Assessment of value of routine bone scans in patients with newly diagnosed prostate cancer

The value of routine bone scans as a staging procedure was assessed in patients with newly diagnosed prostate cancer. Records from 277 patients were reviewed retrospectively to determine the serum acid and alkaline phosphatases, the presence or absence of bone pain, and the results of bone scans and other radiographic studies at the time of initial diagnosis. We determined the sensitivity and specificity of an abnormal acid phosphatase, an abnormal alkaline phosphatase, and the presence of bone pain used in combination for assessing bone metastases. If at least one of these three parameters was present, the sensitivity was 97 percent, whereas if all three tests were normal, the specificity was 78 percent. The negative predictive value for all three tests combined is 99 percent. These results suggest that a routine bone scan to stage patients with newly diagnosed prostate cancer who have no bone pain and normal acid and alkaline phosphatases may not be warranted in all cases.

Routine screening for cancer of the prostate

The value of screening for prostate cancer remains unclear. Although digital rectal examination, transrectal ultrasonography, and determination of serum prostate-specific antigen levels may lead to early detection of a malignancy, these procedures have never been shown to reduce disease-specific mortality from prostate cancer. Unfortunately, several potential errors found in uncontrolled trials may suggest benefit from screening where none exists. Only a large, randomized, controlled clinical study demonstrating decreased mortality from prostate cancer can prove that screening is beneficial. Until such a study is performed, patients should be informed of both the potential benefits and the risks of screening and treatment.

Independent prognostic factors in patients with metastatic (stage D2) prostate cancer. The Zoladex Study Group

The independent prognostic factors affecting survival were assessed in 240 men undergoing treatment for metastatic prostate cancer as part of a randomized clinical trial comparing the gonadotropin releasing hormone analogue Zoladex (goserelin acetate implant) with castration. In a multivariate analysis, the most highly significant predictors were the presence or absence of bone pain, serum testosterone levels, serum alkaline phosphatase levels, and performance status. Patients with all four factors favorable for survival had a 2-year survival rate of 84% as compared with only 8% for patients with none of the four factors favorable for survival. No other factors were significant. A separate analysis of serum testosterone levels revealed that the higher the pretreatment serum testosterone level, the greater the survival rate. Compared with patients with serum testosterone levels less than 6.9 nmol/L, significant differences in survival were observed for patients with serum testosterone levels of 10.4 to 13.9, 13.9 to 17.3, and over 17.3 nmol/L. These results have important implications for the design and analysis of future clinical trials of hormone therapy and for counseling patients regarding the short-term prognosis of their disease.

Response to orchiectomy following Zoladex therapy for metastatic prostate carcinoma

Serum testosterone and prostate-specific antigen (PSA) levels were measured in 3 patients with Stage D2 prostate cancer before and after discontinuation of the long-acting LHRH agonist, goserelin acetate (Zoladex). The patients had received goserelin acetate for ten, sixteen, and thirty months prior to discontinuing the drug because of progressive metastatic disease. In all 3 patients, PSA and testosterone levels increased after goserelin acetate was discontinued. In 2 patients the testosterone level reached normal levels. A bilateral orchiectomy was performed one hundred sixty, one hundred, and seven days, respectively, after the drug was discontinued. In all 3 cases PSA and testosterone levels were reduced following castration, although PSA levels again began to increase within two weeks of orchiectomy in 2 of the 3 patients. These findings suggest that suppression of testosterone by LHRH agonists is not permanent and if tumor progression occurs, maintaining hormone suppression may still be beneficial.

Digital rectal examination in the early detection of prostate cancer

Screening using digital rectal examination improves the clinical stage distribution of prostate cancer and prolongs survival. Unfortunately, digital rectal examination may not be sensitive enough to detect the small-volume tumors that are most amenable to cure. In several studies, approximately 50 per cent of cancers detected through screening had already spread beyond the prostate. Regardless, the key to demonstrating overall benefit from screening is a diminished disease-specific mortality rate. To date, this has not been shown. Lower mortality rates from prostate cancer can be demonstrated only through a randomized study comparing screened and unscreened populations. Such a study, which has recently been approved and funded by the National Institutes of Health, will require 10 to 15 years to complete. Until that time, the value of screening for prostate cancer by digital rectal examination or any other method will be unknown. Beyond a lack of proved benefit, screening for prostate cancer may be harmful because of the variable natural history of the disease and the morbidity and mortality rates associated with treatment. There exists a large population of patients with pathologically detectable prostate cancer who will never have clinical disease. The detection of some of these tumors may expose those patients to the risks of unnecessary treatment. Large-scale prostate cancer screening studies may ultimately be shown to be advantageous. The sooner this occurs, the earlier aggressive screening can be advocated, similar to screening for breast cancer. However, the temptation to embark on such screening programs without first demonstrating clear benefit should be resisted.

