Screening for Prostate Cancer: US Preventive Services Task Force Recommendation Statement

Assessing the clinical utility of genetic risk scores for targeted cancer screening

Background

Genome-wide association studies have identified thousands of disease-associated single nucleotide polymorphisms (SNPs). A subset of these SNPs may be additively combined to generate genetic risk scores (GRSs) that confer risk for a specific disease. Although the clinical validity of GRSs to predict risk of specific diseases has been well established, there is still a great need to determine their clinical utility by applying GRSs in primary care for cancer risk assessment and targeted intervention.

Methods

This clinical study involved 281 primary care patients without a personal history of breast, prostate or colorectal cancer who were 40–70 years old. DNA was obtained from a pre-existing biobank at NorthShore University HealthSystem. GRSs for colorectal cancer and breast or prostate cancer were calculated and shared with participants through their primary care provider. Additional data was gathered using questionnaires as well as electronic medical record information. A t-test or Chi-square test was applied for comparison of demographic and key clinical variables among different groups.

Results

The median age of the 281 participants was 58 years and the majority were female (66.6%). One hundred one (36.9%) participants received 2 low risk scores, 99 (35.2%) received 1 low risk and 1 average risk score, 37 (13.2%) received 1 low risk and 1 high risk score, 23 (8.2%) received 2 average risk scores, 21 (7.5%) received 1 average risk and 1 high risk score, and no one received 2 high risk scores. Before receiving GRSs, younger patients and women reported significantly more worry about risk of developing cancer. After receiving GRSs, those who received at least one high GRS reported significantly more worry about developing cancer. There were no significant differences found between gender, age, or GRS with regards to participants’ reported optimism about their future health neither before nor after receiving GRS results.

Conclusions

Genetic risk scores that quantify an individual’s risk of developing breast, prostate and colorectal cancers as compared with a race-defined population average risk have potential clinical utility as a tool for risk stratification and to guide cancer screening in a primary care setting.

Identification of RNA-binding protein SNRPA1 for prognosis in prostate cancer

Prostate cancer is one of the deadliest cancers in men. RNA-binding proteins play a critical role in human cancers; however, whether they have a significant effect on the prognosis of prostate cancer has yet to be elucidated. In the present study, we performed a comprehensive analysis of RNA sequencing and clinical data from the Cancer Genome Atlas dataset and obtained differentially expressed RNA-binding proteins between prostate cancer and benign tissues. We constructed a protein-protein interaction network and Cox regression analyses were conducted to identify prognostic hub RNA-binding proteins. SNRPA1 was associated with the highest risk of poor prognosis and was therefore selected for further analysis. SNRPA1 expression was positively correlated with Gleason score and pathological TNM stage in prostate cancer patients. Furthermore, the expression profile of SNRPA1 was validated using the Oncomine, Human Protein Atlas, and Cancer Cell Line Encyclopedia databases. Meanwhile, the prognostic profile of SNRPA1 was successfully verified in GSE70769. Additionally, the results of molecular experiments revealed the proliferative role of SNRPA1 in prostate cancer cells. In summary, our findings evidenced a relationship between RNA-binding proteins and prostate cancer and indicated the prognostic significance of SNRPA1 in prostate cancer.

Prostate Cancer: Biology, Incidence, Detection Methods, Treatment Methods, and Vaccines

Cancer of the prostate are cancers in which most incidences are slow-growing, and in the U.S., a record of 1.2 million new cases of prostate cancer occurred in 2018. The rates of this type of cancer have been increasing in developing nations. The risk factors for prostate cancer include age, family history, and obesity. It is believed that the rate of prostate cancer is correlated with the Western diet. Various advances in methods of radiotherapy have contributed to lowering morbidity. Therapy for hormone- refractory prostate cancer is making progress, for almost all men with metastases will proceed to hormone-refractory prostate cancer. Smoking cigarettes along with the presence of prostate cancer has been shown to cause a higher risk of mortality in prostate cancer. The serious outcome of incontinence and erectile dysfunction result from the cancer treatment of surgery and radiation, particularly for prostate- specific antigen detected cancers that will not cause morbidity or mortality. Families of patients, as well as patients, are profoundly affected following the diagnosis of prostate cancer. Poor communication between spouses during prostate cancer increases the risk for poor adjustment to prostate cancer. The use of serum prostate-specific antigen to screen for prostate cancer has led to a greater detection, in its early stage, of this cancer. Prostate cancer is the most common malignancy in American men, accounting for more than 29% of all diagnosed cancers and about 13% of all cancer deaths. A shortened course of hormonal therapy with docetaxel following radical prostatectomy (or radiation therapy) for high-risk prostate cancer has been shown to be both safe and feasible. Patients treated with docetaxel-estramustine had a prostate-specific antigen response decline of at least 50%. Cancer vaccines are an immune-based cancer treatment that may provide the promise of a non-toxic but efficacious therapeutic alternative for cancer patients. Further studies will elucidate improved methods of detection and treatment.

Translation and validation of the Chinese version of medical maximizer-minimizer scale: a cross-sectional study

OBJECTIVE

Medical overutilisation and underutilisation affect optimal healthcare. The Medical Maximizer-Minimizer Scale (MMS) was developed to assess individual medical maximising and minimising tendencies. Despite significant improvement in the healthcare system over the past four decades, no psychometric scales to examine treatment maximising and minimising preferences are available in China. This study aimed to translate the MMS into Chinese and examine its reliability and validity in a Chinese population.

DESIGN

This cross-sectional study was conducted in December 2019 through an online survey panel.

METHODS

The MMS was translated into a Chinese version (CN-MMS) using a forward-backward translation procedure. Next, a random online survey of the general population in China was conducted. Exploratory factor analysis (EFA) and confirmatory factor analysis were performed to examine the underlying factor structure of the CN-MMS. The internal consistency reliability of the scale was determined using Cronbach's α coefficient and corrected item-total correlation. A multivariate linear regression analysis was used to examine associations between medical maximising and minimising preferences and demographic variables in the Chinese population.

RESULTS

This study included 984 participants aged 18-80 years. The CN-MMS retained 10 items, and the EFA supported a two-factor structure. The model fit for this two-factor structure of the CN-MMS was acceptable with χ²/df=3.7, comparative fit index=0.958, goodness-of-fit index=0.951, Tucker-Lewis Index=0.944 and root mean square error of approximation=0.074. The scale had a Cronbach's α coefficient of 0.864, corrected item-total correlation of 0.451-0.667, and test-retest reliability of 0.815. Significant predictors of CN-MMS total score were nationality and household monthly income.

CONCLUSIONS

The CN-MMS showed satisfactory psychometric properties. Therefore, it can be used to investigate the individual medical maximising and minimising tendencies among the general Chinese population.

Identification of Urinary Exosomal miRNAs for the Non-Invasive Diagnosis of Prostate Cancer

Background

Novel and non-invasive biomarkers with higher sensitivity and specificity for the diagnosis of prostate cancer (PCa) is urgently needed. In this study, we used next-generation sequencing (NGS) to characterize the genome-wide exosomal miRNA expression profiling in urine specimens and explored the diagnostic potential of urinary exosomal miRNAs for PCa.

Methods

Urinary exosomal microRNA expression profiling was performed by next-generation sequencing (NGS) and then validated by quantitative real-time PCR.

Results

Significant downregulation of urinary exosomal miR-375 was observed in PCa patients compared with healthy controls, while the expression levels of urinary exosomal miR-451a, miR-486-3p and miR-486-5p were found to be significantly up-regulated in the PCa patients. Furthermore, the expression level of urinary exosomal miR-375 showed a significant correlation with the clinical T-stage and bone metastasis of patients with PCa (P<0.05). Receiver operator characteristic curve demonstrated that the urinary exosomal miR-375, miR-451a, miR-486-3p and miR-486-5p levels can be used to differentiate PCa patients from healthy controls, with area under the curves (AUCs) of 0.788, 0.757, 0.704 and 0.796, respectively. The urinary exosomal miR-375 was found to be superior in discriminating between localized and metastatic PCa with an AUC of 0.806. Moreover, PCa patients can be distinguished from patients with benign prostatic hyperplasia by using a panel combining urinary exosomal miR-375 and miR-451a with an AUC of 0.726.

