It is very clear that in 2010 we have a very poor understanding of the
method by which cancer is spread. Within any cancer there are cells that
cannot spread, cells that generate other cancer cells and stem cells which
generate all the cells, which are less than 1% of the overall population.
2. Dr Myers believes that it is necessary to induce a full remission
and maintain that remission to gain long term durable results. This has
been seen with other cancers such as leukaemia, testicular cancer and
lymphoma.
3. Dr Myers also suggested a long term remission was still possible if the
cancer was not too wide spread - a concept called “oligo metastasis”.
4. Finally when a cancer no longer responds to traditional hormones, it
was Dr Myers’ opinion that a lot of the cancers simply function on less
testosterone or dihydrotestosterone. This led to the theory that complete
blockage of testosterone both inside and outside the cells may be an aim
for further therapy.
Hormone therapy.
Dr Myers felt that total androgen ablation had some advantages over single
LHRH agonists. He also felt that there are many patient’s who have hormone
therapy where the testosterone is suppressed but the dihydrotestosterone
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is not suppressed and he believes that further suppression of the
dihydrotestosterone in people who are not fully responding may be useful.
This would involve the use of Proscar or Avodart.
Second line hormone therapy.
Dr Myers strongly believes that the attempt to get a full remission is
worthwhile as he believes this is more likely to give one a more durable
result. A full remission means no evidence of cancer on all forms of imaging
and a PSA of less than 0.01.
His own second line hormone therapy at this stage is a combination of
Ketoconazole, high dose estradiol and Leukine. The last one unfortunately is
very expensive and not available in Australia. He also mentioned that when
Abiraterone becomes available this drug has the potential to be safer and
have equal or better efficacy than Ketoconazole. The problem with using
Ketoconazole is that it needs to be carefully utilised with particular care
to drug interactions and the affect on the liver and the need to gradually
introduce it and take it regularly every 8 hours. Under the careful supervision
of a medical oncologist or urologist this, however, in experienced hands, is safe.
High dose estradiol is also effective but unfortunately increases the risk of
DVT and pulmonary embolus and therefore one would need to take Warfarin.
Again one would have to be under a careful supervision program of a
medical oncologist. With regard to Leukine there is evidence from Eric Small,
a medical oncologiist and researcher form America that this is synergistic
and this adds to the treatment of Ketoconazole but at this stage unfortunately
it is unavailable in Australia and is expensive.
Abiraterone which is currently in trial in Australia and worldwide appears to
have less interactions with other drugs and is a once a day dosage with less
side effects. There is hope that if this proves successful in phase III trials, it
will be available in the next couple of years.
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Side effects of hormone therapy
The following is a list of the possible side effects of hormone therapy:
Hot flushes
Depression
Decreased libido
Lethargy
Osteoporosis
Abnormal liver function tests
Increased breast size (gynaecomastia)
Hypertension
Diabetes
Hypercholesterolemia
Clearly, many of these side effects can be anticipated and managed.
It is mandatory that the general practitioner for patient’s on hormone
therapy monitor their blood pressure, blood sugar, bone mineral density,
cholesterol, lipids and liver function tests regularly. Furthermore it
is important that specific questioning about hot flushes, depression,
gynaecomastia, lethargy and libido are asked and addressed.
General supportive care.
At all stages of prostate cancer it is important to do the following:
Be positive and optimistic.
Use appropriate supplements
such as pomegranate, fish
oil, lycopene and possibly
resveratrol.
Eat a Mediterranean type diet
and avoid obesity.
Eliminate vitamin D deficiency.
That any side effects of therapy are
addressed such as abnormal liver function
tests, osteoporosis and hot flushes.
Ensure that hypertension, diabetes and
hypercholesterolemia are well controlled.
