Screening for prostate cancer: systematic review and meta-analysis of randomised controlled trials

Fine-mapping the HOXB region detects common variants tagging a rare coding allele: evidence for synthetic association in prostate cancer

The HOXB13 gene has been implicated in prostate cancer (PrCa) susceptibility. We performed a high resolution fine-mapping analysis to comprehensively evaluate the association between common genetic variation across the HOXB genetic locus at 17q21 and PrCa risk. This involved genotyping 700 SNPs using a custom Illumina iSelect array (iCOGS) followed by imputation of 3195 SNPs in 20,440 PrCa cases and 21,469 controls in The PRACTICAL consortium. We identified a cluster of highly correlated common variants situated within or closely upstream of HOXB13 that were significantly associated with PrCa risk, described by rs117576373 (OR 1.30, P = 2.62×10(-14)). Additional genotyping, conditional regression and haplotype analyses indicated that the newly identified common variants tag a rare, partially correlated coding variant in the HOXB13 gene (G84E, rs138213197), which has been identified recently as a moderate penetrance PrCa susceptibility allele. The potential for GWAS associations detected through common SNPs to be driven by rare causal variants with higher relative risks has long been proposed; however, to our knowledge this is the first experimental evidence for this phenomenon of synthetic association contributing to cancer susceptibility.

Evaluation of systems-oriented public health interventions: alternative research designs

The need to provide sound evidence of the costs and benefits of real-world public health interventions has driven advances in the development and analysis of designs other than the controlled trial in which individuals are randomized to an experimental condition. Attention to methodological quality is of critical importance to ensure that any evaluation can accurately answer three fundamental questions: (a) Has a change occurred, (b) did the change occur as a result of the intervention, and (c) is the degree of change significant? A range of alternatives to the individual randomized controlled trial (RCT) can be used for evaluating such interventions, including the cluster RCT, stepped wedge design, interrupted time series, multiple baseline, and controlled prepost designs. The key features and complexities associated with each of these designs are explored.

Management of low risk and low PSA prostate cancer: long term results from the prostate cancer intervention versus observation trial

Management of localized prostate cancer is controversial due in part to the lack of randomized controlled trial information in men diagnosed with prostate specific antigen (PSA) testing. Men with low risk or low PSA (<10 ng/ml) prostate cancer comprise up to 70 % of men currently diagnosed. Evidence suggests an excellent long-term prognosis with observation though nearly 90 % are treated with surgery (radical prostatectomy), external beam radiation, or brachytherapy. Results from the Prostate cancer Intervention Versus Observation Trial (PIVOT) provide high quality Level 1 evidence that observation compared to surgery results in similar long-term overall and prostate cancer survival, prevention of bone metastases and avoidance of surgery related harms. Combined with emerging evidence from screening, natural history, decision analysis and cost-effectiveness modeling studies, these data demonstrate that observation is the preferred treatment option for men with low risk and possibly low PSA prostate cancer. Recommending against PSA testing or, in men who still desire testing, raising thresholds of PSA values used to define abnormal, lengthening intervals between PSA tests and discontinuing testing in men with a life expectancy less than 15 years will reduce diagnostic and treatment related harms without adversely impacting overall or disease specific mortality and morbidity.

Prostate cancer: the need for biomarkers and new therapeutic targets

Prostate cancer (PCa) incidence and mortality have decreased in recent years. Nonetheless, it remains one of the most prevalent cancers in men, being a disquieting cause of men's death worldwide. Changes in many cell signaling pathways have a predominant role in the onset, development, and progression of the disease. These include prominent pathways involved in the growth, apoptosis, and angiogenesis of the normal prostate gland, such as androgen and estrogen signaling, and other growth factor signaling pathways. Understanding the foundations of PCa is leading to the discovery of key molecules that could be used to improve patient management. The ideal scenario would be to have a panel of molecules, preferably detectable in body fluids, that are specific and sensitive biomarkers for PCa. In the early stages, androgen deprivation is the gold standard therapy. However, as the cancer progresses, it eventually becomes independent of androgens, and hormonal therapy fails. For this reason, androgen-independent PCa is still a major therapeutic challenge. By disrupting specific protein interactions or manipulating the expression of some key molecules, it might be possible to regulate tumor growth and metastasis formation, avoiding the systemic side effects of current therapies. Clinical trials are already underway to assess the efficacy of molecules specially designed to target key proteins or protein interactions. In this review, we address that recent progress made towards understanding PCa development and the molecular pathways underlying this pathology. We also discuss relevant molecular markers for the management of PCa and new therapeutic challenges.

Prostate specific antigen testing in family practice: a cross sectional survey of self-reported rates of and reasons for testing participation and risk disclosure

Background

Despite controversy about the benefits of routine prostate specific antigen (PSA) testing, rates of participation continue to rise. It is important to ensure that men are fully informed about the potential risks associated with this test. Little is known about the processes of shared decision making for PSA testing in the family practice setting. This study aimed to explore men’s experiences of PSA testing participation and risk disclosure for PSA testing.

Methods

A cross-sectional survey of male family practice attendees aged 40 years or older, with no previous history of prostate cancer, between June 2010 and November 2011. Questions related to whether participants had undertaken PSA testing or discussed this with their doctor over the past 5 years, whether the patient or doctor had initiated the discussion, reasons for undergoing testing, and whether their doctor had discussed particular risks associated with PSA testing.

Results

Sixty-seven percent (215/320) of men recalled having a PSA test in the past five years. Of the respondents who reported not having a test, 14% had discussed it with their doctor. The main reasons for having a PSA test were doctor recommendation and wanting to keep up to date with health tests. Thirty-eight percent or fewer respondents reported being advised of each potential risk.

Conclusions

Despite debate over the benefits of routine PSA testing, a high proportion of male family practice attendees report undertaking this test. Risks associated with testing appear to be poorly disclosed by general practitioners. These results suggest the need to improve the quality of informed consent for PSA testing in the family practice setting.

MicroRNA profiling in prostate cancer--the diagnostic potential of urinary miR-205 and miR-214

Prostate cancer (PCa) is the most common type of cancer in men in the United States, which disproportionately affects African American descents. While metastasis is the most common cause of death among PCa patients, no specific markers have been assigned to severity and ethnic biasness of the disease. MicroRNAs represent a promising new class of biomarkers owing to their inherent stability and resilience. In the present study, we investigated potential miRNAs that can be used as biomarkers and/or therapeutic targets and can provide insight into the severity and ethnic biasness of PCa. PCR array was performed in FFPE PCa tissues (5 Caucasian American and 5 African American) and selected differentially expressed miRNAs were validated by qRT-PCR, in 40 (15 CA and 25 AA) paired PCa and adjacent normal tissues. Significantly deregulated miRNAs were also analyzed in urine samples to explore their potential as non-invasive biomarker for PCa. Out of 8 miRNAs selected for validation from PCR array data, miR-205 (p<0.0001), mir-214 (p<0.0001), miR-221(p<0.001) and miR-99b (p<0.0001) were significantly downregulated in PCa tissues. ROC curve shows that all four miRNAs successfully discriminated between PCa and adjacent normal tissues. MiR-99b showed significant down regulation (p<0.01) in AA PCa tissues as compared to CA PCa tissues and might be related to the aggressiveness associated with AA population. In urine, miR-205 (p<0.05) and miR-214 (p<0.05) were significantly downregulated in PCa patients and can discriminate PCa patients from healthy individuals with 89% sensitivity and 80% specificity. In conclusion, present study showed that miR-205 and miR-214 are downregulated in PCa and may serve as potential non-invasive molecular biomarker for PCa.