Conclusion

These findings demonstrate that the urinary exosomal miRNAs can serve as novel and non-invasive biomarkers for diagnosing and predicting the progression of PCa.

[PAPPS Cancer Expert Group. Cancer Prevention Recommendations. 2020 PAPPS update]

El cáncer es una de las principales causas de morbilidad y mortalidad. El consumo de tabaco, la dieta poco saludable, la inactividad física son algunos de los factores de riesgo que forman parte del estilo de vida y que han provocado un aumento del cáncer. En este artículo se actualizan las evidencias y recomendaciones de las estrategias de prevención para cada uno de los cánceres con mayor incidencia, con base en la disminución de los factores de riesgo (prevención primaria) y en el diagnóstico precoz del cáncer, a través del cribado y la detección temprana de los signos y síntomas, en población de riesgo medio y de riesgo elevado.

Role of MRI for the detection of prostate cancer

The use of multiparametric MRI has been hastened under expanding, novel indications for its use in the diagnostic and management pathway of men with prostate cancer. This has helped drive a large body of the literature describing its evolving role over the last decade. Despite this, prostate cancer remains the only solid organ malignancy routinely diagnosed with random sampling. Herein, we summarize the components of multiparametric MRI and interpretation, and present a critical review of the current literature supporting is use in prostate cancer detection, risk stratification, and management.

Implementation and Impact of a Risk-Stratified Prostate Cancer Screening Algorithm as a Clinical Decision Support Tool in a Primary Care Network

BACKGROUND

Implementation methods of risk-stratified cancer screening guidance throughout a health care system remains understudied.

OBJECTIVE

Conduct a preliminary analysis of the implementation of a risk-stratified prostate cancer screening algorithm in a single health care system.

DESIGN

Comparison of men seen pre-implementation (2/1/2016-2/1/2017) vs. post-implementation (2/2/2017-2/21/2018).

PARTICIPANTS

Men, aged 40-75 years, without a history of prostate cancer, who were seen by a primary care provider.

INTERVENTIONS

The algorithm was integrated into two components in the electronic health record (EHR): in Health Maintenance as a personalized screening reminder and in tailored messages to providers that accompanied prostate-specific antigen (PSA) results.

MAIN MEASURES

Primary outcomes: percent of men who met screening algorithm criteria; percent of men with a PSA result. Logistic repeated measures mixed models were used to test for differences in the proportion of individuals that met screening criteria in the pre- and post-implementation periods with age, race, family history, and PSA level included as covariates.

KEY RESULTS

During the pre- and post-implementation periods, 49,053 and 49,980 men, respectively, were seen across 26 clinics (20.6% African American). The proportion of men who met screening algorithm criteria increased from 49.3% (pre-implementation) to 68.0% (post-implementation) (p < 0.001); this increase was observed across all races, age groups, and primary care clinics. Importantly, the percent of men who had a PSA did not change: 55.3% pre-implementation, 55.0% post-implementation. The adjusted odds of meeting algorithm-based screening was 6.5-times higher in the post-implementation period than in the pre-implementation period (95% confidence interval, 5.97 to 7.05).

CONCLUSIONS

In this preliminary analysis, following implementation of an EHR-based algorithm, we observed a rapid change in practice with an increase in screening in higher-risk groups balanced with a decrease in screening in low-risk groups. Future efforts will evaluate costs and downstream outcomes of this strategy.

Cancer health disparities in racial/ethnic minorities in the United States

There are well-established disparities in cancer incidence and outcomes by race/ethnicity that result from the interplay between structural, socioeconomic, socio-environmental, behavioural and biological factors. However, large research studies designed to investigate factors contributing to cancer aetiology and progression have mainly focused on populations of European origin. The limitations in clinicopathological and genetic data, as well as the reduced availability of biospecimens from diverse populations, contribute to the knowledge gap and have the potential to widen cancer health disparities. In this review, we summarise reported disparities and associated factors in the United States of America (USA) for the most common cancers (breast, prostate, lung and colon), and for a subset of other cancers that highlight the complexity of disparities (gastric, liver, pancreas and leukaemia). We focus on populations commonly identified and referred to as racial/ethnic minorities in the USA-African Americans/Blacks, American Indians and Alaska Natives, Asians, Native Hawaiians/other Pacific Islanders and Hispanics/Latinos. We conclude that even though substantial progress has been made in understanding the factors underlying cancer health disparities, marked inequities persist. Additional efforts are needed to include participants from diverse populations in the research of cancer aetiology, biology and treatment. Furthermore, to eliminate cancer health disparities, it will be necessary to facilitate access to, and utilisation of, health services to all individuals, and to address structural inequities, including racism, that disproportionally affect racial/ethnic minorities in the USA.

The role of prostate-specific antigen in light of new scientific evidence: An update in 2020

OBJECTIVE

To review and update the latest scientific evidence gathered in recent years regarding prostate-specific antigen (PSA) for better implementation into routine clinical practice.

EVIDENCE ACQUISITION

Analysis of the available evidence on the current role of PSA, based on the experience of an expert panel in the subject under analysis.

EVIDENCE SYNTHESIS

Currently, PSA cannot be considered only as a guide for the presence or absence of prostate cancer. This determination can also help the urologist to decide on the most convenient treatment for a patient with benign prostatic hypertrophy (BPH) as a criterion for disease progression, and it can also suggest the suspicious existence of a prostatic tumor when there is PSA rise of>0.3 ng/ml over the level reached 6 months after having initiated treatment with 5-alpha-reductase inhibitor. However, the limits of this PSA rise with derivatives of alternative 5-alpha-reductase (5-ARI) inhibitors to dutasteride are controversial. Moreover, PSA is a key factor for the follow-up of patients with prostate adenocarcinoma at any stage who have received treatment (surgery, radiotherapy or focal therapies, hormone therapy), it acts as a guide to identify biochemical recurrence, to suspect the existence of local or distant recurrence, as well as to propose or discard adjuvant treatments. Finally, the role of PSA as a screening tool has been recently reinforced, demonstrating increased mortality rates or the existence of more aggressive cases of prostate cancer in those countries where the use of this tool has declined.

CONCLUSIONS

We present new data about the current role of PSA in the management of patients treated for BPH and/or prostate cancer that should be implemented into routine clinical practice, with special emphasis on the relevant role of this biomarker in the screening and follow-up of prostate cancer, as well as in the progression of BPH in dutasteride treatment.

Pseudouridine as a novel biomarker in prostate cancer

Epitranscriptomic analysis has recently led to the profiling of modified nucleosides in cancer cell biological matrices, helping to elucidate their functional roles in cancer and reigniting interest in exploring their use as potential markers of cancer development and progression. Pseudouridine, one of the most well-known and the most abundant of the RNA nucleotide modifications, is the C5-glycoside isomer of uridine and its distinctive physiochemical properties allows it to perform many essential functions. Pseudouridine functionally (a) confers rigidity to local RNA structure by enhancing RNA stacking, engaging in a cooperative effect on neighboring nucleosides that overall contributes to RNA stabilization (b) refines the structure of tRNAs, which influences their decoding activity (c) facilitates the accuracy of decoding and proofreading during translation and efficiency of peptide bond formation, thus collectively improving the fidelity of protein biosynthesis and (e) dynamically regulates mRNA coding and translation. Biochemical synthesis of pseudouridine is carried out by pseudouridine synthases. In this review we discuss the evidence supporting an association between elevated pseudouridine levels with the incidence and progression of human prostate cancer and the translational significance of the value of this modified nucleotide as a novel biomarker in prostate cancer progression to advanced disease.

Short fractionation radiotherapy for early prostate cancer in the time of COVID-19: long-term excellent outcomes from a multicenter Italian trial suggest a larger adoption in clinical practice

INTRODUCTION

To evaluate stereotactic body radiotherapy (SBRT) in low-risk Prostate Cancer patients as preferred treatment option in emergency health conditions.