Have regular exercise
Locally advanced disease
There have been improvements in both the staging techniques and treatment
of locally advanced disease. Example of advances are:
Generally many of these can be controlled by diet, exercise and
counselling whilst others such as hot flushes require treatment such as
estradiol topical patches. Other treatments include tablets to prevent or
treat abnormal liver function tests, tablets to prevent gynaecomastia,
anti depressants in more extreme forms of depression, ace inhibitors
or angiotensin blockers or diuretics to treat hypertension and general
emotional supportive and optimistic care.
1. IMRT ( Image Modulated Radiotherapy ) to more accurately target primary
and secondary prostate cancer.
Maintenance therapy
Dr Myers believes that once a full remission is achieved in patients with
advanced prostate cancer that this needs to be maintained. This can be
achieved in his view with the use of eliminating Vitamin D deficiency,
a Mediterranean diet, regular exercise, decrease in stress and various
supplements such as pomegranate,
lycopene, fish oil and possibly
resveratrol (the active component of
red wine).
Conclusion
Dr Myers has shown that in many of the patients he has treated, they
have performed much better than expected. This may well be due to his
therapy. There was an enormous enthusiasm from the public and all three
meetings throughout Australia and one of the strong points he made was
to generate a sense of optimism in all
patients and show patients what they
can do for themselves to give patients
a sense of power over their own
disease. He was also very optimistic
about the future and some of the new
developments and understanding that
are occurring.
In the high risk situation he has
also trialled the use of Avodart
or Dutasteride, using higher dose
resveratrol and even periodic uses
of Leukine. Much of this data has
limited evidence at this stage though
is supported by some phase II trials.
In the higher risk situation this
would need careful supervision by an
experienced physician.
2. MRI to better image the extent of the cancer in the prostate.
3. Combidex MRI and choline CT/PET fusion to more accurately locate the
site of lymph node metastases.
To purchase this DVD of the talk given
at the Garvan Institute please visit:
www.menshealthmatters.com.au
Dr Myers’ website - www.prostateforum.com
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Eating
healthy
with
Jamie
Jaime Rose Fronzek is an Accredited Practicing Dietitian
(APD) and Accredited Nutritionist who holds a Bachelor degree
in Nutrition & Dietetics from the University of Newcastle. Jaime
works as a privately practising Dietitian at Professor Kerryn
Phelps’ Uclinic and Cooper Street Clinic in the Eastern Suburbs of
Sydney and is a Nutrition Leader for a NSW Health Government
project for overweight and obesity. She has a special interest
in diet & lifestyle for prostate and breast cancer and is strongly
involved with the St Vincents Prostate Cancer Centre.
jaime@uclinic.com.au Patients in all stages of treatment for prostate cancer as well as those on
active surveillance can benefit greatly from a specific diet and lifestyle plan by
supporting them through treatment and assisting in keeping them in remission.
salmon tomato salsa
Ingedients
1 long red chilli, seeds removed, finely chopped
1 tbs lime juice, plus lime wedges to serve
2 tsp fish sauce
2 tsp sesame oil
2 cups coriander leaves
1 cup mint leaves
1 punnet grape tomatoes, halved
2 eschalots, thinly sliced
4 x 180g salmon or ocean trout fillets
1 tbs sunflower oil
Steamed jasmine rice (optional), to serve
Method
0
Preheat oven to 19O C.
Place the chilli, lime juice, fish sauce and sesame oil in a bowl
and stir together. Tear the herbs in a separate bowl and add
the tomatoes and eschalots. Season the salmon fillets with salt
and black pepper and set aside.
Heat the sunflower oil in a non-stick ovenproof frypan over
medium-high heat. Add the salmon and cook for 2 minutes
on each side. Transfer the salmon to the oven for a further 5
minutes or until the salmon is cooked to your liking.
Recipe taken from www.taste.com.au
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Just before serving, toss the dressing with the tomato mixture.
Place the salmon on a plate and top with the salsa. Serve with
lime wedges and steamed jasmine rice, if desired.