Open access integrated therapeutic and diagnostic platforms for personalized cardiovascular medicine

It is undeniable that the increasing costs in healthcare are a concern. Although technological advancements have been made in healthcare systems, the return on investment made by governments and payers has been poor. The current model of care is unsustainable and is due for an upgrade. In developed nations, a law of diminishing returns has been noted in population health standards, whilst in the developing world, westernized chronic illnesses, such as diabetes and cardiovascular disease have become emerging problems. The reasons for these trends are complex, multifactorial and not easily reversed. Personalized medicine has the potential to have a significant impact on these issues, but for it to be truly successful, interdisciplinary mass collaboration is required. We propose here a vision for open-access advanced analytics for personalized cardiac diagnostics using imaging, electrocardiography and genomics.

Prostate-specific antigen testing: men's responses to 2012 recommendation against screening

BACKGROUND

The U.S. Preventive Services Task Force (USPSTF) released a draft recommendation advising against prostate-specific antigen (PSA) testing in October 2011, a major shift from previous years of recommending neither for or against PSA testing due to insufficient evidence.

PURPOSE

The purpose of this study was to assess men's awareness of the new recommendation, and their responses to it.

METHODS

This study comprised a web survey of men aged 40-74 years that was conducted through GfK Custom Research, LLC's Knowledge Panel® from November 22 to December 2, 2011. Chi-square tests and logistic regression analyses were conducted to identify factors associated with disagreement with and intention to follow the recommendation. Data were analyzed in March 2012.

RESULTS

The survey sample included 1089 men without a history of prostate cancer. After reviewing the recommendation, 62% agreed with the recommendation. Age and worry about getting prostate cancer were significantly related to disagreement with the recommendation. Only 13% of respondents were intenders (they planned to follow the U.S. Preventive Services Task Force recommendation and not get a prostate-specific antigen test in the future); 54% were non-intenders (they planned to not follow the U.S. Preventive Services Task Force recommendation and get a prostate-specific antigen test in the future; and 33% were undecided. Black race, higher income, having a PSA test in the past 2 years, and being somewhat/very worried about getting prostate cancer were all positively associated with being a non-intender.

CONCLUSIONS

Study findings suggest that consumers are favorably disposed to PSA testing, despite new evidence suggesting that the harms outweigh the benefits. The new USPSTF recommendation against PSA testing in all men may be met with resistance.

To test or not: a registry-based observational study of an online decision support for prostate-specific antigen tests

BACKGROUND

Watchful waiting is an essential part in the handling of patients with prostate cancer (PC). More effective disease management may be achieved by this strategy. Correct use of prostate-specific antigen (PSA) test is crucial and the general practitioner (GP) may therefore benefit from access to a clinical decision support system (CDSS) that focuses on this challenge. There are many barriers to the use of CDSSs. The aim of the present paper is to study if such barriers may be overcome by granting GPs easier access to a web-based CDSS via a hyperlink in the GPs' electronic medical record system (EMR).

METHODS

In the present population-based observational registry study with an intervention and control group, we created a web-based CDSS that was made accessible to GPs via hyperlink inserted into the EMR medical chart contents. The intervention was introduced 1 January 2011. Our outcome measure was the number of age-standardised PSA test rates per 1000 men per practice during three equally sized periods of 6 months within the study period from 1 January 2010 to 30 June 2011.

RESULTS

We found that none of the differences between intervention and control groups were statistically significant.

CONCLUSIONS

Providing GPs with access to a CDSS to aid their decision to use the PSA, had no measurable effect on the GPs' PSA testing behaviour.

Is prostate-specific antigen effective for population screening of prostate cancer? A systematic review

BACKGROUND

The effectiveness of prostate-specific antigen (PSA) for population screening has presented controversial results in large trials and prior reviews. We investigated the effectiveness of PSA population screening in a systematic review.

METHODS

The study was conducted using existing systematic reviews. We searched Ovid MEDLINE, Embase, Cochrane library, and the major Korean databases. The quality of the systematic reviews was assessed by two reviewers independently using AMSTAR. Randomized controlled trials were assessed using the risk of bias tool in the Cochrane group. Meta-analyses were conducted using Review Manager. The level of evidence of each outcome was assessed using GRADE.

RESULTS

Prostate-cancer-specific mortality was not reduced based on similar prior reviews (relative risk [RR] 0.93; 95% confidence interval [CI], 0.81-1.07, P=0.31). The detection rate of stage 1 prostate cancer was not greater, with a RR of 1.67 (95% CI, 0.95-2.94) and high heterogeneity. The detection rate of all cancer stages in the screening group was high, with a RR of 1.45 (95% CI, 1.13-1.85). No difference in all-cause mortality was observed between the screening and control groups (RR, 0.99; 95% CI, 0.98-1.01, P=0.50). Prostate-cancer-specific mortality, all-cause mortality, and diagnosis of prostate cancer at stages 3-4 showed moderate levels of evidence.

CONCLUSIONS

Differently from prior studies, our review included updated Norrköping data and assessed the sole effect of PSA testing for prostate cancer screening. PSA screening alone did not increase early stage prostate cancer detection and did not lower mortality.

Presenting treatment options to men with clinically localized prostate cancer: the acceptability of active surveillance/monitoring

Presenting treatment options to men with localized prostate cancer is difficult because of the lack of definitive evidence and the range of treatment options available. Active surveillance and monitoring programs are now a recognized treatment option for men with low-risk localized prostate cancer, but many patients are not fully aware of the details of such programs, and most still opt for immediate radical (surgery or radiotherapy) treatment. The provision of high-quality information with decision aids has been shown to increase the acceptability of active surveillance/monitoring programs. This chapter outlines techniques for providing high-quality information about active surveillance/monitoring, based on the findings of a randomized controlled trial of treatments for localized prostate cancer. The ProtecT (Prostate testing for cancer and Treatment) trial has randomized over 1500 men between active monitoring, radical surgery, and radical radiotherapy by ensuring that information was tailored to men's existing knowledge and views. Care was taken with the content, order, and enthusiasm of the presentation of treatments by recruitment staff, and clinicians and other health professionals were supported to feel comfortable with being open about the uncertainties in the evidence and helped to rephrase terminology likely to be misinterpreted by patients. These techniques of information provision should be added to the use of decision aids to enable patients diagnosed with clinically localized prostate cancer in routine practice to reach well-informed and reasoned decisions about their treatment, including full consideration of active surveillance and monitoring programs.

