Prostate Testing for Cancer and Treatment (ProtecT) feasibility study

Pathological findings at radical prostatectomy in Japanese prospective active surveillance cohort

OBJECTIVES

The present study was carried out to analyze pathological features of prostatectomy specimens performed at different timing and trigger during active surveillance.

METHODS

One hundred and thirty-four patients that fit a selection condition similar to the so-called Hopkins' criteria were enrolled into the present study between January 2002 and December 2003. Patients were recommended to start curable treatment when they showed prostate-specific antigen-doubling time of 2 years or shorter or pathological progression at 1-year re-biopsy. Median observation period was 61 months.

RESULTS

Fourteen patients underwent radical prostatectomy immediately after enrollment (Group A) whereas 28 patients underwent radical prostatectomy after substantial periods of active surveillance (Group B). Of the 28 Group B, trigger of radical prostatectomy was on protocol in 17 patients (Group B1) whereas 11 patients underwent radical prostatectomy by their preference (Group B2). Upgrade from initial biopsy was observed in 43% of Group A and 68% of Group B. Upgrade was more frequently observed in Group B1 than B2 with border line significance (P = 0.075). Perineural infiltration and positive surgical margin rates of Group B1 were significantly higher than those of B2 (P < 0.05).

CONCLUSIONS

Unfavorable pathological features of surgical specimens were more frequently observed in patients who underwent radical prostatectomy due to short prostate-specific antigen-doubling time or biopsy findings than those who underwent radical prostatectomy because of other reasons including patients' preference. Rates of unfavorable pathological features at radical prostatectomy that deviate initial selection criteria was high enough to support integration of frequent biopsies into active surveillance program.

Impact of prostate cancer testing: an evaluation of the emotional consequences of a negative biopsy result

BACKGROUND

When testing for prostate cancer, as many as 75% of men with a raised prostate-specific antigen (PSA) have a benign biopsy result. Little is known about the psychological effect of this result for these men.

METHODS

In all, 330 men participating in the prostate testing for cancer and treatment (ProtecT) study were studied; aged 50-69 years with a PSA level of > or = 3 ng ml(-1) and a negative biopsy result. Distress and negative mood were measured at four time-points: two during diagnostic testing and two after a negative biopsy result.

RESULTS

The majority of men were not greatly affected by testing or a negative biopsy result. The impact on psychological health was highest at the time of the biopsy, with around 20% reporting high distress (33 out of 171) and tense/anxious moods (35 out of 180). Longitudinal analysis on 195 men showed a significant increase in distress at the time of the biopsy compared with levels at the PSA test (difference in Impact of Events Scale (IES) score: 9.47; 95% confidence interval (CI) (6.97, 12.12); P<0.001). These levels remained elevated immediately after the negative biopsy result (difference in score: 7.32; 95% CI (5.51, 9.52); P<0.001) and 12 weeks later (difference in score: 2.42; 95% CI (0.50, 1.15); P=0.009). Psychological mood at the time of PSA testing predicted high levels of distress and anxiety at subsequent time-points.

CONCLUSIONS

Most men coped well with the testing process, although a minority experienced elevated distress at the time of biopsy and after a negative result. Men should be informed of the risk of distress relating to diagnostic uncertainty before they consent to PSA testing.

Do anxiety and distress increase during active surveillance for low risk prostate cancer?

PURPOSE

Anxiety and distress may be present in patients with low risk prostate cancer who are on active surveillance. This may be a reason to discontinue active surveillance.

MATERIALS AND METHODS

A total of 150 Dutch patients with prostate cancer on active surveillance in a prospective active surveillance study received questionnaires at study inclusion and 9 months after diagnosis. We assessed changes in scores on decisional conflict with the decisional conflict scale, depression with the Center for Epidemiologic Studies Depression Scale, generic anxiety with the State Trait Anxiety Inventory, prostate cancer specific anxiety with the Memorial Anxiety Scale for Prostate Cancer and the self-estimated risk of progression. We explored scores 9 months after diagnosis vs those at study inclusion for physical health (SF-12 physical component summary), personality (Eysenck Personality Questionnaire), shared decision making, prostate cancer knowledge, demographics, medical parameters and prostate specific antigen doubling time during followup.

RESULTS

Questionnaires at study inclusion and 9 months after diagnosis were completed by 129 of 150 (86%) and 108 of 120 participants (90%) a median of 2.4 and 9.2 months after diagnosis, respectively. Anxiety and distress at study inclusion were previously found to be generally favorable. Significant but clinically irrelevant decreases were seen in mean scores of the State Trait Anxiety Inventory (p = 0.016), Memorial Anxiety Scale for Prostate Cancer fear of progression subscale (p = 0.005) and the self-estimated risk of progression (p = 0.049). Anxiety and distress 9 months after diagnosis were mainly predicted by scores at study inclusion. Higher Eysenck Personality Questionnaire neuroticism score and an important role of the physician in the treatment decision had additionally unfavorable effects. Good physical health, palpable disease and older age had favorable effects. No association was seen for prostate specific antigen doubling time. Nine men discontinued active surveillance, including 2 due to nonmedical reasons.

CONCLUSIONS

Anxiety and distress generally remain favorably low during the first 9 months of surveillance.