8/04/10 10:29 AM
THE DEBATE
Is robotic radical prostatectomy now the
gold standard surgical procedure for the
treatment of localised prostate cancer?
At the recent annual meeting of the Urological Society of Australasia in Perth
A/Prof Phillip Stricker and Dr Geoff Coughlin were invited to participate in the
debate on the above topic against their colleagues from the USA. Here is a
summary of their affirmative argument only.
A/Prof Stricker explained that having done over 2,600 open radical prostatectomies
and over 400 robotic prostatectomies he was in an excellent position to judge
whether robotic prostatectomy was offering his patients better outcomes. He noted
that his patients were having a quicker recovery, less blood loss and transfusion,
less cystogram leaks, less bladder neck contractures, a lower positive surgical
margin rate in PT2 cancers, earlier and more complete return of potency, easier to
perform technically in some patients such as obese patients or people who have
had previous laparoscopic measures for hernia repairs, it was better for him in
terms of the comfort during operating and it was a better teaching tool. He also
made the point that in more extensive cancers it took him longer to achieve equal
outcomes as for his open cases but currently with the experience of having done
over 400 cases he has now mastered the ability to not only achieve equal results
to his open series but also be able to perform extended lymph gland dissections
which are necessary for the higher grade cancers.
A/Prof Stricker explained that there has been considerable evidence from the world
literature suggesting that the surgeon volume has a direct link to patient outcomes.
The learning curve for open surgery and robotic surgery is much longer than
initially appreciated and probably is about 250 cases. With these 2 observations
he made the conclusion that when comparing the different forms of radical
prostatectomy it was mandatory to only compare experienced units and also make
sure that the technique of reporting was standardised.
Looking at the ‘trifecta’ (i.e. the positive surgical margin rate, urinary continence
rates and potency rates), recovery rates and complication rate between the various
techniques i.e. robotic, laparoscopic and open surgery it was very difficult to
compare these technologies until recently when more experienced robotic units
are now starting to report their results. When looking at only centres that have
reported their results of greater than 250 cases and reviewing all the literature
till April 2009 , Patel et al were able to find 48 articles and when looking at the
review of all articles reporting greater than 50 cases from 1996 to 2009 in the
lifebuoy_e1_2010.indd 5
world literature the ICER review committee were able to find 70 articles. On
reviewing the centres that have performed more than 250 cases and comparing
the averages of each technique, the positive surgical margin rate, continence and
potency were better for the robotic technique than either the open or laparoscopic.
When comparing the 70 articles reporting greater than 50 cases, the PT2 positive
margin rate as well as the continence and potency rates were better for the robot
compared to the other techniques but with more extensive cancers they were equal
(ICER review). Ficarra et al , in reviewing the 10 studies that directly compared
robot versus open, there appears to be a benefit for the robot in terms of positive
surgical margin rates.
A snapshot of approximately 40% of all the prostatectomy cases performed
in Australia in 2009 showed that the PT2 positive margin rate was better for
the robotic procedure whilst the PT3 positive margin rate was similar between
all procedures. In specific regard to potency after robotic or open surgery he
referred to the article published by Montorsi et al in Milan who used a validated
questionnaire and followed his patients for 24 months and compared his open and
robotic results. Montorsi is a highly experienced open and robotic surgeon and
he found in his hands the results of nerve sparing surgery seemed to give better
results in the robotic arm.
With regard to complications the national data presented from Medicare collected
in 2003 to 2005 (Hu et al), the results from the Karolinska Institute in Stockholm
(Carlson et al) where a more validated prospective collection was used and then
some of the major reviews of complications which have been performed by Patel
et al shortly to be published in European Urology and ICER which is an institute
which reviews data associated with Massachusetts General and Harvard. In
looking at this information, robotic radical prostatectomy has less blood loss, less
chance of transfusion, less general complications, less chance of bladder neck
contracture, shorter length of stay and has less impact on the surgeons from the
point of view of neck pain and back pain. Furthermore, the point that it is widely
available in the United States and becoming increasingly available in Australia and
the growth of the Da Vinci robot appears to be on track to be readily available to
most Urologists within 3 to 4 years.