The case for intervention bias in the practice of medicine

Bias is an inclination to present or hold a partial perspective at the expense of possibly equal or more valid alternatives. In this paper, we present a series of conditional arguments to prove that intervention bias exists in the practice of medicine. We then explore its potential causes, consequences, and criticisms. We use the term to describe the bias on the part of physicians and the medical community to intervene, whether it is with drugs, diagnostic tests, non-invasive procedures, or surgeries, when not intervening would be a reasonable alternative. The recognition of intervention bias in medicine is critically important given today's emphasis on providing high-value care and reducing unnecessary and potentially harmful interventions.

Histological inflammation and risk of subsequent prostate cancer among men with initially elevated serum prostate-specific antigen (PSA) concentration in the Finnish prostate cancer screening trial

OBJECTIVE

To assess whether histological signs of inflammation are associated with an increased risk of subsequent prostate cancer (PCa) in men with elevated serum prostate-specific antigen (PSA) concentrations and benign initial biopsy.

MATERIALS AND METHODS

Study subjects were men aged 54-67 years with an elevated PSA (≥4 ng/mL or 3-4 ng/mL and free to total PSA ratio ≤0.16 or positive digital rectal examination), but a benign biopsy result within the Finnish population-based randomised screening trial for PCa, which started in 1996. A total of 293 prostate biopsies without PCa or suspicion of malignancy from the first screening round in the Tampere centre were re-evaluated by a uropathologist to assess histological inflammation. Results of the subsequent screening rounds were obtained from the trial database and PCa diagnoses made outside the screening were obtained from the Finnish Cancer Registry. The median length of follow-up was 10.5 years. Cox regression analysis was used to assess PCa risk after the initial benign biopsy.

RESULTS

Histological inflammation was found in 66% of the biopsies. Subjects with inflammation at the biopsy had a slightly lower PCa risk in the second screening round (18 vs 27%, rate ratio 0.69, 95% confidence interval [CI] 0.35-1.34) relative to men without inflammation. In further follow-up, the PCa risk remained nonsignificantly lower (hazard ratio [HR] 0.71, CI 0.46-1.10; P = 0.13). The risk was not appreciably affected by adjustment for age, PSA, prostate volume and family history of PCa (HR 0.67, CI 0.42-1.07; P = 0.092).

CONCLUSIONS

Histological inflammation in a prostate biopsy among men with an initial false-positive screening test was not associated with an increased risk of subsequent PCa, but instead with a decreased risk which was of borderline significance. Inflammation in prostate biopsy is not a useful risk indicator in PCa screening.

Screening for prostate cancer

BACKGROUND

Any form of screening aims to reduce disease-specific and overall mortality, and to improve a person's future quality of life. Screening for prostate cancer has generated considerable debate within the medical and broader community, as demonstrated by the varying recommendations made by medical organizations and governed by national policies. To better inform individual patient decision-making and health policy decisions, we need to consider the entire body of data from randomised controlled trials (RCTs) on prostate cancer screening summarised in a systematic review. In 2006, our Cochrane review identified insufficient evidence to either support or refute the use of routine mass, selective, or opportunistic screening for prostate cancer. An update of the review in 2010 included three additional trials. Meta-analysis of the five studies included in the 2010 review concluded that screening did not significantly reduce prostate cancer-specific mortality. In the past two years, several updates to studies included in the 2010 review have been published thereby providing the rationale for this update of the 2010 systematic review.

OBJECTIVES

To determine whether screening for prostate cancer reduces prostate cancer-specific mortality or all-cause mortality and to assess its impact on quality of life and adverse events.

SEARCH METHODS

An updated search of electronic databases (PROSTATE register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CANCERLIT, and the NHS EED) was performed, in addition to handsearching of specific journals and bibliographies, in an effort to identify both published and unpublished trials.

SELECTION CRITERIA

All RCTs of screening versus no screening for prostate cancer were eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

The original search (2006) identified 99 potentially relevant articles that were selected for full-text review. From these citations, two RCTs were identified as meeting the inclusion criteria. The search for the 2010 version of the review identified a further 106 potentially relevant articles, from which three new RCTs were included in the review. A total of 31 articles were retrieved for full-text examination based on the updated search in 2012. Updated data on three studies were included in this review. Data from the trials were independently extracted by two authors.

MAIN RESULTS

Five RCTs with a total of 341,342 participants were included in this review. All involved prostate-specific antigen (PSA) testing, with or without digital rectal examination (DRE), though the interval and threshold for further evaluation varied across trials. The age of participants ranged from 45 to 80 years and duration of follow-up from 7 to 20 years. Our meta-analysis of the five included studies indicated no statistically significant difference in prostate cancer-specific mortality between men randomised to the screening and control groups (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.86 to 1.17). The methodological quality of three of the studies was assessed as posing a high risk of bias. The European Randomized Study of Screening for Prostate Cancer (ERSPC) and the US Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial were assessed as posing a low risk of bias, but provided contradicting results. The ERSPC study reported a significant reduction in prostate cancer-specific mortality (RR 0.84, 95% CI 0.73 to 0.95), whilst the PLCO study concluded no significant benefit (RR 1.15, 95% CI 0.86 to 1.54). The ERSPC was the only study of the five included in this review that reported a significant reduction in prostate cancer-specific mortality, in a pre-specified subgroup of men aged 55 to 69 years of age. Sensitivity analysis for overall risk of bias indicated no significant difference in prostate cancer-specific mortality when referring to the meta analysis of only the ERSPC and PLCO trial data (RR 0.96, 95% CI 0.70 to 1.30). Subgroup analyses indicated that prostate cancer-specific mortality was not affected by the age at which participants were screened. Meta-analysis of four studies investigating all-cause mortality did not determine any significant differences between men randomised to screening or control (RR 1.00, 95% CI 0.96 to 1.03). A diagnosis of prostate cancer was significantly greater in men randomised to screening compared to those randomised to control (RR 1.30, 95% CI 1.02 to 1.65). Localised prostate cancer was more commonly diagnosed in men randomised to screening (RR 1.79, 95% CI 1.19 to 2.70), whilst the proportion of men diagnosed with advanced prostate cancer was significantly lower in the screening group compared to the men serving as controls (RR 0.80, 95% CI 0.73 to 0.87). Screening resulted in a range of harms that can be considered minor to major in severity and duration. Common minor harms from screening include bleeding, bruising and short-term anxiety. Common major harms include overdiagnosis and overtreatment, including infection, blood loss requiring transfusion, pneumonia, erectile dysfunction, and incontinence. Harms of screening included false-positive results for the PSA test and overdiagnosis (up to 50% in the ERSPC study). Adverse events associated with transrectal ultrasound (TRUS)-guided biopsies included infection, bleeding and pain. No deaths were attributed to any biopsy procedure. None of the studies provided detailed assessment of the effect of screening on quality of life or provided a comprehensive assessment of resource utilization associated with screening (although preliminary analyses were reported).