MATERIALS AND METHODS

From April 2013 to September 2015, 28 patients with low-risk prostate cancer were prospectively enrolled. The SBRT prescribed dose was 36.25 Gy in 5 fractions, twice a week. Primary endpoints were acute and late toxicity. Secondary endpoints were biochemical recurrence free survival (bRFS) and overall survival.

RESULTS

Median follow-up was 65.5 months (range 52-81). No acute G3 or G4 toxicity was recorded. Acute G1 or G2 genitourinary (GU) toxicity occurred in 43% and acute G1-G2 gastrointestinal (GI) toxicity in 14%. Late G1 and G3 GU toxicity in 18% and 3.5%, respectively. The G3 toxicity was not directly attributable to radiotherapy. Late G1 GI toxicity occurred in 18%. 5yy bRFS was 96.5% (95% CI 82.3-99.4%).

CONCLUSIONS

Stereotactic body radiotherapy for early prostate cancer reported safe toxicity profile and a good clinical outcome at the median follow-up of 5 years. It may be an useful option if radiotherapy is required in emergency medical conditions.

Exploring the Process of Cancer Care for Patients With Pre-Existing Mobility Disability

PURPOSE

Approximately 13% of the US population report mobility disability. People with mobility disability experience healthcare disparities, including lower rates of cancer screening and substandard cancer care compared with nondisabled people. We explored clinicians' reports of aspects of diagnosing and treating three common cancer types among persons with pre-existing mobility disability.

METHODS

We used standard diagnosis codes and natural language processing to screen electronic health records (EHR) in the Research Patient Data Repository for patients with pre-existing chronic mobility impairment who were newly diagnosed with one of three common cancers (colorectal, prostate, and non-Hodgkin lymphoma) between 2005 and 2017. We eliminated numerous cases whose EHRs lacked essential information. We reviewed EHRs of 27 cases, using conventional content analysis to identify themes concerning their cancer diagnoses and treatments.

RESULTS

Clinicians' notations coalesced around four major themes: (1) patients' health risks raise concerns about diagnostic processes; (2) cancer signs or symptoms can be erroneously attributed to the patient's underlying disabling condition, delaying diagnosis; (3) disability complicates cancer treatment decisions; and (4) problems with equipment accessibility and disability accommodations impede cancer diagnoses.

DISCUSSION

Clinicians view patients with pre-existing mobility disability as often clinically complex, presenting challenges for diagnosing and treating their cancer. Nonetheless, these patients may experience substandard care because of disability-related problems. Given the growing population of people with mobility disability, further efforts to improve care quality and timeliness of diagnosis are warranted.

Shared Decision-Making and Prevention Recommendations: Evolution, Implications, and Challenges for Public Health

Recent guidelines and recommen dations from government prevention advisory groups endorsing shared clinical decision-making reflect an emerging trend among public health bodies.

Cancer Statistics, 2021

Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths in the United States and compiles the most recent data on population-based cancer occurrence. Incidence data (through 2017) were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data (through 2018) were collected by the National Center for Health Statistics. In 2021, 1,898,160 new cancer cases and 608,570 cancer deaths are projected to occur in the United States. After increasing for most of the 20th century, the cancer death rate has fallen continuously from its peak in 1991 through 2018, for a total decline of 31%, because of reductions in smoking and improvements in early detection and treatment. This translates to 3.2 million fewer cancer deaths than would have occurred if peak rates had persisted. Long-term declines in mortality for the 4 leading cancers have halted for prostate cancer and slowed for breast and colorectal cancers, but accelerated for lung cancer, which accounted for almost one-half of the total mortality decline from 2014 to 2018. The pace of the annual decline in lung cancer mortality doubled from 3.1% during 2009 through 2013 to 5.5% during 2014 through 2018 in men, from 1.8% to 4.4% in women, and from 2.4% to 5% overall. This trend coincides with steady declines in incidence (2.2%-2.3%) but rapid gains in survival specifically for nonsmall cell lung cancer (NSCLC). For example, NSCLC 2-year relative survival increased from 34% for persons diagnosed during 2009 through 2010 to 42% during 2015 through 2016, including absolute increases of 5% to 6% for every stage of diagnosis; survival for small cell lung cancer remained at 14% to 15%. Improved treatment accelerated progress against lung cancer and drove a record drop in overall cancer mortality, despite slowing momentum for other common cancers.

Semi-automated PIRADS scoring via mpMRI analysis

Purpose: Prostate cancer (PCa) is the most common solid organ cancer and second leading cause of death in men. Multiparametric magnetic resonance imaging (mpMRI) enables detection of the most aggressive, clinically significant PCa (csPCa) tumors that require further treatment. A suspicious region of interest (ROI) detected on mpMRI is now assigned a Prostate Imaging-Reporting and Data System (PIRADS) score to standardize interpretation of mpMRI for PCa detection. However, there is significant inter-reader variability among radiologists in PIRADS score assignment and a minimal input semi-automated artificial intelligence (AI) system is proposed to harmonize PIRADS scores with mpMRI data. Approach: The proposed deep learning model (the seed point model) uses a simulated single-click seed point as input to annotate the lesion on mpMRI. This approach is in contrast to typical medical AI-based approaches that require annotation of the complete lesion. The mpMRI data from 617 patients used in this study were prospectively collected at a major tertiary U.S. medical center. The model was trained and validated to classify whether an mpMRI image had a lesion with a PIRADS score greater than or equal to PIRADS 4. Results: The model yielded an average receiver-operator characteristic (ROC) area under the curve (ROC-AUC) of 0.704 over a 10-fold cross-validation, which is significantly higher than the previously published benchmark. Conclusions: The proposed model could aid in PIRADS scoring of mpMRI, providing second reads to promote quality as well as offering expertise in environments that lack a radiologist with training in prostate mpMRI interpretation. The model could help identify tumors with a higher PIRADS for better clinical management and treatment of PCa patients at an early stage.

Real-world Evidence to Estimate Prostate Cancer Costs for First-line Treatment or Active Surveillance

Background

Prostate cancer is the most common cancer in men and second leading cause of cancer-related deaths. Changes in screening guidelines, adoption of active surveillance (AS), and implementation of high-cost technologies have changed treatment costs. Traditional cost-effectiveness studies rely on clinical trial protocols unlikely to capture actual practice behavior, and existing studies use data predating new technologies. Real-world evidence reflecting these changes is lacking.

Objective

To assess real-world costs of first-line prostate cancer management.

Design setting and participants

We used clinical electronic health records for 2008-2018 linked with the California Cancer Registry and the Medicare Fee Schedule to assess costs over 24 or 60 mo following diagnosis. We identified surgery or radiation treatments with structured methods, while we used both structured data and natural language processing to identify AS.

Outcome measurements and statistical analysis

Our results are risk-stratified calculated cost per day (CCPD) for first-line management, which are independent of treatment duration. We used the Kruskal-Wallis test to compare unadjusted CCPD while analysis of covariance log-linear models adjusted estimates for age and Charlson comorbidity.

Results and limitations

In 3433 patients, surgery (54.6%) was more common than radiation (22.3%) or AS (23.0%). Two years following diagnosis, AS ($2.97/d) was cheaper than surgery ($5.67/d) or radiation ($9.34/d) in favorable disease, while surgery ($7.17/d) was cheaper than radiation ($16.34/d) for unfavorable disease. At 5 yr, AS ($2.71/d) remained slightly cheaper than surgery ($2.87/d) and radiation ($4.36/d) in favorable disease, while for unfavorable disease surgery ($4.15/d) remained cheaper than radiation ($10.32/d). Study limitations include information derived from a single healthcare system and costs based on benchmark Medicare estimates rather than actual payment exchanges.

Patient summary

Active surveillance was cheaper than surgery (-47.6%) and radiation (-68.2%) at 2 yr for favorable-risk disease, which decreased by 5 yr (-5.6% and -37.8%, respectively). Surgery was less costly than radiation for unfavorable risk for both intervals (-56.1% and -59.8%, respectively).