As a teaching tool the da Vinci robot is excellent in providing better visualisation,
the opportunity for simulation, supervision and video based learning. From the
point of view of the future, it readily lends itself to fusion of images such as MRI
with operating procedures and also working in concert with the new developments
where single holes and normal orifice surgery are developing, this would enable
this to become a reality.
As with every new technology there are various stages; firstly, the earlier adopter
phase where there are increased complications and a longer learning curve;
8/04/10 10:29 AM
secondly, where disadvantages are noted but advantages are seen; next the
criticism by established users; then overcoming the disadvantages; then the
standardisation of technique and the wider availability and finally the establishment
of training programs. At this point one can call something the gold standard and I
believe robotic radical prostatectomy has reached that point.
In summary it appears that robotic radical prostatectomy has advantages over
the previous gold standard open radical prostatectomy in experienced hands.
The ‘trifecta’ in experienced hands is at least equal to the best open radical
prostatectomy series and there are fewer complications, a quicker recovery,
lower blood loss, lower anastomotic strictures, improved surgeon economics,
reproducibility, a standardised technique, it is widely available, readily teachable
and greater potential for future advances.
His colleague Dr Geoff Coughlin in rebuttal of the opponents view addressed
the argument that there were potentially more complications with the robotic
technology as reported by Hu et al in 2009 when he reviewed the Medicare data
of America from 2003 to 2005. It became very clear that Hu was comparing an
inexperienced group of robotic surgeons to an experienced open team. A further
paper by Schroeck et al discussing the lack of satisfaction with robotic surgery
was also reviewed. It was noted that in this paper, that the difference between
satisfaction rates with open and robotic surgery was not statistically significant.
When it came to the cost of the two procedures it was acknowledged that initially
cost was more expensive until the volume of cases that went through a unit
became high and indeed Dr Coughlin suggested that in a public hospital such
as Royal Brisbane Hospital there was significant savings doing robotic surgery
compared to open. This was mainly based on the fact that patients went home
between 1 and 2 days with the robot and on day 5 with the open.
Making A Difference
It was also explained that laparoscopy when performed by an expert gives
excellent results but it has only been adopted by less than 1% of people in the
United States and all the top units are now converting to robotic. It can therefore
not be regarded as the gold standard as it is not widely enough adopted.
R
With regard to open surgery it was noted that this has previously been the
gold standard and indeed an excellent open surgeon can overcome most of the
difficulties of access bleeding, complications and ergonomics. The problem that is
occurring world wide is that the numbers of these cases are declining and this will
impact upon training and therefore this will no longer be the gold standard.
It was pointed out that most young surgeons are much more likely to take up a
robot fellowship than an open or laparoscopic fellowship and therefore this will
make robotic surgery more likely to be the gold standard in the future.
It was finally noted that one of our opponents from the United States Dr Jeff
Caddedu when interviewed in the New York times felt that the battle was lost when
it came to robot versus open surgery!
TABLE 1
ROBOT
(13)
LAP
(12)
OPEN
(23)
Pre operative PSA
7.23
8.8
7.13
Positive margin
13.6
21.3
24.4
Continence - 1 year
92%
85.6%
81.5%
Potency - 1 year
2 nerves spared
93.5%
54%
67%
Siobhan drives across Australia on a 1964 Lambretta
TV 175 Series 2 to raise money for breast and
prostate cancer research at St Vincent’s Hospital.
In November 2007 Siobhan Ellis was a patient in St Vincent’s Hospital
after an oncoming car did a u-turn in front of her. She suffered a damaged
shoulder and a fractured skull - even though she was wearing a helmet!