AUTHORS' CONCLUSIONS

Prostate cancer screening did not significantly decrease prostate cancer-specific mortality in a combined meta-analysis of five RCTs. Only one study (ERSPC) reported a 21% significant reduction of prostate cancer-specific mortality in a pre-specified subgroup of men aged 55 to 69 years. Pooled data currently demonstrates no significant reduction in prostate cancer-specific and overall mortality. Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity. Overdiagnosis and overtreatment are common and are associated with treatment-related harms. Men should be informed of this and the demonstrated adverse effects when they are deciding whether or not to undertake screening for prostate cancer. Any reduction in prostate cancer-specific mortality may take up to 10 years to accrue; therefore, men who have a life expectancy less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial. No studies examined the independent role of screening by DRE.

Prediction of the risk of harboring prostate cancer by a prebiopsy nomogram based on extended biopsy protocol

OBJECTIVE

We aimed to build a nomogram allowing to predict the probability of prostate cancer (PC) after an initial 21-core biopsy and with readily available clinical data.

METHODS

1,490 screened men who underwent an initial 21-core biopsy protocol were included. A multivariate logistic regression was realized including age, prostate volume, prostate-specific antigen (PSA) level, digital rectal examination (DRE) and transrectal ultrasonography (TRUS). Receiver-operating characteristic estimates were used to quantify accuracy of each model.

RESULTS

PC was detected in 41.3% of the patients. Median PSA, age and prostate volume were 6.2 ng/ml (range 0.2-50), 64.6 years (range 33-87) and 40 ml (range 10-270), respectively. Abnormal TRUS findings were detected in 14.7% of patients. Age, PSA level, prostate volume, DRE and TRUS were significantly associated with PC (all p ≤ 0.004) in univariable logistic regression analysis. In multivariate logistic regression analysis, significant associations were found for age, PSA level, prostate volume and DRE. Predictive accuracy estimate of this model was equal to 0.70. TRUS was not an independent predictor of PC.

CONCLUSIONS

We constructed the first prebiopsy predictive nomogram based on an extended 21-core biopsy procedure with age, PSA level, DRE and prostate volume which are readily available clinical data to urologists.

The endocannabinoid system and sex steroid hormone-dependent cancers

The "endocannabinoid system (ECS)" comprises the endocannabinoids, the enzymes that regulate their synthesis and degradation, the prototypical cannabinoid receptors (CB1 and CB2), some noncannabinoid receptors, and an, as yet, uncharacterised transport system. Recent evidence suggests that both cannabinoid receptors are present in sex steroid hormone-dependent cancer tissues and potentially play an important role in those malignancies. Sex steroid hormones regulate the endocannabinoid system and the endocannabinoids prevent tumour development through putative protective mechanisms that prevent cell growth and migration, suggesting an important role for endocannabinoids in the regulation of sex hormone-dependent tumours and metastasis. Here, the role of the endocannabinoid system in sex steroid hormone-dependent cancers is described and the potential for novel therapies assessed.

Differential effects of estrogen receptor ligands on regulation of dihydrotestosterone-induced cell proliferation in endothelial and prostate cancer cells

Androgen deprivation therapy of prostate cancer with estrogens shows significant cardiovascular side-effects. To develop effective prostate cancer therapeutic agent(s) with minimal cardiovascular side-effects, we compared the effects of various estrogen receptor (ER) ligands on the modulation of dihydrotestosterone (DHT) actions in LAPC-4 and LNCaP prostate cancer cells and human aortic endothelial cells (HAECs). DHT stimulated the proliferation of HAEC, LAPC-4 and LNCaP cells and induced PSA mRNA expression in LAPC-4 cells. These DHT actions were differentially modulated by ER ligands in a cell-dependent manner. In LAPC-4 cells, knockdown of ERβ expression partially eliminated the βE2 inhibition of DHT-induced LAPC-4 cell proliferation, and a parallel change was observed between ER ligand modulation of DHT-induced cell proliferation and cyclin A expression. The obtained data suggest that it is feasible to develop effective agent(s) for prostate cancer therapy with minimal cardiovascular side-effects and 17α-estradiol and genistein are such potential agents.

Landmarks in prostate cancer screening

• Prostate-specific antigen (PSA) has been widely applied to diagnosis and follow-up of prostate cancer, which led to research on its potential role in the early detection of the disease and its use in screening. • The value of PSA screening in reducing disease mortality is controversial and several studies have been conducted to determine the actual benefits. One of the early studies, the Tyrol Screening Study conducted in 1993, showed that during 2004 to 2008 there was a significant reduction in prostate cancer mortality in men aged >60 years compared with the mortality rate during 1989 to 1993. • Two studies that showed no benefit of screening in terms of prostate cancer death were conducted in Sweden in 1987 and 1988. • The Prostate, Lung, Colorectal, and Ovarian Screening Study conducted in the USA during 1993 to 2001 and involving 76,693 men showed no benefit of screening at 10 years but the trial can be criticised due to excessive contamination of the unscreened group. • In contrast, the European Randomized Study of Screening for Prostate Cancer (ERSPC), the largest randomised study with 162,388 participants study, showed that at a median follow-up of 9 years a prostate cancer mortality reduction of 20% resulted (P= 0.04). In an analysis limited to four ERSPC centres with a follow-up of 12.0 years, screening resulted in an overall reduction of metastatic disease of 31%. • The arguments against PSA screening include the risks associated with screening tests themselves, e.g. biopsy-related haematuria, urosepsis, and over diagnosis and overtreatment of prostate cancer. The overall evidence points in favour of PSA screening and steps can be taken to avoid overtreatment by offering patients active surveillance.

Simulation optimization of PSA-threshold based prostate cancer screening policies

We describe a simulation optimization method to design PSA screening policies based on expected quality adjusted life years (QALYs). Our method integrates a simulation model in a genetic algorithm which uses a probabilistic method for selection of the best policy. We present computational results about the efficiency of our algorithm. The best policy generated by our algorithm is compared to previously recommended screening policies. Using the policies determined by our model, we present evidence that patients should be screened more aggressively but for a shorter length of time than previously published guidelines recommended.

Hiperplasia Prostática Benigna e PSA: o efeito dominó

Após a publicação de uma recomendação contra o rastreio câncer prostático pela U.S. Preventive Services Task Force, a comunidade médica não poderá desvincular-se das particularidades relacionadas com o antígeno prostático específico (PSA). O enfoque dado às guidelines da Hiperplasia Prostática surge pela possível partilha, a determinado ponto da sua abordagem, de um trilho que cursa também com a solicitação do PSA. Os resultados de dois grandes ensaios clínicos constituem o maior corpo da evidência actual e deles sobressai que o número de homens que evitaram a morte por câncer prostático após submetidos ao rastreio foi reduzido. Há evidência de que 100-200 em 1000 homens rastreados terão um falso-positivo, a maioria dos quais será biopsada, com possíveis danos psicológicos e orgânicos. O Médico de Família deverá relembrar que não é recomendado que se ofereça esta análise, sem que primeiro discuta, juntamente com o paciente, as questões inerentes ao PSA.