Clinical utility of the exosome based ExoDx Prostate(IntelliScore) EPI test in men presenting for initial Biopsy with a PSA 2-10 ng/mL

BACKGROUND

The ExoDx Prostate(IntelliScore) (EPI) test is a non-invasive risk assessment tool for detection of high-grade prostate cancer (HGPC) that informs whether to proceed with prostate biopsy. We sought to assess the impact of EPI on the decision to biopsy in a real-world clinical setting.

METHODS

We conducted a prospective, randomized, blinded, two-armed clinical utility study that enrolled 1094 patients with 72 urologists from 24 urology practices. Patients were considered for prostate biopsy at enrollment based on standard clinical criteria. All patients had an EPI test; however, patients were randomized into EPI vs. control arms where only the EPI arm received results for their biopsy decision.

RESULTS

In the EPI arm (N = 458), 93 patients received negative EPI scores of which 63% were recommended to defer biopsy by the urologist and 74% ultimately deferred. In contrast, 87% of patients with positive EPI scores were recommended to undergo biopsy with a 72% compliance rate to the urologist's recommendation. This led to detection of 30% more HGPC compared to the control arm, and we estimate that 49% fewer HGPC were missed due to deferrals compared to standard of care (SOC). Overall, 68% of urologists reported that the EPI test influenced their biopsy decision. The primary reason not to comply with EPI results was rising PSA.

CONCLUSION

To our knowledge this is the first report on a PC biomarker utility study with a blinded control arm. The study demonstrates that the EPI test influences the overall decision to defer or proceed with a biopsy and improves patient stratification.

Prostate Cancer Biomarker Development: National Cancer Institute's Early Detection Research Network Prostate Cancer Collaborative Group Review

Prostate cancer remains the most common non-skin cancer and second leading cause of death among men in the United States. Although progress has been made in diagnosis and risk assessment, many clinical questions remain regarding early identification of prostate cancer and management. The early detection of aggressive disease continues to provide high curative rates if diagnosed in a localized state. Unfortunately, prostate cancer displays significant heterogeneity within the prostate organ and between individual patients making detection and treatment strategies complex. Although prostate cancer is common among men, the majority will not die from prostate cancer, introducing the issue of overtreatment as a major concern in clinical management of the disease. The focus of the future is to identify those at highest risk for aggressive prostate cancer and to develop prevention and screening strategies, as well as discerning the difference in malignant potential of diagnosed tumors. The Prostate Cancer Research Group of the National Cancer Institute's Early Detection Research Network has contributed to the progress in addressing these concerns. This summary is an overview of the activities of the group.See all articles in this CEBP Focus section, "NCI Early Detection Research Network: Making Cancer Detection Possible."

Autophagy-related genes are potential diagnostic and prognostic biomarkers in prostate cancer

Background

Recently, autophagy was found related to several malignances.

Methods

To explore the diagnostic and prognostic values of autophagy in prostate cancer (PCa), we first identified differentially expressed autophagy-related genes (DEARGs) based on The Cancer Genome Atlas (TCGA) Prostate Adenocarcinoma (PRAD) dataset. Gene ontology (GO) analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment were applied to perform gene functional annotation. Then, multivariate logistic regression analysis was applied to construct the risk index (RI). Receiver operating characteristic (ROC), calibration and decision curve analysis (DCA) curves were performed to identify the effectiveness of RI. Next, multivariate Cox regression analyses were performed to construct the prognostic index (PI) and autophagy-clinical prognostic index (ACPI).

Results

We identified 16 DEARGs and functional annotation demonstrated the relevance of these genes to autophagy and revealed the association of these DEARGs with digestive system, drug resistance and apoptosis. Then, the RI was constructed based on 5 DEARGs and the area under the ROC curve (AUC) was 0.9858. Validation based on Gene Expression Omnibus (GEO) datasets suggested that the RI was effective. Next, 7 ARGs were identified associated with overall survival (OS) and the PI was developed composed of 3 ARGs. Finally, ACPI was constructed based on PI and the M stage.

Conclusions

This study provided potential models for predicting the risk and prognosis of PCa and indicated the molecular insights of autophagy in PCa. While no other dataset was applied to test the effectiveness of the PI and ACPI models attribute to the well prognosis of PCa.

Recognition of Invasive Prostate Cancer Using a GHRL Polypeptide Probe Targeting GHSR in a Mouse Model In Vivo

BACKGROUND

Ghrelin (GHRL) is a polypeptide that can specifically bind to the growth hormone secretagogue receptor (GHSR). The expression of GHSR is significantly different in normal and prostate cancer (PC) tissues in humans. It is important to find an effective diagnostic method for the diagnosis and prognosis of invasive PC/neuroendocrine prostate cancer (NEPC).

METHODS

GHRL and GHSR mRNA levels were determined by a quantitative real-time polymerase chain reaction in PC tissues. The expression of GHRL and GHSR proteins was assessed by Western blot assay and immunohistochemistry. A GHRL polypeptide probe was synthesized by standard solid-phase polypeptide synthesis, and labeled with Alexa Fluor 660. Confocal microscopy was used to capture fluorescence images. Living imaging analysis showed tumor areas of different invasiveness in mice models.

RESULTS

The levels of GHRL and GHSR copy number amplification and mRNA expression were increased in invasive PC/NEPC, and the protein expression levels of GHRL and GHSR were similarly increased in NEPC. The GHRL polypeptide probe could effectively bind to GHSR. In PC3 cells, it was found that the GHRL probe specifically binds to GHSR on the cell membrane and accumulates in the cells through internalization after binding. Live imaging in mice models showed that there were different signal intensities in tumor areas with different invasiveness.

CONCLUSION

GHSR and GHRL might be used in molecular imaging diagnosis for invasive PC/NEPC in the future.

Performance of Three Inherited Risk Measures for Predicting Prostate Cancer Incidence and Mortality: A Population-based Prospective Analysis

BACKGROUND

Single nucleotide polymorphism-based genetic risk score (GRS) has been developed and validated for prostate cancer (PCa) risk assessment. As GRS is population standardized, its value can be interpreted as a relative risk to the general population.

OBJECTIVE

To compare the performance of GRS with two guideline-recommended inherited risk measures, family history (FH) and rare pathogenic mutations (RPMs), for predicting PCa incidence and mortality.

DESIGN, SETTING, AND PARTICIPANTS

A prospective cohort was derived from the UK Biobank where 208 685 PCa diagnosis-free participants at recruitment were followed via the UK cancer and death registries.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Rate ratios (RRs) of PCa incidence and mortality for FH (positive vs negative), RPMs (carriers vs noncarriers), and GRS (top vs bottom quartile) were measured.

RESULTS AND LIMITATIONS

After a median follow-up of 9.67 yr, 6890 incident PCa cases (419 died of PCa) were identified. Each of the three measures was significantly associated with PCa incidence in univariate analyses; RR (95 % confidence interval [CI]) values were 1.88 (1.75-2.01) for FH, 2.89 (1.89-4.25) for RPMs, and 1.97(1.87-2.07) for GRS (all p < 0.001). The associations were independent in multivariable analyses. While FH and RPMs identified 11 % of men at higher PCa risk, addition of GRS identified an additional 22 % of men at higher PCa risk, and increases in C-statistic from 0.58 to 0.67 for differentiating incidence (p < 0.001) and from 0.65 to 0.71 for differentiating mortality (p = 0.002). Limitations were a small number of minority patients and short mortality follow-up.

CONCLUSIONS

This population-based prospective study suggests that GRS complements two guideline-recommended inherited risk measures (FH and RPMs) for stratifying the risk of PCa incidence and mortality.

PATIENT SUMMARY

In a large population-based prostate cancer (PCa) prospective study derived from UK Biobank, genetic risk score (GRS) complements two guideline-recommended inherited risk measures (family history and rare pathogenic mutations) in predicting PCa incidence and mortality. These results provide critical data for including GRS in PCa risk assessment.