Mutation analysis of the MSMB gene in familial prostate cancer

Background:

MSMB, a gene coding for β-microseminoprotein, has been identified as a candidate susceptibility gene for prostate cancer (PrCa) in two genome-wide association studies (GWAS). SNP rs10993994 is 2 bp upstream of the transcription initiation site of MSMB and was identified as an associated PrCa risk variant. The MSMB protein is underexpressed in PrCa and it was previously proposed to be an independent marker for the recurrence of cancer after radical prostatectomy.

Methods:

In this study, the coding region of this gene and 1500 bp upstream of the 5′UTR has been sequenced in germline DNA in 192 PrCa patients with family history. To evaluate the possible effects of these variants we used in silico analysis.

Results:

No deleterious mutations were identified, however, nine new sequence variants were found, most of these in the promoter and 5′UTR region. In silico analysis suggests that four of these SNPs are likely to have some effect on gene expression either by affecting ubiquitous or prostate-specific transcription factor (TF)-binding sites or modifying splicing efficiency.

Interpretation

We conclude that MSMB is unlikely to be a familial PrCa gene and propose that the high-risk alleles of the SNPs in the 5′UTR effect PrCa risk by modifying MSMB gene expression in response to hormones in a tissue-specific manner.

Psychological distress and prostate specific antigen levels in men with and without prostate cancer

The role of psychological distress in the onset and progression of prostate cancer is an under-researched area. We report results from a cohort study in which we have examined the relationship between indices of psychological distress and prostate specific antigen (PSA) levels (a glycoprotein associated with prostatic diseases including cancer) in men with and without prostate cancer and also the relationship between distress and the likelihood of receiving a diagnosis of prostate cancer. Data were obtained from 4886 men who attended PSA testing and biopsy as part of the ProtecT (Prostate testing for cancer and treatment) study (mean age 62years; 98.9% White). Men completed questionnaires measuring anxiety, depression and urinary symptoms at initial PSA testing and again at biopsy when PSA was re-measured. Regardless of the subsequent diagnosis, there was no association between psychological distress scores at initial PSA testing and PSA measured at biopsy. However, analyses pertaining to the relationship between distress and cancer diagnosis showed that men with 'possible' clinical depression at initial PSA testing (n=519/4886) were 23% more likely to have a diagnosis of prostate cancer. These analyses highlight the need for further investigations into the possible role of depressed mood in the onset of prostate cancer and, in particular, research examining the biological basis for these relationships.

Identification of seven new prostate cancer susceptibility loci through a genome-wide association study

Prostate cancer (PrCa) is the most frequently diagnosed cancer in males in developed countries. To identify common PrCa susceptibility alleles, we previously conducted a genome-wide association study in which 541,129 SNPs were genotyped in 1,854 PrCa cases with clinically detected disease and in 1,894 controls. We have now extended the study to evaluate promising associations in a second stage in which we genotyped 43,671 SNPs in 3,650 PrCa cases and 3,940 controls and in a third stage involving an additional 16,229 cases and 14,821 controls from 21 studies. In addition to replicating previous associations, we identified seven new prostate cancer susceptibility loci on chromosomes 2, 4, 8, 11 and 22 (with P = 1.6 x 10(-8) to P = 2.7 x 10(-33)).

Canary Prostate Active Surveillance Study: design of a multi-institutional active surveillance cohort and biorepository

Active surveillance is a management plan for localized prostate cancer that offers selective delayed intervention on indication of disease progression, allowing patients to delay or avoid treatment and associated side-effects. Outcomes from centers that promote active surveillance are favorable, with high rates of disease-specific survival. However, there remains a need for prognostic variables or biomarkers that distinguish with high specificity the aggressive cancers that progress on surveillance from the indolent cancers. The Canary Prostate Active Surveillance Study is a multicenter study and a biorepository that will discover and confirm biomarkers of aggressive disease as defined by histologic, prostate-specific antigen, or clinical criteria.

Life course sun exposure and risk of prostate cancer: population-based nested case-control study and meta-analysis

There is currently no means of primary prevention for prostate cancer. Increased exposure to ultraviolet-radiation may be protective, but the literature is inconclusive. We investigated associations of life course exposure to sunlight with prostate cancer. The study design was a UK-wide nested case-control study, based on 1,020 prostate specific antigen-detected cases and 5,044 matched population controls and a systematic review with meta-analysis. Men with olive/brown skin (OR = 1.47; 95% CI: 1.00 to 2.17), men who burnt rarely/never (OR = 1.11; 0.95 to 1.29) and men with the lowest levels of intense sun exposure in the 2 years prior to diagnosis (OR = 1.24; 1.03 to 1.50) had an increased prostate cancer risk. However, amongst men with prostate cancer, spending less time outside was associated with a reduced risk of advanced cancer (OR = 0.49; 0.27 to 0.89) and high Gleason grade (OR = 0.62; 0.43 to 0.91), and men who burnt rarely/never had a reduced risk of advanced cancer (OR = 0.71; 0.47 to 1.08). The meta-analysis provided weak evidence that men with the lowest (versus highest) sunlight exposure had an increased prostate cancer risk (4 studies, random-effects pooled relative risk = 1.13; 0.98 to 1.29) and higher advanced or fatal prostate cancer risk (6 studies, random-effects pooled relative risk = 1.14; 0.98 to 1.33). Our data and meta-analyses provide limited support for the hypothesis that increased exposure to sunlight may reduce prostate cancer risk. The findings warrant further investigation because of their implications for vitamin D chemoprevention trials.