Educating men about prostate cancer in the workplace

Prostate cancer is a common cancer affecting men worldwide. Few men access health services with respect to early detection. Workplace health education initiatives can promote behavior change in men. A total of 12 in-depth interviews with men were conducted in this study to examine how a workplace-based educational campaign on prostate cancer influences the knowledge, awareness, and beliefs of male workers on screening for prostate cancer. Analyses of interview transcripts identified that men had a poor overall knowledge about prostate cancer, its screening, and treatment. Participants were receptive to the introduction of workplace-based health education initiatives to promote men's health issues but recommended an integrated health approach that incorporated information delivered by medical professionals, cancer survivors, supplemented with existing patient education materials. Further research is required to formally evaluate the impact of workplace-based education strategies on men's health.

An inherited NBN mutation is associated with poor prognosis prostate cancer

BACKGROUND

To establish the contribution of eight founder alleles in three DNA damage repair genes (BRCA1, CHEK2 and NBS1) to prostate cancer in Poland, and to measure the impact of these variants on survival among patients.

METHODS

Three thousand seven hundred fifty men with prostate cancer and 3956 cancer-free controls were genotyped for three founder alleles in BRCA1 (5382insC, 4153delA, C61G), four alleles in CHEK2 (1100delC, IVS2+1G>A, del5395, I157T), and one allele in NBS1 (657del5).

RESULTS

The NBS1 mutation was detected in 53 of 3750 unselected cases compared with 23 of 3956 (0.6%) controls (odds ratio (OR)=2.5; P=0.0003). A CHEK2 mutation was seen in 383 (10.2%) unselected cases and in 228 (5.8%) controls (OR=1.9; P<0.0001). Mutation of BRCA1 (three mutations combined) was not associated with the risk of prostate cancer (OR=0.9; P=0.8). In a subgroup analysis, the 4153delA mutation was associated with early-onset (age ≤ 60 years) prostate cancer (OR=20.3, P=0.004). The mean follow-up was 54 months. Mortality was significantly worse for carriers of a NBS1 mutation than for non-carriers (HR=1.85; P=0.008). The 5-year survival for men with an NBS1 mutation was 49%, compared with 72% for mutation-negative cases.

CONCLUSION

A mutation in NBS1 predisposes to aggressive prostate cancer. These data are relevant to the prospect of adapting personalised medicine to prostate cancer prevention and treatment.

General health checks in adults for reducing morbidity and mortality from disease

BACKGROUND

General health checks are common elements of health care in some countries. These aim to detect disease and risk factors for disease with the purpose of reducing morbidity and mortality. Most of the commonly used screening tests offered in general health checks have been incompletely studied. Also, screening leads to increased use of diagnostic and therapeutic interventions, which can be harmful as well as beneficial. It is, therefore, important to assess whether general health checks do more good than harm.

OBJECTIVES

We aimed to quantify the benefits and harms of general health checks with an emphasis on patient-relevant outcomes such as morbidity and mortality rather than on surrogate outcomes such as blood pressure and serum cholesterol levels.

SEARCH METHODS

We searched The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, MEDLINE, EMBASE, Healthstar, CINAHL, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) to July 2012. Two authors screened titles and abstracts, assessed papers for eligibility and read reference lists. One author used citation tracking (Web of Knowledge) and asked trialists about additional studies.

SELECTION CRITERIA

We included randomised trials comparing health checks with no health checks in adults unselected for disease or risk factors. We did not include geriatric trials. We defined health checks as screening general populations for more than one disease or risk factor in more than one organ system.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed the risk of bias in the trials. We contacted authors for additional outcomes or trial details when necessary. For mortality outcomes we analysed the results with random-effects model meta-analysis, and for other outcomes we did a qualitative synthesis as meta-analysis was not feasible.

MAIN RESULTS

We included 16 trials, 14 of which had available outcome data (182,880 participants). Nine trials provided data on total mortality (155,899 participants, 11,940 deaths), median follow-up time nine years, giving a risk ratio of 0.99 (95% confidence interval (CI) 0.95 to 1.03). Eight trials provided data on cardiovascular mortality (152,435 participants, 4567 deaths), risk ratio 1.03 (95% CI 0.91 to 1.17) and eight trials on cancer mortality (139,290 participants, 3663 deaths), risk ratio 1.01 (95% CI 0.92 to 1.12). Subgroup and sensitivity analyses did not alter these findings.We did not find an effect on clinical events or other measures of morbidity but one trial found an increased occurrence of hypertension and hypercholesterolaemia with screening and one trial found an increased occurence of self-reported chronic disease. One trial found a 20% increase in the total number of new diagnoses per participant over six years compared to the control group. No trials compared the total number of prescriptions, but two out of four trials found an increased number of people using antihypertensive drugs. Two out of four trials found small beneficial effects on self-reported health, but this could be due to reporting bias as the trials were not blinded. We did not find an effect on admission to hospital, disability, worry, additional visits to the physician, or absence from work, but most of these outcomes were poorly studied. We did not find useful results on the number of referrals to specialists, the number of follow-up tests after positive screening results, or the amount of surgery.

AUTHORS' CONCLUSIONS

General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased. Important harmful outcomes, such as the number of follow-up diagnostic procedures or short term psychological effects, were often not studied or reported and many trials had methodological problems. With the large number of participants and deaths included, the long follow-up periods used, and considering that cardiovascular and cancer mortality were not reduced, general health checks are unlikely to be beneficial.

Prostate specific antigen testing policy worldwide varies greatly and seems not to be in accordance with guidelines: a systematic review

BACKGROUND

Prostate specific antigen (PSA) testing is widely used, but guidelines on follow-up are unclear.

METHODS

We performed a systematic review of the literature to determine follow-up policy after PSA testing by general practitioners (GPs) and non-urologic hospitalists, the use of a cut-off value for this policy, the reasons for repeating a PSA test after an initial normal result, the existence of a general cut-off value below which a PSA result is considered normal, and the time frame for repeating a test. Data sources. MEDLINE, Embase, PsychInfo and the Cochrane library from January 1950 until May 2011. Study eligibility criteria. Studies describing follow-up policy by GPs or non-urologic hospitalists after a primary PSA test, excluding urologists and patients with prostate cancer. Studies written in Dutch, English, French, German, Italian or Spanish were included. Excluded were studies describing follow-up policy by urologists and follow-up of patients with prostate cancer. The quality of each study was structurally assessed.

RESULTS

Fifteen articles met the inclusion criteria. Three studies were of high quality. Follow-up differed greatly both after a normal and an abnormal PSA test result. Only one study described the reasons for not performing follow-up after an abnormal PSA result.

CONCLUSIONS

Based on the available literature, we cannot adequately assess physicians' follow-up policy after a primary PSA test. Follow-up after a normal or raised PSA test by GPs and non-urologic hospitalists seems to a large extent not in accordance with the guidelines.