Prostate Cancer Screening with PSA: Ten Years' Experience of Population Based Early Prostate Cancer Detection Programme in Lithuania

The aim of this study is to report key performance estimates from the ten years of a population-based prostate cancer screening programme in Lithuania. Retrospective analysis of screening activities recorded in 2006–2015 among men aged 50–74 years was performed. We estimated screening coverage, cancer detection rate, compliance to biopsy, and positive predictive values in each screening round inside and outside the target population. In the first 10 years of screening, 16,061 prostate cancer cases were registered within the screening programme, 10,202 were observed among screened men but reported outside the screening programme, and 1455 prostate cancers were observed in a screening-naïve population. Screening cover reached up to 45.5% of the target population in the recent rounds. The proportion of prostate specific antigen (PSA) test-positive men decreased from 16.9% in 2006 to 10.7% in 2014–2015. Up to 40.0% of PSA test-positive men received a biopsy, of whom 42.0% were positive for prostate cancer. The cancer detection rate was 10.4−15.0% among PSA test-positives and 1.4–1.9% among screened individuals. Screening participants were more likely to be diagnosed with organ-confined disease as compared to non-participants. Despite the unorganized screening practices being employed and low coverage per screening round, 70% of the target population were screened at least once in the first 10 years of screening.

Prostate Cancer Screening Patterns Among Sexual and Gender Minority Individuals

One in six gay and bisexual men will be diagnosed with prostate cancer in their lifetime. Lesbian, gay, bisexual, and transgender (LGBT) populations are under-represented in cancer research, and guidelines on prostate-specific antigen (PSA) screening are limited. We performed a cross-sectional study to assess patterns of PSA screening and decision-making in this cohort. The Behavioral Risk Factor Surveillance System database was queried for LGBT adults for 2014-2016 and 2018, when PSA questions were asked in the annual survey. Multivariable logistic regression was performed to evaluate the association of LGBT status with PSA screening and informed and shared decision-making. A total of 164 370 participants were eligible for PSA screening, representing a weighted estimate of 1.2 million LGBT individuals. Compared to cisgender (CG) straight individuals, CG gay/bisexual cohorts were more likely to participate in PSA screening (CG gay: odds ratio [OR] 1.07; p < 0.001; CG bisexual: OR 1.06; p < 0.001). CG gay participants were more likely to make informed decisions (OR 1.10; p < 0.001) and engage in shared decision-making (OR 2.55; p < 0.001). Select gay populations were more likely to undergo PSA screening recommended by their clinicians and participate in informed and shared decision-making. PATIENT SUMMARY: This large study of sexual and gender minorities in the USA suggests that gay and bisexual individuals were more likely to undergo prostate cancer screening and that select gay individuals were more likely to make informed and shared decisions. However, transgender individuals were less likely to have prostate cancer screening and make informed decisions.

A multifaceted approach to quality in the MRI-directed biopsy pathway for prostate cancer diagnosis

KEY POINTS

• Identify, assure, and measure major sources of variability affecting the MRI-directed biopsy pathway for prostate cancer diagnosis.• Develop strategies to control and minimize variations that impair pathway effectiveness including the performance of main players and team working.• Assure end-to-end quality of the diagnostic chain with robust multidisciplinary team working.

Historical Considerations and Surgical Quality Improvement in Robotic Prostatectomy

Laparoscopic prostatectomy was technically challenging and not widely adopted. Robotics led to the widespread adoption of minimally invasive prostatectomy, which has been used heavily, supplanting the open and traditional laparoscopic approach. The benefits of robotic prostatectomy are disputed. Data suggest that robotic prostatectomy outcomes have improved over time.

PI-RADS Committee Position on MRI Without Contrast Medium in Biopsy-Naive Men With Suspected Prostate Cancer: Narrative Review

The steadily increasing demand for diagnostic prostate MRI has led to concerns regarding the lack of access to and the availability of qualified MRI scanners and sufficiently experienced radiologists, radiographers, and technologists to meet the demand. Solutions must enhance operational benefits without compromising diagnostic performance, quality, and delivery of service. Solutions should also mitigate risks such as decreased reader confidence and referrer engagement. One approach may be the implementation of MRI without the use gadolinium-based contrast medium (bipara-metric MRI), but only if certain prerequisites such as high-quality imaging, expert interpretation quality, and availability of patient recall or on-table monitoring are mandated. Alternatively, or in combination, a clinical risk-based approach could be used for protocol selection, specifically, which biopsy-naive men need MRI with contrast medium (multiparametric MRI). There is a need for prospective studies in which biopsy decisions are made according to MRI without contrast enhancement. Such studies must define clinical and operational benefits and identify which patient groups can be scanned successfully without contrast enhancement. These higher-quality data are needed before the Prostate Imaging Reporting and Data System (PI-RADS) Committee can make evidence-based recommendations about MRI without contrast enhancement as an initial diagnostic approach for prostate cancer workup.

Association between inflammatory bowel disease and prostate cancer: A large-scale, prospective, population-based study

Inflammatory bowel disease (IBD) is an established risk factor for colorectal cancer. Recent reports suggesting IBD is also a risk factor for prostate cancer (PC) require further investigation. We studied 218 084 men in the population-based UK Biobank cohort, aged 40 to 69 at study entry between 2006 and 2010, with follow-up through mid-2015. We assessed the association between IBD and subsequent PC using multivariable Cox regression analyses, adjusting for age at assessment, ethnic group, UK region, smoking status, alcohol drinking frequency, body mass index, Townsend Deprivation Index, family history of PC and previous prostate-specific antigen testing. Mean age at study entry was 56 years, 94% of the men were white, and 1.1% (n = 2311) had a diagnosis of IBD. After a median follow-up of 78 months, men with IBD had an increased risk of PC (adjusted hazard ratio [aHR] = 1.31, 95% confidence interval [CI] = 1.03-1.67, P = .029). The association with PC was only among men with the ulcerative colitis (UC; aHR = 1.47, 95% CI = 1.11-1.95, P = .0070), and not Crohn's disease (aHR 1.06, 95% CI = 0.63-1.80, P = .82). Results are limited by lack of data on frequency of health care interactions. In a large-scale, prospective cohort study, we detected an association between IBD, and UC specifically, with incident PC diagnosis.

Platinum(IV)-Estramustine Multiaction Prodrugs Are Effective Antiproliferative Agents against Prostate Cancer Cells

Herein, we describe the synthesis, characterization, and biological properties of Pt(IV) derivatives of cisplatin with estramustine at the first axial position, which is known to disrupt the microtubule assembly and act as an androgen antagonist, and varying the second axial position using an innocent ligand (acetate or hydroxyl) to prepare dual-action and triple-action prodrugs with known inhibitors of histone deacetylase, cyclooxygenase, and pyruvate dehydrogenase kinase. We demonstrate superior antiproliferative activity at submicromolar concentrations of the prodrugs against a panel of cancer cell lines, particularly against prostate cancer cell lines. The results obtained in this study exemplify the complex mode of action of "multiaction" Pt(IV) prodrugs. Interestingly, changing the second axial ligand in the Pt-estramustine complex has a significant effect on the mode of action, suggesting that all three components of the Pt(IV) prodrugs (platinum moiety and axial ligands) contribute to the killing of cells and not just one dominant component.

A 3D-2D Hybrid U-Net Convolutional Neural Network Approach to Prostate Organ Segmentation of Multiparametric MRI

OBJECTIVE

Prostate cancer is the most commonly diagnosed cancer in men in the United States with more than 200,000 new cases in 2018. Multiparametric MRI (mpMRI) is increasingly used for prostate cancer evaluation. Prostate organ segmentation is an essential step of surgical planning for prostate fusion biopsies. Deep learning convolutional neural networks (CNNs) are the predominant method of machine learning for medical image recognition. In this study, we describe a deep learning approach, a subset of artificial intelligence, for automatic localization and segmentation of prostates from mpMRI.