Current strategies for monitoring men with localised prostate cancer lack a strong evidence base: observational longitudinal study

Background:

The UK National Institute for Health and Clinical Excellence (NICE) guidance recommends conservative management of men with ‘low-risk’ localised prostate cancer, monitoring the disease using prostate-specific antigen (PSA) kinetics and re-biopsy. However, there is little evidence of the changes in PSA level that should alert to the need for clinical re-assessment.

Methods:

This study compares the alerts resulting from PSA kinetics and a novel longitudinal reference range approach, which incorporates age-related changes, during the monitoring of 408 men with localised prostate cancer. Men were monitored by regular PSA tests over a mean of 2.9 years, recording when a man's PSA doubling time fell below 2 years, PSA velocity exceeded 2 ng ml^–1 per year, or when his upper 10% reference range was exceeded.

Results:

Prostate-specific antigen doubling time and PSA velocity alerted a high proportion of men initially but became unresponsive to changes with successive tests. Calculating doubling time using recent PSA measurements reduced the decline in response. The reference range method maintained responsiveness to changes in PSA level throughout the monitoring.

Conclusion:

The increasing unresponsiveness of PSA kinetics is a consequence of the underlying regression model. Novel methods are needed for evaluation in cohorts currently being managed by monitoring. Meanwhile, the NICE guidance should be cautious.

PTGS2-899G>C and prostate cancer risk: a population-based nested case-control study (ProtecT) and a systematic review with meta-analysis

Prostaglandin endoperoxidase synthase 2 is a key regulator of inflammation and may play a role in prostate carcinogenesis. The polymorphism, -899G>C (rs20417), alters a transcription factor-binding site and is associated with a reduced risk of colorectal adenoma. We tested the hypothesis that rs20417 may influence prostate cancer risk, using a large case-control study (n(cases)=1608, n(controls)=3058). We found no evidence that rs20417 alters prostate cancer risk (odds ratio (OR(CC & GC v GG)=1.05, 95% confidence interval (CI)=0.91-1.20). A meta-analysis of three studies also found little evidence that rs20417 alters risk (pooled OR(CC & GC v GG)=1.04, 95% CI=0.93-1.17), making it unlikely that rs20417 contributes in any major way to prostate cancer aetiology.

It's not just what you say, it's also how you say it: opening the 'black box' of informed consent appointments in randomised controlled trials

Randomised controlled trials (RCTs) represent the gold standard methodology for determining effectiveness of healthcare interventions. Poor recruitment to RCTs can threaten external validity and waste resources. An inherent tension exists between safeguarding informed decision-making by participants and maximising numbers enrolled. This study investigated what occurs during informed consent appointments in an ongoing multi-centre RCT in the UK. Objectives were to investigate: 1] how study staff presented study information to participants; 2] what evidence emerged as to how well-informed participants were when proceeding to randomisation or treatment selection; and 3] what aspects of the communication process may facilitate improvements in providing evidence of informed consent. Qualitative analysis of a purposive sample of 23 recruitment appointments from three study centres and involving several recruitment staff applied techniques of thematic, content and conversation analysis (CA). Thematic analysis and CA revealed variation in appointment content and structure. Appointments were mostly recruiter-led or participant-led, and this structure was associated with what evidence emerged as to how participants understood information provided and whether they were in equipoise. Participant-led appointments provided this evidence more consistently. Detailed CA identified communication techniques which, when employed by recruiters, provided evidence as to how participants understood the choices before them. Strategic use of open questions, pauses and ceding the floor in the interaction facilitated detailed and systematic exploration of each participant's concerns and position regarding equipoise. We conclude that the current focus on content to be provided to achieve informed consent should be broadened to encompass consideration of how information is best conveyed to potential participants. A model of tailored information provision using the communication techniques identified and centred on eliciting and addressing participants' concerns is proposed. Use of these techniques is necessary to make potential participants' understanding of key issues and their position regarding equipoise explicit in order to facilitate truly informed consent.

The routine use of prostate-specific antigen for early detection of cancer prostate in India: Is it justified?

BACKGROUND

The use of prostate-specific antigen (PSA) for early detection of prostate cancer is a widely debated issue. The average Indian urologist is faced with the dilemma of whether PSA testing should be routinely offered to men over 50 years of age. The Urological Society of India is yet to issue any guidelines on PSA testing. This article attempts to explore scientific evidence dealing with this controversial subject.

MATERIALS AND METHODS

A MEDLINE search was performed using the words 'PSA screening', 'prostate cancer statistics', and 'PSA screening guidelines'. The relevant articles were then analysed for evidence regarding the utility of PSA screening.

RESULTS

Prostate cancer does not qualify to be categorized as a major health problem in India. The natural history of screen-detected cancer is not known. Prostate-specific antigen testing for early detection of prostate cancer has questionable benefits and has a potential to cause harm to asymptomatic individuals. There is no consensus amongst learned medical societies as to what should be the best approach for PSA testing. Most organizations caution against widespread PSA screening and emphasize on informed consent and patient counseling with regard to PSA testing. Randomized prospective trials are ongoing to assess to the true impact of screening on prostate cancer mortality.

CONCLUSIONS

There is no scientific rationale to advocate routine use of PSA for early detection of prostate cancer in Indian males. Results of randomized screening trials are awaited to clarify on this issue.