Prostate specific antigen for assessing response to ketoconazole and prednisone in patients with hormone refractory metastatic prostate cancer

Serial prostate specific antigen levels were assessed in 15 patients with hormone refractory metastatic prostate cancer treated with ketoconazole and prednisone. Of the men 12 (80%) with continually increasing prostate specific antigen levels before treatment had a decrease in prostate specific antigen with a median duration of response of 3 months. Three patients (20%) had a prolonged response (greater than or equal to 8 months) as seen by a persistently decreasing prostate specific antigen and improvement in bone pain. There appears to be a small subgroup of patients with progressive prostate cancer despite androgen ablation who will benefit from ketoconazole and glucocorticoid treatment. The use of serial prostate specific antigen levels appears to help define this subgroup and avoid the need for multiple radiological procedures to assess response.

Effect of external beam radiation therapy on serum prostate-specific antigen

The effect of external beam radiation on serum prostate-specific antigen (PSA) was determined in 20 patients with nonmetastatic carcinoma of the prostate. An abnormal PSA was measured in 91 percent and 93 percent, respectively, of the samples collected prior to or during radiation therapy. By seven months, 8/15 men still had an abnormal PSA level. Four of 5 men with an elevated PSA at least twenty-three months after radiation therapy had a positive prostatic biopsy, and 3/3 patients with a normal PSA had a negative ultrasonically guided biopsy. The rate of decline of serum PSA after radiation therapy is variable. These preliminary data suggest that serum PSA may be useful for assessing the local response of prostate cancer to radiation therapy.

Screening for prostate cancer. Role of ultrasonography

Over the next 10 years, prostate cancer will be the cause of death in a large number of men. Perhaps the most feasible approach to reducing this mortality is early detection. The initial studies with transrectal ultrasonography demonstrate that this test is capable of detecting prostate cancers that are not detected by the digital rectal examination. A reasonable conclusion from these data is that every man over age 50 should have a sonogram as part of his annual check-up. Unfortunately, routine screening may also lead to serious morbidity, yet it may not lower the mortality rate from this disease. Therefore, before screening is recommended, randomized controlled clinical trials are needed to assess the impact of routine sonograms on asymptomatic men. These trials will be costly and time-consuming, but worthwhile, as the variable biology of this tumor means that screening may not accomplish its stated goals. That is, it is entirely possible that life-threatening tumors will not be detected by screening in time to alter the outcome, whereas many of the potentially curable tumors that are diagnosed and treated would never have caused a man's death. The initial results with screening by ultrasonography are encouraging, however. Therefore, further studies should be pursued because of the potential benefit if screening by ultrasonography proves effective.

Early detection and screening for prostatic cancer

In the past thirty years, the mortality rate from prostate cancer has not declined. This is due in part to the small number of tumors diagnosed while they are still curable by surgery or radiation. Recent studies have demonstrated that transrectal sonography can detect nonpalpable tumors, which are usually potentially curable. As a result, some physicians now recommend routine screening of all men over age fifty. The main goal of a cancer screening test is to help reduce mortality. To date, it has been shown that screening can increase early detection and survival, but there is no experimental evidence that screening reduces mortality. Therefore, screening for prostate cancer may not be worthwhile. The large number of prostate tumors found on autopsy series indicates that only a small fraction of patients with prostate cancer actually die of it. The risk of screening is that many insignificant tumors may be diagnosed and patients may be treated unnecessarily, resulting in significant morbidity, mortality, and expense. For now, it may be appropriate to let patients choose whether or not to have the test performed, after informing them screening can increase early detection, but could also result in overdiagnosis and treatment. However, screening should not be advocated across-the-board until a randomized, carefully controlled, large-scale clinical trial has shown that it saves lives.

Intravesical interferon treatment of superficial bladder cancer

Superficial transitional cell carcinoma (TCC) of the bladder and carcinoma in situ (CIS) have a high recurrence rate and a variable incidence of progressive disease. Conventional intravesical agents used to treat these carcinomas have achieved only a variable degree of success, and have adverse side effects. Recently, intravesical interferon has been explored as a treatment for TCC and CIS. In a randomized, controlled trial, patients with CIS exhibited a significantly higher rate of complete response (CR) to high-dose (100 x 10(6) IU) than to low-dose (10 x 10(6) IU) interferon (45% vs 6%, respectively, p less than 0.0001). To date, 9/19 patients in the high-dose CR group have maintained a CR for at least six months. Five patients receiving high-dose therapy and 5 receiving low-dose therapy subsequently underwent cystectomy, but median time to surgery was 33.5 weeks for the high-dose group vs eighteen weeks for the low-dose group. Intravesical interferon was generally well tolerated. These results suggest that randomized clinical trials are warranted to assess the efficacy of intravesical interferon, as compared to BCG, for the treatment of CIS.