MATERIALS AND METHODS

This retrospective study included patients who underwent prostate MRI and ultrasound-MRI fusion transrectal biopsy between September 2014 and December 2016. Axial T2-weighted images were manually segmented by two abdominal radiologists, which served as ground truth. These manually segmented images were used for training on a customized hybrid 3D-2D U-Net CNN architecture in a fivefold cross-validation paradigm for neural network training and validation. The Dice score, a measure of overlap between manually segmented and automatically derived segmentations, and Pearson linear correlation coefficient of prostate volume were used for statistical evaluation.

RESULTS

The CNN was trained on 299 MRI examinations (total number of MR images = 7774) of 287 patients. The customized hybrid 3D-2D U-Net had a mean Dice score of 0.898 (range, 0.890-0.908) and a Pearson correlation coefficient for prostate volume of 0.974.

CONCLUSION

A deep learning CNN can automatically segment the prostate organ from clinical MR images. Further studies should examine developing pattern recognition for lesion localization and quantification.

[Immunohistochemical study of Ki-67, p53 and Notch1 expressions in prostate cancer of different grades]

OBJECTIVE

To determine the prognostic value of the expression of Ki-67, p53, and Notch1 in the diagnosis of prostate cancer.

MATERIAL AND METHODS

Surgical and diagnostic materials obtained from patients with benign prostatic hyperplasia, prostate intraepithelial neoplasia, and prostate cancer of different grades underwent studies; a total of 98 patients were examined. Cell antigens were determined using rabbit anti-Ki-67 monoclonal antibodies (Clone SP6), mouse anti-p53 monoclonal antibodies (Clone Y5), and recombinant anti-Notch1 antibodies (Clone EP1238Y).

RESULTS

Comparing Ki-67, p53, and Notch1 expression indices revealed statistically significant differences. There was a significant direct correlation between Ki-67 and p53 expression indices and prostate cancer grade groups based on the morphological Gleason grading system (r_s=0.736; p<0.001; r_s=0.682; p=0.035, respectively) and a strong inverse correlation between Notch1 expression and prostate cancer grade groups (r_s= -0.425, p<0.001).

CONCLUSION

Notch1 expression in conjunction with the low proliferative activity of cells and the absence of p53 (Y5) protein may suggest that the mechanism of apoptosis is preserved in tumor cells, which expands indications for medical treatment of prostate cancer.

Impact of health literacy on shared decision making for prostate-specific antigen screening in the United States

BACKGROUND

Current guidelines endorse shared decision making (SDM) for prostate-specific antigen (PSA) screening. The relationship between a patient's health literacy (HL) and SDM remains unclear. In the current study, the authors sought to identify the impact of HL on the rates of PSA screening and on the relationship between HL and SDM following the 2012 US Preventive Services Task Force recommendations against PSA screening.

METHODS

Using data from the 2016 Behavioral Risk Factor Surveillance System, the authors examined PSA screening in the 13 states that administered the optional "Health Literacy" module. Men aged ≥50 years were examined. Complex samples multivariable logistic regression models were computed to assess the odds of undergoing PSA screening. The interactions between HL and SDM were also examined.

RESULTS

A weighted sample of 12.249 million men with a rate of PSA screening of 33.4% were identified. Approximately one-third self-identified as having optimal HL. Rates of PSA screening were found to be highest amongst the highest HL group (42.2%). Being in this group was a significant predictor of undergoing PSA screening (odds ratio, 1.214; 95% confidence interval, 1.051-1.403). There was a significant interaction observed between HL and SDM (P for interaction, <.001) such that higher HL was associated with a lower likelihood of undergoing PSA screening when SDM was present.

CONCLUSIONS

In the uncertain environment of multiple contradictory screening guidelines, men who reported higher levels of HL were found to have higher levels of screening. The authors demonstrated that increased HL may reduce the screening-promoting effect of SDM. These findings highlight the dynamic interplay between HL and SDM that should inform the creation and promulgation of SDM guidelines, specifically when considering patients with low HL.

EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer-2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent

OBJECTIVE

To present a summary of the 2020 version of the European Association of Urology (EAU)-European Association of Nuclear Medicine (EANM)-European Society for Radiotherapy and Oncology (ESTRO)-European Society of Urogenital Radiology (ESUR)-International Society of Geriatric Oncology (SIOG) guidelines on screening, diagnosis, and local treatment of clinically localised prostate cancer (PCa).

EVIDENCE ACQUISITION

The panel performed a literature review of new data, covering the time frame between 2016 and 2020. The guidelines were updated and a strength rating for each recommendation was added based on a systematic review of the evidence.

EVIDENCE SYNTHESIS

A risk-adapted strategy for identifying men who may develop PCa is advised, generally commencing at 50 yr of age and based on individualised life expectancy. Risk-adapted screening should be offered to men at increased risk from the age of 45 yr and to breast cancer susceptibility gene (BRCA) mutation carriers, who have been confirmed to be at risk of early and aggressive disease (mainly BRAC2), from around 40 yr of age. The use of multiparametric magnetic resonance imaging in order to avoid unnecessary biopsies is recommended. When a biopsy is performed, a combination of targeted and systematic biopsies must be offered. There is currently no place for the routine use of tissue-based biomarkers. Whilst prostate-specific membrane antigen positron emission tomography computed tomography is the most sensitive staging procedure, the lack of outcome benefit remains a major limitation. Active surveillance (AS) should always be discussed with low-risk patients, as well as with selected intermediate-risk patients with favourable International Society of Urological Pathology (ISUP) 2 lesions. Local therapies are addressed, as well as the AS journey and the management of persistent prostate-specific antigen after surgery. A strong recommendation to consider moderate hypofractionation in intermediate-risk patients is provided. Patients with cN1 PCa should be offered a local treatment combined with long-term hormonal treatment.

CONCLUSIONS

The evidence in the field of diagnosis, staging, and treatment of localised PCa is evolving rapidly. The 2020 EAU-EANM-ESTRO-ESUR-SIOG guidelines on PCa summarise the most recent findings and advice for their use in clinical practice. These PCa guidelines reflect the multidisciplinary nature of PCa management.

PATIENT SUMMARY

Updated prostate cancer guidelines are presented, addressing screening, diagnosis, and local treatment with curative intent. These guidelines rely on the available scientific evidence, and new insights will need to be considered and included on a regular basis. In some cases, the supporting evidence for new treatment options is not yet strong enough to provide a recommendation, which is why continuous updating is important. Patients must be fully informed of all relevant options and, together with their treating physicians, decide on the most optimal management for them.

Prostate Cancer Screening Recommendations for General and Specific Populations in the Western Nations

There is a chaotic scenario that exists in the field of prostate cancer (PCa) screening. To balance goals, such as decreasing mortality, avoiding unnecessary procedures, and decreasing the cost of medical care, the pendulum seems to have swung to the side of more restricted screening. The decrease in PCa screening has led to a slowly creeping decline in the favourable outcomes that existed among patients with PCa. If a potential patient or a family member is trying to get clear guidance about PCa screening by searching the internet, they will end up confused by several recommendations from many organisations. It is even more challenging to obtain any clarity about PCa screening for special populations, such as those with a family history of PCa, those of African descent/African Americans, and the elderly. The advent of genomic medicine and precision medicine is an opportunity to identify those at a very high risk of developing aggressive PCa, so that PCa screening can be more actively undertaken among them. In this paper, the authors review the current recommendations by different entities and summarise emerging molecular markers that may help bring clarity to PCa screening. The authors predict that concrete, consensual guidelines will emerge in less than one decade. Meanwhile, this article suggests intermediary steps that will help save lives from PCa mortality, especially for under-represented populations. This paper is a catalyst to stimulate further discussion and serves as a guide to noncancer-specialists for the near future as precision medicine progresses to better understand risk–benefit and cost–benefit ratios in PCa screening.