Feasibility and cost of obtaining informed consent for essential review of medical records in large-scale health services research

Objective:

To evaluate the effectiveness and cost of obtaining consent for review of medical records within the passively observed non-intervention arm of a cluster randomized controlled trial, ‘Comparison Arm for ProtecT’.

Methods:

Two hundred and thirty men, who had been notified to the trial by cancer registries as having prostate cancer, were sent a consent form from their general practitioner or secondary care clinician. The consent rate of participants to the review of their medical records and the estimated costs of the process were evaluated.

Results:

One hundred and seventy-nine men (84%: 95% CI = 78%, 89%) consented to have their medical notes reviewed at an estimated cost of £123 (€172, $248) per person.

Conclusions:

A high consent rate for review of medical notes is achievable but at a cost. There needs to be renewed debate about the automatic need for consent to review medical records where the chance of personal harm is negligible and the purpose of the review is to provide robust evidence to save lives, prevent needless suffering, and improve the effectiveness and efficiency of health care delivery.

Mean sojourn time, overdiagnosis, and reduction in advanced stage prostate cancer due to screening with PSA: implications of sojourn time on screening

This study aimed to assess the mean sojourn time (MST) of prostate cancer, to estimate the probability of overdiagnosis, and to predict the potential reduction in advanced stage disease due to screening with PSA. The MST of prostate cancer was derived from detection rates at PSA prevalence testing in 43 842 men, aged 50–69 years, as part of the ProtecT study, from the incidence of non-screen-detected cases obtained from the English population-based cancer registry database, and from PSA sensitivity obtained from the medical literature. The relative reduction in advanced stage disease was derived from the expected and observed incidences of advanced stage prostate cancer. The age-specific MST for men aged 50–59 and 60–69 years were 11.3 and 12.6 years, respectively. Overdiagnosis estimates increased with age; 10–31% of the PSA-detected cases were estimated to be overdiagnosed. An interscreening interval of 2 years was predicted to result in 37 and 63% reduction in advanced stage disease in men 65–69 and 50–54 years, respectively. If the overdiagnosed cases were excluded, the estimated reductions were 9 and 54%, respectively. Thus, the benefit of screening in reducing advanced stage disease is limited by overdiagnosis, which is greater in older men.

Development of a new method for monitoring prostate-specific antigen changes in men with localised prostate cancer: a comparison of observational cohorts

BACKGROUND

Prostate-specific antigen (PSA) measurements are increasingly used to monitor men with localised prostate cancer (PCa), but there is little consensus about the method to use.

OBJECTIVE

To apply age-specific predictions of PSA level (developed in men without cancer) to one cohort of men with clinically identified PCa and one cohort of men with PSA-detected PCa. We hypothesise that among men with clinically identified cancer, the annual increase in PSA level would be steeper than in men with PSA-detected cancer.

DESIGN, SETTING, AND PARTICIPANTS

The Scandinavian Prostate Cancer Group 4 (SPCG-4) cohort consisted of 321 men assigned to the watchful waiting arm of the SPCG-4 trial. The UK cohort consisted of 320 men with PSA-detected PCa in the Prostate testing for cancer and Treatment (ProtecT) study who opted for monitoring. Multilevel models describing changes in PSA level were fitted to the two cohorts, and average PSA level at age 50, change in PSA level with age, and predicted PSA values were derived.

MEASUREMENTS

PSA level.

RESULTS AND LIMITATIONS

In the SPCG-4 cohort, mean PSA at age 50 was similar to the cancer-free cohort but with a steeper yearly increase in PSA level (16.4% vs 4.0%). In the UK cohort, mean PSA level was higher than that in the cancer-free cohort (due to a PSA biopsy threshold of 3.0 ng/ml) but with a similar yearly increase in PSA level (4.1%). Predictions were less accurate for the SPCG-4 cohort (median difference between observed and predicted PSA level: -2.0 ng/ml; interquartile range [IQR]: -7.6-0.7 ng/ml) than for the UK cohort (median difference between observed and predicted PSA level: -0.8 ng/ml; IQR: -2.1-0.1 ng/ml).

CONCLUSIONS

In PSA-detected men, yearly change in PSA was similar to that in cancer-free men, whereas in men with symptomatic PCa, the yearly change in PSA level was considerably higher. Our method needs further evaluation but has promise for refining active monitoring protocols.

Using qualitative research methods to improve recruitment to randomized controlled trials: the Quartet study

OBJECTIVE

Randomized controlled trials (RCTs) are considered the optimum method for evaluating health care interventions, yet many fail to recruit sufficient participants in a timely manner. The ProtecT (Prostate testing for cancer and Treatment) study employed qualitative research methods as part of a complex intervention to improve recruitment to the RCT. The Quartet (Qualitative research to improve recruitment to trials) study was set up to evalute whether the ProtecT study's success in increasing randomization rates could be replicated in other trials experiencing recruitment difficulties. This paper reports on the issues that emerged from the attempts to apply qualitative research methods to improve recruitment rates in RCTs collaborating with the Quartet team.

METHODS

The methods used were: investigation of RCT documents; semi-structured interviews and focus groups with RCT staff; audio-recording of recruitment appointments; and individual and group feedback sessions for RCT staff. Data were analysed using content and thematic analysis.