Luteinizing hormone-releasing hormone (LHRH) agonists for treatment of advanced prostatic carcinoma

The identification of the decapeptide luteinizing hormone-releasing hormone (LHRH) has led to the development of LHRH agonists, which are a new class of drugs for the treatment of advanced prostate cancer. These peptides have a modified amino acid structure that makes them more potent than LHRH. Prolonged administration of LHRH agonists results in down-regulation of the LHRH receptors in the pituitary and decreased secretion of luteinizing hormone. The result is decreased production of testosterone by Leydig cells, which is the basis for the use of LHRH agonists to treat prostate cancer. The effectiveness of LHRH agonists has been demonstrated in the United States in several randomized, controlled clinical trials. Daily administration of leuprolide produced equivalent results compared with diethylstilbestrol (DES). More recently, in two separate, randomized studies, the long-acting LHRH agonist Zoladex (ICI Pharma, Wilmington, Delaware) produced the same objective response rate as DES or bilateral orchiectomy. The equivalent response rates obtained with LHRH agonists indicate that these drugs can now be considered a reasonable treatment option for patients with metastatic prostatic cancer.

Assessment of screening for prostate cancer using the digital rectal examination

An early detection study for prostate cancer was initiated to determine the effect of routine digital rectal examinations on the stage of prostate cancer at diagnosis. A prostate biopsy was recommended if induration, asymmetry or nodules were detected on the digital examination. During a 6-year period 4,160 examinations were performed on 2,131 men more than 45 years old. A prostate biopsy was performed on 144 men and 36 malignant tumors were detected, of which 68 per cent were clinically localized. Pelvic lymph node metastases were found in 6 per cent of the surgically staged cancer patients and in 10 per cent of the patients who had a high grade tumor. Surgical staging revealed that 50 per cent of the patients with clinical stage B disease were upstaged to stage C or D1 disease. These results suggest that mass screening programs using digital examination may not add sufficient benefit over conventional medical care to warrant the expense. Definitive proof that screening can lower the mortality rate from prostate cancer can be obtained only by a prospective randomized clinical trial.

Early detection of prostate cancer

Prostate cancer is of increasing concern because its mortality has not decreased significantly in the last 30 years. It is suggested that a reduction in death rate may be possible as a result of early detection of the disease, but several factors indicate that presently, routine screening cannot be justified.

Progress and problems in screening for carcinoma of the prostate

Carcinoma of the prostate is the second most common cause of cancer-related deaths in American men. This is due, in part, to the low percentage of cases that are diagnosed when the tumor is still curable. To improve early detection, routine screening has been performed using one or a combination of tests that included open prostate biopsy, serum acid phosphatase, the digital rectal exam, and transrectal sonography. These studies have been critically reviewed and the problems associated with prostate cancer screening have been discussed. No study has proven that routine screening reduces the mortality from prostate cancer. Furthermore, the positive predictive value and the sensitivity of each of these tests are too low for any of them to be useful for screening at the present time. To determine the value of screening, new studies are needed which should include a control group and an assessment of the disadvantages of screening as well as the potential benefits. Based on published reports, however, routine screening for prostate cancer using any test should be considered investigational at the present time.

Transrectal aspiration biopsy of the prostate: the importance of atypia

Transrectal aspiration biopsy is useful as an alternative method to examine the prostate. As a means to improve the sensitivity of this method we investigated the significance of cellular atypia. Transrectal aspiration biopsy revealed highly atypical cells in 30 of 225 patients and in 17 patients slightly atypical cells were found. Biopsy was repeated in 22 patients with highly atypical cells and cancer was confirmed in 17 (77 per cent). In the group with only slight atypia 2 of 6 patients had cancer upon repeat prostatic biopsy. When transrectal aspiration biopsy contains highly atypical cells biopsy should be repeated to avoid a false negative diagnosis. These results suggest that atypia is an abnormal finding that must be followed clearly to maintain a high sensitivity with this biopsy method.