Positive predictive value of prostate biopsy indicated by prostate-specific-antigen-based prostate cancer screening: trends over time in a European randomized trial*

Study Type--Diagnosis (validating cohort) Level of Evidence 1b. What's known on the subject? and What does the study add? The European Randomized study of Screening for Prostate Cancer (ERSPC) showed a reduction in prostate cancer mortality of 21% for PSA-based screening at a median follow-up of 11 years. In the ERSPC, men are screened at 4-year intervals. A prostate biopsy is recommended for men with a PSA level ≥ 3.0 ng/mL. The study shows that the positive predictive value (PPV) of a prostate biopsy indicated by PSA-based screening remains equal throughout consecutive screening rounds in men without a previous biopsy. In men who have previously had a benign biopsy, the PPV drops considerably, but 20% of the cancers detected still show aggressive characteristics.

OBJECTIVE

• To assess the positive predictive value (PPV) of prostate biopsy, indicated by a prostate-specific antigen (PSA) threshold of ≥ 3.0 ng/mL, over time, in the Rotterdam section of the European Randomized study of Screening for Prostate Cancer (ERSPC).

PATIENTS AND METHODS

• In the Rotterdam section of the ERSPC, a total of 42,376 participants, aged 55-74 years, identified from population registries were randomly assigned to a screening or control arm. • For the ERSPC men undergo PSA screening at 4-year intervals. A total of three screening rounds were evaluated; therefore, only men aged 55-69 years at the first screening were eligible for the present study.

RESULTS

• PPVs for men without previous biopsy remained equal throughout the three subsequent screenings (25.5, 22.3 and 24.8% respectively). • Conversely, PPVs for men with a previous negative biopsy dropped significantly (12.0 and 15.2% at the second and third screening, respectively). • Additionally, in men with and without previous biopsy, the percentage of aggressive prostate cancers (clinical stage >T2b, Gleason score ≥ 7) decreased after the first round of screening from 44.4 to 23.8% in the second (P < 0.001) and 18.6% in the third round (P < 0.001). • Repeat biopsies accounted for 24.6% of all biopsies, but yielded only 8.6% of all aggressive cancers.

CONCLUSIONS

• In consecutive screening rounds the PPV of PSA-based screening remains equal in previously unbiopsied men. • In men with a previous negative biopsy the PPV drops considerably, but 20% of cancers detected still show aggressive characteristics. • Individualized screening algorithms should incorporate previous biopsy status in the decision to perform a repeat biopsy with the aim of further reducing unnecessary biopsies.

Furthering the prostate cancer screening debate (prostate cancer specific mortality and associated risks)

Screening for prostate cancer remains a contentious issue. As with other cancer screening programs, a key feature of the debate is verification of cancer-specific mortality reductions. Unfortunately the present evidence, two systematic reviews and six randomized controlled trials, have reported conflicting results. Furthermore, half of the studies are poor quality and the evidence is clouded by key weaknesses, including poor adherence to screening in the intervention arm or high rates of screening in the control arm. In high quality studies of prostate cancer screening (particularly prostate-specific antigen), in which actual compliance was anticipated in the study design, there is good evidence that prostate cancer mortality is reduced. The numbers needed to screen are at least as good as those of mammography for breast cancer and fecal occult blood testing for colorectal cancer. However, the risks associated with prostate cancer screening are considerable and must be weighed against the advantage of reduced cancer-specific mortality. Adverse events include 70% rate of false positives, important risks associated with prostate biopsy, and the serious consequences of prostate cancer treatment. The best evidence demonstrates prostate cancer screening will reduce prostate cancer mortality. It is time for the debate to move beyond this issue, and begin a well-informed discussion on the remaining complex issues associated with prostate cancer screening and appropriate management.

Beyond prostate-specific antigen - future biomarkers for the early detection and management of prostate cancer

Prostate-specific antigen is currently commonly used as a screening biomarker for prostate cancer, but it has limitations in both sensitivity and specificity. The development of novel biomarkers for early cancer detection has the potential to improve survival, reduce unnecessary investigations and benefit the health economy. Here we review the use and limitations of prostate-specific antigen and its subtypes, urinary biomarkers including PCA3, alpha-methylacyl-CoA racemase, the TMPRSS2-ERG fusion gene and microseminoprotein-beta, and other novel markers in both serum and urine. Many of these biomarkers are at early stages of development and require evaluation in prospective trials to determine their potential usefulness in clinical practice. Genetic profiling may allow for the targeting of high-risk populations for screening and may offer the opportunity to combine biomarker results with genotype to aid risk assessment.

Trends in prostate cancer incidence and mortality in Croatia, 1988-2008

Aim

To describe and interpret prostate cancer incidence and mortality trends in Croatia between 1988 and 2008.

Methods

Incidence data for the period 1988-2008 were obtained from the Croatian National Cancer Registry. The number of prostate cancer deaths was obtained from the World Health Organization mortality database. We also used population estimates for Croatia from the Population Division of the Department of Economic and Social Affairs of the United Nations. Age standardized incidence and mortality rates were calculated by the direct standardization method. To describe time trends of incidence and mortality, joinpoint regression analysis was used.

Results

Average age-standardized incidence rate between the first and last five-year period doubled, from 19.0/100 000 in 1988-1992 to 39.1 per 100 000 in 2004-2008. Age-standardized mortality rate increased by 6.9%, from 14.5 to 15.5 per 100 000. Joinpoint analysis of incidence identified two joinpoints. The increasing incidence trend started from 1997, with the estimated annual percent of change (EAPC) of 12.9% from 1997-2002 and of 4.1% from 2002-2008. Joinpoint analyses of mortality identified one joinpoint. Mortality trend first decreased, with EAPC of -3.0% from 1988-1995 to increase later with EAPC of 2.0% from 1995-2008.

Conclusion

The incidence of prostate cancer in Croatia has been on the increase since 1997. Trend in mortality is increasing, contrary to the trends in some higher-income countries. An improvement in the availability of different treatment modalities as well as establishing prostate cancer units could have a positive impact on prostate cancer mortality in Croatia.

Critical role of prostate biopsy mortality in the number of years of life gained and lost within a prostate cancer screening programme

Study Type--Therapy (data synthesis) Level of Evidence 2b. What's known on the subject? and What does the study add? The efficacy of prostate cancer screening using PSA testing is still being debated, with conflicting results in randomized trials. The study shows that, even using the hypothesis most favourable to prostate cancer screening with PSA, the net number of years of life does not favour screening.

OBJECTIVE

• To evaluate the impact of the implementation a prostate-specific antigen (PSA) screening programme using the European Randomized Study of Screening for Prostate Cancer (ERSPC) results and taking into account the impact of prostate biopsy and over-treatment on mortality.

MATERIALS AND METHODS

• We used a model based on the number of years of life gained and lost owing to screening, using data reported in the ERSPC. • We conducted a critical evaluation of the ERSPC results and of the Swedish arm of the study.

RESULTS

•  Accounting for biopsy-specific mortality and for over-treatment, the balance of number of years of life was negative in the ERSPC study, with an estimated loss of 3.6 years of life per avoided death. • The number of years of life becomes positive (real gain) only when fewer than 666 screened individuals are required to avoid one death. • We found that in the Swedish arm of the ERSPC there was a biopsy rate of 40% compared with 27% in the ERSPC overall. The over-treatment rate was also greater with 4.1% compared with 3.4% overall. • For the last 20 years, there has been a marked difference in prostate cancer-specific mortality between Sweden and the rest of Europe: in 2005, for the age group 65-74 the rate was 140 per 100,000 person years in Sweden and ~80 per 100,000 for the rest of Europe.