RESULTS

Barriers arose when we attempted to establish collaborations with RCTs. Difficulties were encountered in securing the commitment of all relevant staff because of poor communication between lead investigators and other staff as well as RCT staff's concerns about having recruitment appointments audio-recorded. Recruitment processes were often more complex than anticipated. Governance procedures took considerable time and resources, limiting the time available for data collection and implementation of the intervention before recruitment closure.

CONCLUSION

Straightforward replication of the ProtecT complex intervention was more complicated than expected. However, the study has increased understanding of RCT recruitment and identified ways to overcome barriers to collaboration. Such research is more easily undertaken in the feasibility stage of an RCT, and greater success will be achieved if the research is integrated into the everyday conduct of RCTs.

Stage shift in PSA-detected prostate cancers - effect modification by Gleason score

OBJECTIVE

This paper aims to investigate whether the stage shift (where more cancers are detected at an earlier stage) in prostate-specific antigen (PSA)-detected cancers differs by Gleason score.

METHODS

Between 2002 and 2005, 1514 men aged 50-69 years were identified with prostate cancer following community-based PSA testing as part of the ProtecT study. In the same period, 2021 men aged 50-69 years with clinically diagnosed prostate cancer were registered at a population-based cancer registry in the East of England. Using logistic regression analysis and controlling for age, the odds ratio (OR) for advanced stage (TNM stage T3 and above) prostate cancer among the PSA-detected group was compared with the clinically diagnosed tumours. The evidence that stage shift differs by Gleason score was assessed using the likelihood ratio test for interaction.

RESULTS

Advanced stage disease among the PSA-detected cancers was less common than among the clinically detected cancers (OR = 0.47, 95% CI 0.39-0.56). PSA-detected tumours had a substantial shift to earlier-stage disease where the Gleason score was <7 (OR = 0.52; 95% CI 0.36-0.77, P < 0.001) but showed no such shift where the Gleason score was 7 or more (OR = 0.84; 95% CI 0.66-1.07, P = 0.1). There was evidence of interaction between detection mode and Gleason score (P = 0.03).

CONCLUSION

The observed stage shift could be partially explained by length bias or overdiagnosis. These findings may have implications on understanding pathways of prostate cancer progression and on identifying potential targets for screening, pending further investigation of complexities of associations between PSA testing, Gleason score, and stage.

Multiple novel prostate cancer predisposition loci confirmed by an international study: the PRACTICAL Consortium

A recent genome-wide association study found that genetic variants on chromosomes 3, 6, 7, 10, 11, 19 and X were associated with prostate cancer risk. We evaluated the most significant single-nucleotide polymorphisms (SNP) in these loci using a worldwide consortium of 13 groups (PRACTICAL). Blood DNA from 7,370 prostate cancer cases and 5,742 male controls was analyzed by genotyping assays. Odds ratios (OR) associated with each genotype were estimated using unconditional logistic regression. Six of the seven SNPs showed clear evidence of association with prostate cancer (P = 0.0007-P = 10(-17)). For each of these six SNPs, the estimated per-allele OR was similar to those previously reported and ranged from 1.12 to 1.29. One SNP on 3p12 (rs2660753) showed a weaker association than previously reported [per-allele OR, 1.08 (95% confidence interval, 1.00-1.16; P = 0.06) versus 1.18 (95% confidence interval, 1.06-1.31)]. The combined risks associated with each pair of SNPs were consistent with a multiplicative risk model. Under this model, and in combination with previously reported SNPs on 8q and 17q, these loci explain 16% of the familial risk of the disease, and men in the top 10% of the risk distribution have a 2.1-fold increased risk relative to general population rates. This study provides strong confirmation of these susceptibility loci in multiple populations and shows that they make an important contribution to prostate cancer risk prediction.

Preference assessment of recruitment into a randomized trial for adolescent idiopathic scoliosis

BACKGROUND

Randomized controlled trials are powerful tools to evaluate the outcomes of clinical treatments. However, these trials tend to be expensive and time-consuming, and their conclusions can be threatened by several limitations. This study estimated the strength of three common limitations (underenrollment, selective enrollment, and nonadherence to protocol) in a proposed study of adolescent idiopathic scoliosis.

METHODS

Patients with scoliosis and their parents were asked to complete a web-based survey about their preferences concerning a hypothetical randomized trial. Adolescents without scoliosis and their parents also participated. Surveys included questions about treatment preference, likelihood of participation, required risk reduction, and propensity to drop out or choose a different treatment while enrolled in the study.

RESULTS

Ninety adolescents and eighty-three parents participated. Observation was preferred to bracing by the majority of subjects. Overall, 33% of the parents and adolescents would both agree to participate in the hypothetical trial. Of the subjects who would not agree to participate, the majority would rather share the decision-making responsibility with the physician than have the treatment chosen in a random fashion. Many of the subjects would consider changing treatments during the course of the trial if they were not satisfied with the outcomes; the majority of parents who preferred bracing would consider crossing over to the bracing arm if their children were randomized to observation.

CONCLUSIONS

Recruitment into a randomized trial of bracing compared with observation for the treatment of adolescent idiopathic scoliosis may well be problematic, considering the relatively small percentage of families who said they would consider randomization. Additionally, the threat of nonadherence to protocol may be strong and must be addressed in the protocol of the trial. Most families wanted to make the treatment decision with the physician in lieu of randomization; therefore, the role of the physician in patient recruitment and retention should not be underestimated.