Primary Care Guidance for Persons With Human Immunodeficiency Virus: 2020 Update by the HIV Medicine Association of the Infectious Diseases Society of America

Advances in antiretroviral therapy (ART) have made it possible for persons with human immunodeficiency virus (HIV) to live a near expected life span, without progressing to AIDS or transmitting HIV to sexual partners or infants. There is, therefore, increasing emphasis on maintaining health throughout the life span. To receive optimal medical care and achieve desired outcomes, persons with HIV must be consistently engaged in care and able to access uninterrupted treatment, including ART. Comprehensive evidence-based HIV primary care guidance is, therefore, more important than ever. Creating a patient-centered, stigma-free care environment is essential for care engagement. Barriers to care must be decreased at the societal, health system, clinic, and individual levels. As the population ages and noncommunicable diseases arise, providing comprehensive healthcare for persons with HIV becomes increasingly complex, including management of multiple comorbidities and the associated challenges of polypharmacy, while not neglecting HIV-related health concerns. Clinicians must address issues specific to persons of childbearing potential, including care during preconception and pregnancy, and to children, adolescents, and transgender and gender-diverse individuals. This guidance from an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America updates previous 2013 primary care guidelines.

Racial and Ethnic Variation in PSA Testing and Prostate Cancer Incidence Following the 2012 USPSTF Recommendation

BACKGROUND

The 2012 US Preventive Services Task Force recommendation against routine prostate-specific antigen (PSA) testing led to a decrease in prostate cancer screening, but the heterogeneity of its impact by race and ethnicity remains unclear.

METHODS

The proportion of 40- to 74-year-old men who self-reported receiving a routine PSA test in the past year was estimated in the Behavioral Risk Factor Surveillance System (2012-2018). Odds ratios (ORs) of undergoing screening by race and ethnicity were estimated, adjusting for healthcare-related factors. Prostate cancer incidence rates and rate ratios (IRRs) by race and ethnicity were estimated using Surveillance, Epidemiology, and End Results registry data (2004-2017).

RESULTS

PSA testing frequencies were 32.3% (95% confidence interval [CI] = 31.7% to 32.8%) among non-Hispanic White (NHW), 30.3% (95% CI = 28.3% to 32.3%) among non-Hispanic Black (NHB), 21.8% (95% CI = 19.9% to 23.7%) among Hispanic, and 17.7% (95% CI = 14.1% to 21.3%) among Asian and Pacific Islander men in 2012. The absolute screening frequency declined by 9.5% from 2012 to 2018, with a larger decline among NHB (11.6%) than NHW men (9.3%). The relative annual decrease was greater among NHB (OR = 0.86, 95% CI = 0.84 to 0.88) than NHW men (OR = 0.89, 95% CI = 0.89 to 0.90; Pheterogeneity = .005), driven by a larger decline among NHB men ages 40-54 years. The NHB to NHW IRR for total prostate cancer increased from 1.73 (95% CI = 1.69 to 1.76) in 2011 to 1.87 (95% CI = 1.83 to 1.92) in 2012 and has remained elevated, driven by differences in localized tumor incidence. Metastatic disease incidence is rising across all racial and ethnic groups.

CONCLUSIONS

The frequency of prostate cancer screening varies by race and ethnicity, and there was a modestly steeper decline in PSA testing among younger NHB men relative to NHW men since 2012. The NHB to NHW IRR for localized prostate cancer modestly increased following 2012.

Heart transplantation in patients with localized prostate cancer-Are we denying a life-saving therapy due to an indolent tumor?

BACKGROUND

Prostate cancer (PC) is the most common non-cutaneous cancer in men. Approximately 90% of these cancers are localized (LPC) with a cancer-specific survival rate of 99% at 10 years. Some heart transplant centers (HTCs) regard PC as an absolute contraindication to heart transplantation (HT). This study aims to understand the current status of HT in patients with advanced heart failure (AHF) and concurrent LPC in the United States.

METHODS

Adult HTCs in the United States were asked to fill out an email questionnaire addressing their current approach to HT in AHF patients with concurrent LPC.

RESULTS

Fifty of the 90 HTCs that received the questionnaire responded. Only 16% of HTCs had a formal policy regarding HT in patients with LPC, while only 10% had patients with LPC on the HT waitlist at the time of the survey. Overall, 84% of the HTCs had never performed HT in a patient with LPC in the history of their transplant program.

CONCLUSION

An overwhelming majority of HTCs in the United States do not consider HT an option for AHF patients with concurrent LPC and lack a formal policy regarding the same.

Characterization and validation of long noncoding RNAs as new candidates in prostate cancer

Background

Long noncoding RNAs (lncRNAs) have been proved to be an important regulator in gene expression. In almost all kinds of cancers, lncRNAs participated in the process of pathogenesis, invasion, and metastasis. Meanwhile, compared with the large amounts of patients, there is rare knowledge about the role of lncRNAs in prostate cancer (PCa).

Material/Method

In this study, lncRNA expression profiles of prostate cancer were detected by Agilent microarray chip, 5 pairs of case and control specimens were involved in. Differentially expressed lncRNAs were screened out by volcano plot for constructing lncRNA-miRNA-mRNA central network. Then, the top ten up-regulated and down-regulated lncRNAs were validated by qRT-PCR in another 5 tumor specimens and 7 para-cancerous/benign contrasts. Furthermore, we searched for the survival curve of the top 10 upregulated and downregulated lncRNAs.

Results

A total of 817 differentially expressed lncRNAs were filtered out by the criteria of fold change (FC) and t-test p < 0.05. Among them, 422 were upregulated, whereas 395 were downregulated in PCa tissues. Gene ontology and KEGG pathway analyses showed that many lncRNAs were implicated in carcinogenesis. lnc-MYL2-4:1 (FC = 0.00141, p = 0.01909) and NR_125857 (FC = 59.27658, p = 0.00128) had the highest magnitude of change. The subsequent qPCR confirmed the expression of NR_125857 was in accordance with the clinical samples. High expression of PCA3, PCAT14 and AP001610.9 led to high hazard ratio while low expression of RP11-279F6.2 led to high hazard ratio.

Conclusions

Our study detected a relatively novel complicated map of lncRNAs in PCa, which may have the potential to investigate for diagnosis, treatment and follow-up in PCa. Our study revealed the expression of NR_125857 in human PCa tissues was most up-regulated. Further studies are needed to investigate to figure out the mechanisms in PCa.

The Importance of Cancer Screening

The burden of cancer in the United States is substantial, providing important opportunity and obligation for primary care clinicians to promote cancer prevention and early detection. Without a system of organized screening to support reminders and follow-up of cancer screening, primary care clinicians face challenges in addressing risk assessment, informed/shared decision making, reminders for screening, and tracking adherence to screening recommendations. Tools exist for collecting information about family history, tracking screening adherence, and reminding patients when they are due for screening, and strategies exist for making cancer prevention and early detection an office policy and delegating roles and responsibilities to office staff.

Screening for Prostate Cancer

This article gives an overview of the current state of the evidence for prostate cancer early detection with prostate-specific antigen (PSA) and summarizes current recommendations from guideline groups. The article reviews the global public health burden and risk factors for prostate cancer with clinical implications as screening tools. Screening studies, novel biomarkers, and MRI are discussed. The article outlines 7 key practice points for primary care physicians and provides a simple schema for facilitating shared decision-making conversations.

Changing Provider PSA Screening Behavior Using Best Practice Advisories: Interventional Study in a Multispecialty Group Practice

BACKGROUND

Most guidelines recommend against PSA-based screening for prostate cancer in men ≥ 70 years of age. Adherence to these guidelines is variable.

OBJECTIVE

To determine whether the use of a "Best Practice Advisory" (BPA) intervention within the electronic medical record (EMR) system can alter the rate of PSA screening in men ≥ 70 years of age.

DESIGN

This is an interventional study spanning the years 2013 through 2017, in men ≥ 70 years of age in Kaiser Permanente Northern California with no prior history of prostate cancer. The BPA intervention was activated in the EMR system on October 15, 2015, with no prior notice or education.

SETTING

Integrated healthcare system including all Kaiser Permanente Northern California facilities.

PARTICIPANTS

A population-based sample that included all male members ≥ 70 years of age without a history of prostate cancer.

MAIN MEASURES

The main outcome was the rate of PSA testing in men ≥ 70 years of age. We compared the rates of PSA testing between the pre-BPA period (January 1, 2013-October 14, 2015) and the post-BPA period (October 15, 2015-December 31, 2017). An interrupted time series analysis of PSA ordering rates was performed.