CONCLUSION

• Overall, PSA testing in Europe is associated with a loss in years of life and should thus not be recommended.

Exploring patient perceptions of PSA screening for prostate cancer: risks, effectiveness, and importance

OBJECTIVE

To study the beliefs of a group of Canadian men regarding the risks, effectiveness, and importance of routine prostate-specific antigen (PSA) testing when used as a screening tool for prostate cancer.

DESIGN

A 1-page questionnaire designed to gauge patient beliefs about PSA screening.

SETTING

Two primary care clinics in Kingston, Ont.

PARTICIPANTS

Seventy-two men aged 41 to 80.

MAIN OUTCOME MEASURES

Whether men believed that the PSA blood test was not risky when used as a screening test for prostate cancer, was effective at preventing death from prostate cancer, and was important for their health.

RESULTS

Fifteen men reported having visited their physicians because of difficulty urinating in the past 2 years, or a personal history of prostate cancer, and were excluded; for these men, the use of the PSA blood test would not be for screening. Of the 57 men considered in the study, 54 (95%) believed that using the PSA blood test as a screening tool for prostate cancer was not risky, 39 (68%) believed that the PSA blood test was good or very good at preventing death from prostate cancer, and 45 (79%) believed that the routine use of the PSA blood test was important or very important for their health. Men in the suggested screening age group of 51 to 70 years (n = 32) had an equally positive impression of PSA screening.

CONCLUSION

Despite a limited body of evidence showing its effectiveness, Canadian men continue to have a favourable impression of PSA screening and remain largely unaware of potential adverse events associated with PSA testing.

Screening for prostate cancer with prostate-specific antigen testing: American Society of Clinical Oncology Provisional Clinical Opinion

PURPOSE

An American Society of Clinical Oncology (ASCO) provisional clinical opinion (PCO) offers timely clinical direction to the ASCO membership after publication or presentation of potentially practice-changing data from major studies. This PCO addresses the role of prostate-specific antigen (PSA) testing in the screening of men for prostate cancer.

CLINICAL CONTEXT

Prostate cancer is the second leading cause of cancer deaths among men in the United States. The rationale for screening men for prostate cancer is the potential to reduce the risk of death through early detection.

RECENT DATA

Evidence from a 2011 Agency for Healthcare Research and Quality systematic review primarily informs this PCO on the benefits and harms of PSA-based screening. An update search was conducted to March 16, 2012, for additional evidence related to the topic.

RESULTS

In one randomized trial, PSA testing in men who would not otherwise have been screened resulted in reduced death rates from prostate cancer, but it is uncertain whether the size of the effect was worth the harms associated with screening and subsequent unnecessary treatment. Although there are limitations to the existing data, there is evidence to suggest that men with longer life expectancy may benefit from PSA testing. Adverse events associated with prostate biopsy are low for the majority of men; however, several population-based studies have shown increasing rates of infectious complications after prostate biopsy, which is a concern.

Current trends in the management of post-prostatectomy incontinence

One of the annoying complications of radical prostatectomy is urinary incontinence. Post-prostatectomy incontinence (PPI) causes a significant impact on the patient's health-related quality of life. Although PPI is stress urinary incontinence caused by intrinsic sphincter deficiency in most cases, bladder dysfunction and vesicourethral anastomotic stenosis can induce urine leakage also. Exact clinical assessments, such as a voiding diary, incontinence questionnaire, pad test, urodynamic study, and urethrocystoscopy, are necessary to determine adequate treatment. The initial management of PPI is conservative treatment including lifestyle interventions, pelvic floor muscle training with or without biofeedback, and bladder training. An early start of conservative treatment is recommended during the first year. If the conservative treatment fails, surgical treatment is recommended. Surgical treatment of stress urinary incontinence after radical prostatectomy can be divided into minimally invasive and invasive treatments. Minimally invasive treatment includes injection of urethral bulking agents, male suburethral sling, and adjustable continence balloons. Invasive treatment includes artificial urinary sphincter implantation, which is still the gold standard and the most effective treatment of PPI. However, the demand for minimally invasive treatment is increasing, and many urologists consider male suburethral slings to be an acceptable treatment for PPI. The male sling is usually recommended for patients with persistent mild or moderate incontinence. It is necessary to improve our understanding of the pathophysiologic mechanisms of PPI and to compare different procedures for the development of new and potentially better treatment options.

The epigenetic promise for prostate cancer diagnosis

BACKGROUND

Prostate cancer is the most common cancer diagnosis in men and a leading cause of death. Improvements in disease management would have a significant impact and could be facilitated by the development of biomarkers, whether for diagnostic, prognostic, or predictive purposes. The blood-based prostate biomarker PSA has been part of clinical practice for over two decades, although it is surrounded by controversy. While debates of usefulness are ongoing, alternatives should be explored. Particularly with recent recommendations against routine PSA-testing, the time is ripe to explore promising biomarkers to yield a more efficient and accurate screening for detection and management of prostate cancer. Epigenetic changes, more specifically DNA methylation, are amongst the most common alterations in human cancer. These changes are associated with transcriptional silencing of genes, leading to an altered cellular biology.

METHODS

One gene in particular, GSTP1, has been widely studied in prostate cancer. Therefore a meta-analysis has been conducted to examine the role of this and other genes and the potential contribution to prostate cancer management and screening refinement.

RESULTS

More than 30 independent, peer reviewed studies have reported a consistently high sensitivity and specificity of GSTP1 hypermethylation in prostatectomy or biopsy tissue. The meta-analysis combined and compared these results.

CONCLUSIONS

GSTP1 methylation detection can serve an important role in prostate cancer managment. The meta-analysis clearly confirmed a link between tissue DNA hypermethylation of this and other genes and prostate cancer. Detection of DNA methylation in genes, including GSTP1, could serve an important role in clinical practice.

Applications of transrectal ultrasound in prostate cancer

Transrectal ultrasound (TRUS) was first developed in the 1970s. TRUS-guided biopsy, under local anaesthetic and prophylactic antibiotics, is now the most widely accepted method to diagnose prostate cancer. However, the sensitivity and specificity of greyscale TRUS in the detection of prostate cancer is low. Prostate cancer most commonly appears as a hypoechoic focal lesion in the peripheral zone on TRUS but the appearances are variable with considerable overlap with benign lesions. Because of the low accuracy of greyscale TRUS, TRUS-guided biopsies have become established in the acquisition of systematic biopsies from standard locations. The number of systematic biopsies has increased over the years, with 10-12 cores currently accepted as the minimum standard. This article describes the technique of TRUS and biopsy and its complications. Novel modalities including contrast-enhanced modes and elastography as well as fusion techniques for increasing the sensitivity of TRUS-guided prostate-targeted biopsies are discussed along with their role in the diagnosis and management of prostate cancer.