Radical prostatectomy versus watchful waiting in localized prostate cancer: the Scandinavian prostate cancer group-4 randomized trial

BACKGROUND

The benefit of radical prostatectomy in patients with early prostate cancer has been assessed in only one randomized trial. In 2005, we reported that radical prostatectomy improved prostate cancer survival compared with watchful waiting after a median of 8.2 years of follow-up. We now report results after 3 more years of follow-up.

METHODS

From October 1, 1989, through February 28, 1999, 695 men with clinically localized prostate cancer were randomly assigned to radical prostatectomy (n = 347) or watchful waiting (n = 348). Follow-up was complete through December 31, 2006, with histopathologic review and blinded evaluation of causes of death. Relative risks (RRs) were estimated using the Cox proportional hazards model. Statistical tests were two-sided.

RESULTS

During a median of 10.8 years of follow-up (range = 3 weeks to 17.2 years), 137 men in the surgery group and 156 in the watchful waiting group died (P = .09). For 47 of the 347 men (13.5%) who were randomly assigned to surgery and 68 of the 348 men (19.5%) who were not, death was due to prostate cancer. The difference in cumulative incidence of death due to prostate cancer remained stable after about 10 years of follow-up. At 12 years, 12.5% of the surgery group and 17.9% of the watchful waiting group had died of prostate cancer (difference = 5.4%, 95% confidence interval [CI] = 0.2 to 11.1%), for a relative risk of 0.65 (95% CI = 0.45 to 0.94; P = .03). The difference in cumulative incidence of distant metastases did not increase beyond 10 years of follow-up. At 12 years, 19.3% of men in the surgery group and 26% of men in the watchful waiting group had been diagnosed with distant metastases (difference = 6.7%, 95% CI = 0.2 to 13.2%), for a relative risk of 0.65 (95% CI = 0.47 to 0.88; P = .006). Among men who underwent radical prostatectomy, those with extracapsular tumor growth had 14 times the risk of prostate cancer death as those without it (RR = 14.2, 95% CI = 3.3 to 61.8; P < .001).

CONCLUSION

Radical prostatectomy reduces prostate cancer mortality and risk of metastases with little or no further increase in benefit 10 or more years after surgery.

Factors distinguishing general practitioners who more readily participated in a large randomized trial were identified

OBJECTIVE

To investigate factors associated with the successful recruitment of general practices to a randomized controlled trial.

STUDY DESIGN AND SETTING

Analysis of accrual of primary care centers to a randomized controlled trial in the UK.

RESULTS

Those practices promptly agreeing to take part had better target achievement and a higher proportion of white British residents locally. Participating practices had a mean Quality and Outcomes Framework attainment of 92% of the points available, whereas nonparticipating practices achieved 88% (P=0.009). Participating practices were located in areas with a higher proportion of white British residents (mean 89%), in comparison to nonparticipating practices (mean 84%, P=0.004). Reasons given by practices to explain nonparticipation were primarily related to internal factors, with 38% of practices approached saying that they could not participate for such reasons.

CONCLUSION

There are some small differences between participating practices and nonparticipants in achievement of government targets and in the local ethnic mix. The primary reason given by practices for nonparticipation was workload or time pressures, with over a third of practices reporting being prevented by issues relating to practice organization. It may be that practices with workload or organizational difficulties require additional support to participate in research.

Prostate-cancer mortality in the USA and UK in 1975-2004: an ecological study

BACKGROUND

There is no conclusive evidence that screening based on serum prostate-specific antigen (PSA) tests decreases prostate-cancer mortality. Since its introduction in the USA around 1990, uptake of PSA testing has been rapid in the USA, but much less common in the UK. Our aim was to study trends over time in prostate-cancer mortality and incidence in the USA and UK in 1975-2004, and compare these patterns with trends in screening and treatment.

METHODS

Joinpoint regression analysis of cancer-mortality statistics from Cancer Research UK (London, UK) and from the US National Cancer Institute Surveillance, Epidemiology and End Results (SEER) programme from 1975 to 2004 was used to estimate the annual percentage change in prostate-cancer mortality in both countries and the points in time when trends changed. The ratio of USA to UK age-adjusted prostate-cancer incidence was also assessed.

FINDINGS

Age-specific and age-adjusted prostate-cancer mortality peaked in the early 1990s at almost identical rates in both countries, but age-adjusted mortality in the USA subsequently declined after 1994 by -4.17% (95% CI -4.34 to -3.99) each year, four-times the rate of decline in the UK after 1992 (-1.14% [-1.44 to -0.84]). The mortality decline in the USA was greatest and most sustained in patients aged 75 years or older (-5.32% [-8.23 to -2.32]), whereas death rates had plateaued in this age group in the UK by 2000. The mean ratio of USA to UK age-adjusted prostate-cancer incidence rates in 1975-2003 was 2.5, with a pronounced peak around the time that PSA testing was introduced in the USA. Numbers needed to treat to prevent one death from prostate cancer were 33 000 in the 55-64-year age group.

INTERPRETATION

The striking decline in prostate-cancer mortality in the USA compared with the UK in 1994-2004 coincided with much higher uptake of PSA screening in the USA. Explanations for the different trends in mortality include the possibility of an early effect of initial screening rounds on men with more aggressive asymptomatic disease in the USA, different approaches to treatment in the two countries, and bias related to the misattribution of cause of death. Speculation over the role of screening will continue until evidence from randomised controlled trials is published.