It was after this hospital experience that she decided to raise money for
breast and prostate cancer at St Vincent’s and Mater Health. Why cancer
research? Siobhan had lost a few friends recently to cancer – specifically,
Kirsty Rae and Peter Wherret.
Siobhan completed her ride. Well done! For more information go to:
http://www.lammiedrive.org.au
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G
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RESEARCH UPDATE
Amila Siriwardana
Sara Bassin
My name is Amila Siriwardana and I have just completed my 3rd year of
undergraduate Medicine at the University of New South Wales (UNSW). The
majority of my degree so far has been grounded in science. Being involved in
more practical hospital activities has reinforced my passion for healthcare.
My name is Sara Bassin and I am about to embark on my final year of
Medical studies after 9 years at university. I began my studies in 2001 at
UNSW in Bioinformatics, which I can best explain as a fusion of genetics,
molecular biology and computer science. I then undertook a research
masters in Bioinformatics and attempted to get into medicine. 3 years on,
I couldn’t be more satisfied with my chosen path.
I started work at The Garvan Institute of Medical Research in late 2008,
in the prostate cancer research group. Specifically I am involved in the
prostate cancer quality of life study which looks into the outcomes of
patients after treatment and the monitoring of those with high risk of
prostate cancer. Being responsible for patient recruitment and management
of incoming and outgoing questionnaires for the study has allowed me to
be actively involved in the progress of a leading research project, and it has
been interesting to see its development from the ground up. Learning about
research protocols and study design in this project has not only allowed me
to greater appreciate the importance of quality medical research, but has
also opened my eyes to just how complicated and involved research is.
I have been working with at the Garvan Institute since I started my medical
degree in 2007. As I had 2 years experience in scientific research, I was
eager to continue to be involved in a research environment throughout
my degree. The Garvan Institute provided the perfect opportunity. Since
beginning here, my main area of focus has been on the Quality of Life
project, comparing quality of life outcomes in different arms of prostate
cancer treatment. I have found the work here to be both stimulating and
satisfying and am grateful for all the exposure I have gained to the world
of medical research.
Save the Date !
GARVAN INSTITUTE
OPEN DAY
The Garvan Institute of Medical Research is pleased to announce that its next
Open Day will be held from 9am – 3pm on Sunday 24th October 2010.
This is your opportunity to see medical research and internationally renowned
Garvan researchers in action. The day will include a mini-expo, educational
seminars and tours of Garvan’s state-of-the-art medical labs. Please put this date
in your diary and invite friends and family – it will be an event not to be missed.
Garvan Institute, 384 Victoria Street, Darlinghurst
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8/04/10 10:29 AM
Help us ‘go green’ by emailing your name and address to
support@prostate.com.au. We will then send you the PDF
version to the email address from which you sent the email.
Alternatively, complete this form and check the PDF offer.
If you still want the paper version of Lifebuoy and are not
on our mailing list or your address has changed please
complete and return this form. If you no longer want to
receive the newsletters please tick the appropriate box.
Yes, I’ll go green! Send me the PDF version
I no longer want to receive the Lifebuoy newsletter
Meetings for 2010
n Wednesday May 12th - Prof Warick Delprado DHM Pathologist
Your Prostate From the Inside
n Wednesday August 11th -Dr Joe Enis
An Update
n Wednesday November 10th - tba
lifebuoy_e1_2010.indd 8
E-mail address
Name
Address
Please complete
this form and
return to:
St Vincent’s Prostate Cancer Centre
St Vincent’s Clinic
Suite 508 - 438 Darlinghurst Street
Darlinghurst NSW 2010
or email: jmatthews@stvincents.com.au
All meetings are held in the Clinic Function Room,
Level 4, St Vincent’s Clinic
438 Victoria Street
(Cnr Victoria & Oxford Sts)
Darlinghurst. NSW
Car parking available - entry via Barcom avenue
Check www.prostate.com.au for details
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