The accuracy of different biopsy strategies for the detection of clinically important prostate cancer: a computer simulation

PURPOSE

The true accuracy of different biopsy strategies for detecting clinically significant prostate cancer is unknown, given the positive evaluation bias required for verification by radical prostatectomy. To evaluate how well different biopsy strategies perform at detecting clinically significant prostate cancer we used computer simulation in cystoprostatectomy cases with cancer.

MATERIALS AND METHODS

A computer simulation study was performed on prostates acquired at radical cystoprostatectomy. A total of 346 prostates were processed and examined for prostate cancer using 3 mm whole mount slices. The 96 prostates that contained cancer were digitally reconstructed. Biopsy simulations incorporating various degrees of random localization error were performed using the reconstructed 3-dimensional prostate computer model. Each biopsy strategy was simulated 500 times. Two definitions of clinically significant prostate cancer were used to define the reference standard, including definition 1--Gleason score 7 or greater, and/or lesion volume 0.5 ml or greater and definition 2--Gleason score 7 or greater, and/or lesion volume 0.2 ml or greater.

RESULTS

A total of 215 prostate cancer foci were present. The ROC AUC to detect and rule out definition 1 prostate cancer was 0.69, 0.75, 0.82 and 0.91 for 12-core transrectal ultrasound biopsy with a random localization error of 15 and 10 mm, 14-core transrectal ultrasound biopsy and template prostate mapping using a 5 mm sampling frame, respectively.

CONCLUSIONS

To our knowledge our biopsy simulation study is the first to evaluate the performance of different sampling strategies to detect clinically important prostate cancer in a population that better reflects the demographics of a screened cohort. Compared to other strategies standard transrectal ultrasound biopsy performs poorly for detecting clinically important cancer. Marginal improvement can be achieved using additional cores placed anterior but the performance attained by template prostate mapping is optimal.

Identifying candidates for active surveillance: an evaluation of the repeat biopsy strategy for men with favorable risk prostate cancer

PURPOSE

Active surveillance is increasingly recommended to reduce overtreatment in men with favorable risk prostate cancer. A repeat confirmatory biopsy has become the standard recommendation for these men to increase the precision of this risk attribution. We investigate the usefulness of this approach by comparing the current practice standard, repeat transrectal ultrasound biopsy, with template prostate mapping.

MATERIALS AND METHODS

A total of 124 men who were attributed a favorable risk prostate cancer status based on transrectal ultrasound guided biopsy and who were considering a policy of active surveillance underwent combined transrectal ultrasound biopsy and template prostate mapping as a confirmatory strategy. Maximum Gleason grade and disease burden were compared between the 2 confirmatory tests.

RESULTS

Depending on the definition used between 8% and 22% of men had prostate cancer reclassified as clinically important by repeat transrectal ultrasound biopsy whereas template guided prostate mapping reclassified the disease in 41% to 85% of the men. Repeat transrectal ultrasound biopsy failed to detect up to 80% of clinically important cancers detected by the reference standard. The sensitivity of repeat transrectal ultrasound biopsy to identify clinically important disease varied from 9% to 24% with the negative predictive value ranging from 23% to 60%.

CONCLUSIONS

When applied to a population of men initially deemed to have favorable risk prostate cancer, transrectal ultrasound biopsy will miss a large proportion of clinically important cancers compared to template guided prostate mapping. The usefulness of repeat transrectal ultrasound biopsy in ruling out clinically important prostate cancer needs to be reconsidered.

Radical prostatectomy versus observation for localized prostate cancer

BACKGROUND

The effectiveness of surgery versus observation for men with localized prostate cancer detected by means of prostate-specific antigen (PSA) testing is not known.

METHODS

From November 1994 through January 2002, we randomly assigned 731 men with localized prostate cancer (mean age, 67 years; median PSA value, 7.8 ng per milliliter) to radical prostatectomy or observation and followed them through January 2010. The primary outcome was all-cause mortality; the secondary outcome was prostate-cancer mortality.

RESULTS

During the median follow-up of 10.0 years, 171 of 364 men (47.0%) assigned to radical prostatectomy died, as compared with 183 of 367 (49.9%) assigned to observation (hazard ratio, 0.88; 95% confidence interval [CI], 0.71 to 1.08; P=0.22; absolute risk reduction, 2.9 percentage points). Among men assigned to radical prostatectomy, 21 (5.8%) died from prostate cancer or treatment, as compared with 31 men (8.4%) assigned to observation (hazard ratio, 0.63; 95% CI, 0.36 to 1.09; P=0.09; absolute risk reduction, 2.6 percentage points). The effect of treatment on all-cause and prostate-cancer mortality did not differ according to age, race, coexisting conditions, self-reported performance status, or histologic features of the tumor. Radical prostatectomy was associated with reduced all-cause mortality among men with a PSA value greater than 10 ng per milliliter (P=0.04 for interaction) and possibly among those with intermediate-risk or high-risk tumors (P=0.07 for interaction). Adverse events within 30 days after surgery occurred in 21.4% of men, including one death.

CONCLUSIONS

Among men with localized prostate cancer detected during the early era of PSA testing, radical prostatectomy did not significantly reduce all-cause or prostate-cancer mortality, as compared with observation, through at least 12 years of follow-up. Absolute differences were less than 3 percentage points. (Funded by the Department of Veterans Affairs Cooperative Studies Program and others; PIVOT ClinicalTrials.gov number, NCT00007644.).

Long-term disease-specific functioning among prostate cancer survivors and noncancer controls in the prostate, lung, colorectal, and ovarian cancer screening trial

PURPOSE

Within the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO), we assessed the long-term disease-specific functioning among prostate cancer (PCa) survivors versus noncancer controls, the impact of trial arm (screening/usual care) on functioning, and the effect of treatment modality on functioning.

PATIENTS AND METHODS

PCa survivors (n = 529), 5 to 10 years postdiagnosis, were frequency-matched to noncancer controls (n = 514) for race, screening center, year of enrollment, and trial arm. Participants completed a telephone interview regarding PCa-specific symptomatology. Weights accounted for patient selection from the five PLCO screening centers. Propensity-score methods were used to balance groups of interest with respect to demographic and medical characteristics.

RESULTS

Weighted linear regression analyses revealed poorer sexual and urinary function among PCa survivors compared with noncancer controls (P < .001). Trial arm was not significantly related to any outcome (P > .31). Compared with radical prostatectomy patients (n = 201), radiation-therapy patients (n = 110) reported better sexual (P < .05) and urinary (P < .001) functioning but poorer bowel outcomes (P < .05). Survivors who received treatment combinations including androgen deprivation (n = 207) reported significantly poorer hormone-related symptoms compared with radical prostatectomy patients (P < .05). CONCLUSION This study demonstrated the persistence of clinically significant, long-term PCa treatment-related sexual and urinary adverse effects up to 10 years postdiagnosis. To our knowledge, this was the first comparison of prostate-related dysfunction among screened survivors versus screened noncancer controls and indicated that these long-term problems were attributable to PCa treatment and not to aging or comorbidities. Finally, differences in long-term adverse effects between treatment modalities are particularly relevant for patients and clinicians when making treatment decisions.