Prostate-specific antigen and prostate cancer: prediction, detection and monitoring

Testing for prostate-specific antigen (PSA) has profoundly affected the diagnosis and treatment of prostate cancer. PSA testing has enabled physicians to detect prostate tumours while they are still small, low-grade and localized. This very ability has, however, created controversy over whether we are now diagnosing and treating insignificant cancers. PSA testing has also transformed the monitoring of treatment response and detection of disease recurrence. Much current research is directed at establishing the most appropriate uses of PSA testing and at developing methods to improve on the conventional PSA test.

Qualitative research to improve RCT recruitment: issues arising in establishing research collaborations

INTRODUCTION

Strategies to improve recruitment to RCTs (randomised controlled trials) are limited. The ProtecT (Prostate testing for cancer and Treatment) study successfully developed a complex intervention based on qualitative research methods to increase recruitment rates. The Quartet study (Qualitative Research to Improve Recruitment to RCTs) was established to evaluate whether the ProtecT qualitative methods could be transferred into other RCTs. This paper reports on the barriers and facilitators in setting up these collaborations.

METHODS

The Quartet study collaborated with five RCTs. Qualitative methods used were: interviews and focus groups with RCT staff; audio-recording recruitment interactions; and feedback sessions for RCT staff based on qualitative findings. Data were audio-recorded, transcribed and analysed using content and thematic analyses. Issues arising during establishment of collaborations were recorded and analysed.

RESULTS

Establishing collaborations proved challenging and not always surmountable. Difficulties were encountered in gaining agreement of RCT staff to participate because of central RCT staff's lack of authority over recruitment staff, poor communication within RCTs and recruiters' reluctance to have their practice scrutinised. The complexity of the recruitment process also hindered translation of ProtecT methods. Although Quartet enabled significant recruitment issues to surface, the bureaucratic tasks involved in securing governance approval delayed onset of collaborations, reducing the time to address issues and evaluate Quartet's impact.

DISCUSSION

The Quartet study established collaborations with a range of RCTs and gained valuable insights for future collaborations between qualitative researchers and RCTs. Qualitative research methods need to be included at the feasibility stage of a RCT or fully integrated into the RCT, as in the ProtecT study, with routine audio-recording for monitoring and training purposes. Quartet-like collaborations could then be established without delay, and recruitment processes of RCTs could become transparent, monitored and improved.

Detection of prostate cancer in unselected young men: prospective cohort nested within a randomised controlled trial

OBJECTIVE

To investigate the feasibility of testing for prostate cancer and the prevalence and characteristics of the disease in unselected young men.

DESIGN

Prospective cohort nested within a randomised controlled trial, with two years of follow-up.

SETTING

Eight general practices in a UK city.

PARTICIPANTS

1299 unselected men aged 45-49.

INTERVENTION

Prostate biopsies for participants with a prostate specific antigen level of 1.5 ng/ml or more and the possibility of randomisation to three treatments for those with localised prostate cancer.

MAIN OUTCOME MEASURES

Uptake of testing for prostate specific antigen; positive predictive value of prostate specific antigen; and prevalence of prostate cancer, TNM disease stage, and histological grade (Gleason score).

RESULTS

442 of 1299 men agreed to be tested for prostate specific antigen (34%) and 54 (12%) had a raised level. The positive predictive value for prostate specific antigen was 21.3%. Ten cases of prostate cancer were detected (2.3%) with eight having at least two positive results in biopsy cores and three showing perineural invasion. One tumour was of high volume (cT2c), Gleason score 7, with a positive result on digital rectal examination; nine tumours were cT1c, Gleason score 6, and eight had a negative result on digital rectal examination. Five of the nine eligible participants (55%) agreed to be randomised. No biochemical disease progression in the form of a rising prostate specific antigen level occurred in two years of follow-up.

CONCLUSIONS

Men younger than 50 will accept testing for prostate cancer but at a much lower rate than older men. Using an age based threshold of 1.5 ng/ml, the prevalence of prostate cancer was similar to that in older men (3.0 ng/ml threshold) and some cancers of potential clinical significance were found.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN20141297.

Psychosocial barriers to active surveillance for the management of early prostate cancer and a strategy for increased acceptance

OBJECTIVES

To review the psychosocial needs of men undergoing active surveillance (AS, the monitoring of early prostate cancer, with curative intervention only if the disease significantly progresses) for prostate cancer, and barriers to its uptake.

METHODS

The introduction of screening for prostate-specific antigen (PSA) has led to more men diagnosed with early and nonlife-threatening forms of prostate cancer; about half of men diagnosed as a result of PSA testing have cancers that would never cause symptoms if left untreated and yet up to 90% of such men receive curative therapy, then living with the toxicity of treatment but with no benefit. Thus AS is increasingly being promoted, but if such a strategy is to succeed, the psychosocial barriers that discourage men from adopting AS must be addressed. We reviewed and assessed reports on this topic, published in English since 1994.

RESULTS

There is relatively little research on AS, as most published reports refer to watchful waiting (which is a palliative management approach). Men with prostate cancer generally have lower levels of psychological disturbance than for other cancers, but the psychosocial issues identified include anxiety in response to no intervention, uncertainty related to loss of control, and lack of patient education and support, particularly around the time of initial treatment planning. Approaches that were identified to improve uptake of AS include increased education and improved communication, interventions to reduce anxiety and uncertainty, and the empowerment of patients by the development of a sense of control and meaning. Physicians attitudes are influential and the education of physicians about AS as an appropriate option is to be encouraged. Peer-support groups were also identified as being of particular value.