KEY RESULTS

Following the 2015 BPA intervention, screening rates substantially declined from 36.0 per 100 person-years to 14.9 per 100 person-years (rate ratio = 0.415; 95% CI: 0.410-0.419). The effect of the BPA was comparable among all patient races and ordering provider specialties. The interrupted time series analysis showed a rapid, large, and sustained drop in the rate of PSA ordering, and much less temporal variation in test ordering after activation of the BPA.

CONCLUSION

Following activation of a BPA within the EMR, the rates of inappropriate PSA testing significantly declined by 58.5% in men ≥ 70 years of age and temporal variation was reduced.

Cancer Screening in Older Adults: Individualized Decision-Making and Communication Strategies

Cancer screening decisions in older adults can be complex due to the unclear cancer-specific mortality benefits of screening and several known harms including false positives, overdiagnosis, and procedural complications from downstream diagnostic interventions. In this review, we provide a framework for individualized cancer screening decisions among older adults, involving accounting for overall health and life expectancy, individual values, and the risks and benefits of specific cancer screening tests. We then discuss strategies for effective communication of recommendations during clinical visits that are considered more effective, easy to understand, and acceptable by older adults and clinicians.

Analysis of serum glycome by lectin microarrays for prostate cancer patients - a search for aberrant glycoforms

This is the first work focused on glycoprofiling of whole N- and O- glycome using lectins in an array format applied for analysis of serum samples from healthy individuals, benign prostate hyperplasia (BPH) patients, and prostate cancer (PCa) patients. Lectin microarray was prepared using traditional lectins with the incorporation of 2 recombinant bacterial lectins and 3 human lectins (17 lectins in total). Clinical validation of glycans as biomarkers was done in two studies: discrimination of healthy individuals with BPH patients vs. PCa patients (C vs. PCa) and discrimination of healthy individuals vs. BPH and PCa patients (H vs. PCond). Single lectins (17 lectins) and a combination of two lectins (136 binary lectin combinations) were applied in the clinical validation of glycan biomarkers providing 153 AUC values from ROC curves for both studies (C vs. PCa and H vs. PCond). Potential N- and O-glycans as biomarkers were identified and possible carriers of these glycans are shortly discussed.

Prostate-Specific Antigen Screening and Recent Increases in Advanced Prostate Cancer

Recent studies show decreasing prostate-specific antigen utilization and increasing incidence of metastatic prostate cancer in the United States after national recommendations against screening in 2012. Yet, whether the increasing incidence of metastatic prostate cancer is consistent in magnitude with the expected impact of decreased screening is unknown. We compared observed incidence of metastatic prostate cancer from the Surveillance, Epidemiology, and End Results program and published effects of continued historical screening and discontinued screening starting in 2013 projected by 2 models of disease natural history, screening, and diagnosis. The observed rate of new metastatic prostate cancer cases in 2017 was 44%-60% of the projected increase under discontinued screening relative to continued screening. Thus, the observed increase in incident metastatic prostate cancer is consistent with the expected impact of reduced screening. Although this comparison does not establish a causal relationship, it highlights the plausible role of decreased screening in the observed trend.

Tobacco and marijuana use and their association with serum prostate-specific antigen levels among African American men in Chicago

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AA men are under-represented in PSA research, a biomarker of prostate cancer aggresiveness.

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Cigarette smoking was associated with an increase in PSA among older AA men.

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Tobacco use was associated with an increase in PSA among older AA men.

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Marijuana use was associated with a decrease in PSA among older AA men.

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Future behavioral risk factor studies linked to biopsy outcomes are warranted.

African American (AA) men experience more than twice the prostate cancer mortality as White men yet are under-represented in academic research involving prostate-specific antigen (PSA), a biomarker of prostate cancer aggressiveness. We examined the impact of self-reported tobacco (cigarette pack-years and current tobacco use including e-cigarettes) and current regular marijuana use on serum PSA level based on clinical laboratory testing among 928 AA men interviewed 2013–2018 in Chicago. We defined outcome of elevated PSA ≥ 4.0 ng/mL for logistic regression models and continuous PSA increases for general linear models. All models were adjusted for age, sociodemographic characteristics, healthcare utilization, body mass index, and self-reported health. Among 431 AA men age ≥ 55 years, we observed ∼ 5 times the odds of elevated PSA among those with > 1 pack-years of cigarette smoking vs. never-smokers (odds ratio [OR] = 5.09; 95% confidence interval [CI] = 1.57–16.6) and a quarter the odds of elevated PSA among current marijuana users vs. non-users (OR = 0.27; 95% CI = 0.08–0.96). PSA increased on average 1.20 ng/mL among other current tobacco users vs. non-users. Among older AA men, cigarette smoking history and current tobacco use were positively associated with an increase in PSA levels and current marijuana use were inversely associated with PSA levels. Future work with studies of diverse patient populations with cancer outcomes are needed to assess whether these behavioral characteristics contribute to racial/ ethnic disparities in prostate cancer outcomes. Our study provides novel evidence regarding potential differences in PSA levels among older AA men according to behavioral characteristics.

An Up-to-date Assessment of US Prostate Cancer Incidence Rates by Stage and Race: A Novel Approach Combining Multiple Imputation with Age and Delay Adjustment

BACKGROUND

In the USA, it is unknown whether metastatic prostate cancer incidence has continued to increase and whether racial differences have persisted.

OBJECTIVE

Combining multiple imputation with age and delay adjustment, we provide an up-to-date, comprehensive assessment of US prostate cancer incidence trends by stage and race.

DESIGN, SETTING, AND PARTICIPANTS

From Surveillance Epidemiology and End Results (SEER)-18, 774 240 prostate cancer cases were diagnosed during 2004-2017.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Multiple imputation assigned prostate cancer stage to the 4.7% of cases with missing stage, which varied by year and race-ethnicity. SEER delay factors adjusted case counts to anticipated future data corrections. Twenty datasets were imputed, and Rubin's rules were used for summary estimation. Overall and stage-specific rates were estimated and stratified by race and age group. Joinpoint software identified significant temporal changes and estimated annual percentage changes. We compared these estimates without multiple imputation and delay adjustment.

RESULTS AND LIMITATIONS

Metastatic prostate cancer incidence increased during 2011-2017, with an annual percentage change of 5.5. This was followed by increases in localized and regional disease since 2014. Non-Hispanic black men continued to have the highest incidence, especially for metastatic disease. The increasing rate of metastatic prostate cancer in non-Hispanic white men aged 50-74 yr accelerated recently, and the incidence was 56% higher in 2017 than in 2004. Rates without multiple imputation and delay adjustment were quantitatively and qualitatively different. This observational study is unable to assign causes to observed changes in prostate cancer incidence.

CONCLUSIONS

Multiple imputation and delay adjustment are essential for portraying accurately stage- and race-specific prostate cancer incidence as clinical practice evolves.

PATIENT SUMMARY

In the USA, diagnosis of prostate cancer that has spread to distant sites (metastatic disease) continues to increase. Black men continue to have higher risks of being diagnosed with metastatic prostate cancer than other race-ethnicities.

Geographic-Level Association of Contemporary Changes in Localized and Metastatic Prostate Cancer Incidence in the Era of Decreasing PSA Screening

Decreased prostate-specific antigen screening since 2008 has generated much concern, including report of recent increase in metastatic prostate cancer incidence among older men. Although increased metastatic disease was temporally proceeded by decreased screening and decreased localized prostate cancer at diagnosis, it is unclear whether the 2 trends are geographically connected. We therefore used the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database to assess geographic-specific associations between changes in localized (2008-2011) and later changes in metastatic prostate cancer incidence (2012-2015). We examined trends from 200 health-care service areas (HSAs) within SEER 18 registries. While on average for each HSA, localized incidence decreased by 27.4 and metastatic incidence increased by 2.3 per 100 000 men per year, individual HSA-level changes in localized incidence did not correlate with later changes in metastatic disease. Decreased detection of localized disease may not fully explain the recent increase in metastatic disease at diagnosis.