Increased levels of fibroblast growth factor-like activity in urine from patients with bladder or kidney cancer

Growth factor activity was partially purified from human renal tumors and a human bladder cancer cell line by heparin-Sepharose chromatography. This activity stimulated bovine capillary endothelial cell proliferation and DNA synthesis in BALB/c 3T3 cells. Partially purified growth factor preparations from these tumors contained a protein with an approximate molecular weight of 17,000 which was recognized by a polyclonal antiserum raised against a peptide fragment of basic fibroblast growth factor (FGF). This growth factor activity appears to be related to basic fibroblast growth factor. Measurement of FGF-like activity in 50 urine samples from 32 adult males showed that 55% (6 of 11) of the urine samples from patients with bladder cancer and 100% (7 of 7) of the urine samples from patients with kidney cancer contained activity equivalent to more than 20 ng of basic FGF/h of urine production. In contrast, only 6% (2 of 32) of the urine samples from controls, patients with a benign disease, or patients with a history of bladder or kidney cancer contained this level of growth factor activity. These results suggest that patients with bladder or kidney cancer release an FGF-like factor into urine which may be used as a marker for these tumors.

A programmable and implantable pumping system for systemic chemotherapy: a performance analysis in 52 patients

We have prospectively evaluated the performance of the implanted battery-powered Medtronic (Minneapolis) SynchroMed infusion system. Between July 1984 and July 1986, fifty-three SynchroMed pumps were implanted in 52 patients for phase I and II trials of low-dose continuous-infusion doxorubicin (N = 35) or vinblastine (N = 17). The median duration of pump function was 145 days (mean, 180; range, 20 to 787 +) and the systems infused drugs for 61% (range, 32% to 100%) of their patient implant time. During 10,045 patient days (27.5 years) of implantation, there have been no failures of the pump mechanism and pump accuracy was excellent (2.2% error rate in 256 analyzed refills). The median cost of the hospitalization for implantation was +17,140 in 14 analyzed cases. Complications requiring a second surgical procedure occurred with 13 systems (24%). Two of the complications were related to localized cutaneous hypersensitivity to vinblastine, four were directly related to system complications, and seven were secondary to implant procedure problems. Seven patients (13%) requested removal of the device after tumor progression occurred. Based on this experience, the company has made improvements in certain aspects of system design and has implemented a comprehensive user training program to minimize procedure-related problems. The Medtronic SynchroMed is an accurate and sophisticated system that allows infusion of low-dose doxorubicin and of vinblastine for prolonged periods. Extravasation of these vesicant agents must be carefully prevented. The financial cost of this implanted system may limit its use to patients with an expected survival of 5 months or longer.

Presence of heparin binding growth factor in mouse bladder tumors and urine from mice with bladder cancer

Heparin affinity chromatography has been used to partially purify angiogenic factors from normal and neoplastic tissue. The same technique was used to partially purify angiogenic-like factors from two mouse bladder tumors and urine from mice with bladder cancer. Both MBT-2 and MB49 tumors contained heparin-binding 3T3 cell growth factor activity that was eluted by 1.2 to 1.4 M salt. The growth factor isolated from MBT-2 tumor was mitogenic for capillary endothelial cells. Analysis of the 1.2 M heparin eluate by high-pressure liquid chromatography showed that it consisted of two 3T3 cell growth factors with molecular weights of 16,000 and 26,000. The growth factor activity isolated from MB49 tumors had an affinity for Bio-rex 70 which was similar to other cationic heparin binding growth factors. Analysis of urine pooled from tumor-bearing mice by heparin-Sepharose chromatography demonstrated 3T3 cell growth factor activity in fractions eluted with 1 to 1.4 and 2.5 M dsalt, whereas no significant growth factor activity was detected in pooled urine from control mice. The growth factor activity found in mouse bladder tumors differed from epidermal growth factor, transforming growth factor-alpha, and platelet-derived growth factor in terms of affinity for heparin-Sepharose and molecular weight. The observation that urine from tumor-bearing mice contains increased concentrations of this growth factor compared to normal urine suggests that a similar relationship may exist for human urine.

Comparison of digital examination and transrectal ultrasonography for the diagnosis of prostatic cancer

The ability to detect prostatic cancer by transrectal ultrasonography was evaluated in a prospective blind study of 216 men. The sensitivity of transrectal ultrasonography was 86 per cent but the specificity was only 41 per cent. Tumors less than 1 cm. in diameter were most difficult to detect by transrectal ultrasonography. The positive and negative predictive values of transrectal ultrasonography were 36 and 89 per cent, respectively. Abnormal scans that strongly suggested carcinoma were present in 10 per cent of the men who had a normal digital examination but no biopsy was performed. Transrectal ultrasound is a sensitive method to detect all but small prostatic tumors and it can detect tumors that are not evident by digital examination. To date, however, transrectal ultrasonography may be difficult to use for routine screening in the United States because of the low positive predictive value. Nevertheless, further investigation of this technique is warranted to define its role in improving the diagnosis of prostatic cancer.