CONCLUSIONS

There are several strategies that should be developed if AS is to become more widely adopted. Increased education and good communication can alleviate anxiety and uncertainty, as can interventions for cognitive re-framing. Inviting patients to become active participants in their management might enhance the patients' sense of control, and the involvement of peer-support groups might be beneficial.

Decision-making about PSA testing and prostate biopsies: a qualitative study embedded in a primary care randomised trial

OBJECTIVES

The overall aim was to increase understanding of men's decision-making about prostate-specific antigen (PSA) testing and subsequent biopsy.

METHODS

This qualitative interview study was nested within the primary care-based Prostate Testing for Cancer and Treatment (ProtecT) trial in nine United Kingdom areas (ISRCTN number: 20141297). Fifty-eight men aged 50-69 yr (mean: 62 yr), accepting (n=14) or not responding (n=7) to invitations for PSA testing and accepting (n=24) or refusing (n=13) prostate biopsy were interviewed.

RESULTS

In this study, men accepting PSA testing and biopsy reported positively on their experiences, regardless of the final outcome. PSA testing was considered routine and biopsy acceptable to most men. Men both responding and not responding to PSA testing often perceived themselves to be at low risk for prostate cancer. Men refusing biopsy also tended to perceive themselves to be at low risk and many were anxious about the test itself. Misunderstandings about the relationship between urinary symptoms and risk of prostate cancer were identified.

CONCLUSIONS

Most men found PSA testing and biopsy acceptable, but perceptions of risk were not always accurate and the provision of more tailored information may help facilitate informed decision-making.

The spectrum of prostate cancer care: From curative intent to palliation

Prostate cancer is one of the most prevalent malignancies affecting men in the developed world. A spectrum of disease states exists and management is tailored to individual patients. Increasing public awareness and prostate-specific antigen testing have led to earlier detection and the possibility of cure but have increased the risk of overtreatment of indolent disease. Advances in curative modalities have reduced side effects and offer patients a choice of treatments. Nonetheless, many need no intervention and may be safely treated with active monitoring. Choice and timing of therapy for locally advanced and recurrent disease are variable, with potential benefits of early intervention counterbalanced by side effects of treatment. Progress has been made in the management of advanced disease; skeletal-related events have been reduced and survival has been increased. This review examines the evidence and rationale behind the treatment options from curative intent to management of locally advanced disease and palliation of metastatic disease.

Metastatic disease of screen-detected prostate cancer : characteristics at diagnosis

BACKGROUND

Screening for prostate cancer has not only led to a stage migration, but also to a higher incidence of the disease. A decrease in mortality has occurred in several countries during the same time period. Risk stratification of screen-detected cancers at diagnosis has become more important for the anticipation and interpretation of changing incidence/mortality ratios.

METHODS

From 1993 to 1998, 633 men were diagnosed with nonmetastatic prostate cancer in the prevalence screen of the Rotterdam section of the European Randomized study of Screening for Prostate Cancer (ERSPC). The characteristics at diagnosis of men who developed metastatic disease were compared with men without evidence of metastases during follow-up.

RESULTS

During the median follow-up of 7.5 years, 41 men developed metastatic disease. After 10 years the metastasis-free survival rate was 89.6%, the overall survival 64.7%. In a Cox-model 2logPSA (prostate-specific antigen), biopsy Gleason score and the number of biopsy cores with prostate cancer were independent predictors for the development of metastases; the latter only predicted metastases that presented within 60 months of follow-up.

CONCLUSIONS

The metastasis-free survival of men with prostate cancer detected in a prevalence screening was very high. Whether this was related to the beneficial effects of screening or to overdiagnosis due to screening (or both) remains unclear. The prognostic factors known for clinically diagnosed disease also hold for screen-detected disease.

The use of prostate-specific antigen testing in men presenting with haematuria

OBJECTIVES

To analyse prostate-specific antigen (PSA) levels and clinical outcome in men presenting with haematuria, to develop an evidence-base for the use of PSA testing in this setting, as haematuria is a known complication of locally invasive prostate cancer, and so PSA levels are often measured in patients presenting with haematuria.

PATIENTS AND METHODS

We reviewed the records of 637 men presenting with haematuria to our urology department between April 2002 and June 2005.

RESULTS

Of 373 men aged 50-79 years, 278 (75%) had their PSA level measured, and 50 were abnormal. Prostate biopsies were taken in 27 men with an abnormal PSA level (54%) and one man with a normal PSA level but an abnormal digital rectal examination. Prostate cancer was detected in 22 patients (8% of those tested, and 71% of those biopsied); 4.7% of all men presenting with macroscopic haematuria and aged 50-79 years were found to have prostate cancer, vs 8.5% of those with microscopic haematuria.

CONCLUSIONS

We report a higher proportion of prostate cancers in men presenting with haematuria and aged 50-79 years than reported in previous screening studies, and a cancer detection rate of 71% of those biopsied, which is at least double the detection rates seen in screening studies. In the absence of a prospective controlled trial, PSA testing will remain part of our protocol for both macroscopic and microscopic haematuria.