The role of transrectal aspiration biopsy in the diagnosis of prostatic cancer

We reviewed our experience with transrectal aspiration biopsy during an 18-month period. This procedure was the sole technique used in 75 men and prostatic cancer was diagnosed in 19. Two of these patients were not treated because a core biopsy performed at another hospital was negative for carcinoma. Aspiration and transperineal core biopsies were performed in 62 other cases. The sensitivity of aspiration to diagnose prostatic cancer was 98 per cent (45 of 46 biopsies) compared to only 81 per cent (37 of 46) for the core biopsy method. No patient suffered a complication following the aspiration biopsy. These data further support the value of transrectal aspiration biopsy as a sensitive, easy to perform method for sampling an abnormal prostate. More widespread use of this technique in the United States should be encouraged.

Partial characterization of a cell motility factor from human urine

Dialyzed, concentrated urine from 21 patients with a history of bladder cancer or a gross bladder tumor was tested for cell motility activity using BALB/c/3T3 cells. Thirteen urine samples from patients with a gross bladder tumor produced a greater increase in cell migration than 8 urine samples from patients with a history of bladder cancer [167% +/- 14 (S.E.), 64% +/- 19, respectively; p less than 0.001]. Protease treatment of urine from a patient with bladder cancer caused a 95% loss of activity, while heating to 100 degrees for 2 min caused an 86% loss of activity. High-performance liquid chromatography of urine from a patient with bladder cancer revealed that the greatest activity was present in fractions with a molecular weight between 18,000 and 30,000. These results suggest that motility-stimulating factor may be a useful marker for detecting carcinoma of the bladder.

Early detection of prostate cancer by routine screening

In an attempt to detect prostate cancer when the disease was still localized, a free screening clinic was established for men over the age of 45 years. Digital rectal examinations were performed for 811 men. Prostate biopsy was recommended to 43 in whom abnormalities were found by digital rectal examination; only 38 complied. Prostate cancer was detected in 11 men. The patients with cancer ranged in age from 60 to 79 years, with the highest incidence of cancer in the group aged 70 to 79 years. The overall incidence in men between 51 and 80 years old was 1.7%. Staging evaluation revealed that none of the patients with prostate cancer had metastases to the bone or elevated serum acid phosphatase levels. Five men (45%) were found by clinical or pathological methods to have stage B disease. Two others (18%) showed radiographic evidence of lymph node metastases (stage D1). The cost of detecting each cancerous prostate tumor was approximately +6,300. Routine screening can be a cost-effective method for diagnosing prostate cancer in patients with less extensive disease. The ability of early detection to prolong survival of patients with this disease will require further investigation.

Detection of angiogenesis activity in malignant bladder tissue and cells

Neoplastic and non-neoplastic mammalian urothelium was tested for angiogenesis activity in the rabbit iris assay. Tiny fragments of tissue were placed on a rabbit's iris and observed through a slit lamp stereoscope for as long as 4 days after implantation. Angiogenesis activity was demonstrated either by the appearance of new capillary growth or, following an injection of fluorescein, by a green fluorescence around an implant. Capillary proliferation was stimulated by 99 per cent of the specimens containing malignant urothelium, while only 9 per cent of normal urothelial specimens had this effect (p less than .001). Cells grown in vitro were similarly tested for angiogenesis by implanting 1 mm. fragments of collagen coated either with malignant or normal cells. A total of 92 per cent of the specimens covered with neoplastic cells induced angiogenesis, while only 15 per cent of the implants covered by normal cells caused this response (p less than .001). Benign reversible hyperplasia was induced in a rabbit bladder by systemic administration of cyclophosphamide, and an angiogenic response could not be detected in a small number of specimens. The results suggest that angiogenesis activity may be a reliable method for distinguishing between benign and malignant bladder tissue.

Transrectal aspiration biopsy versus transperineal core biopsy for the diagnosis of carcinoma of the prostate

Transrectal aspiration and transperineal core biopsies were performed on 38 patients with suspicious prostatic examinations. The false negative rate was 14 per cent by the core method but no cancer was missed by the aspiration technique. There was insufficient material for diagnosis in 14 per cent of the biopsies obtained by the core technique but in only 3 per cent with the aspiration biopsy method. Malignant cells were confirmed by cytology in 1 patient who had had 2 normal core biopsies. The cytological grade was only moderately consistent with the Gleason sum. No complications developed after either procedure. Transrectal aspiration biopsy offers several advantages over conventional biopsy methods and should be used regularly to diagnose abnormalities of the prostate.