Prostate cancer screening in the randomized Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial: mortality results after 13 years of follow-up

Towards personalized prostate cancer screening

The value of the prostate-specific antigen (PSA) in prostate cancer (PCa) screening is controversial. Contradictory results have been reported in the literature as to whether PSA-based screening reduces mortality. Also, some of the studies published are methodologically flawed. However, evidence consistently demonstrates that screening programs results in the identification of patients with indolent prostatic tumors which rate has increased. Controversy is not only about the value of PSA-based screening, but also about the age range for screening, risk groups based on baseline PSA, PSA ranges, or the use of other biomarkers (PHI, 4Kscore). At present, PCa screening in the general population is not recommended by most scientific societies, although it can be used after discussing the risks and benefits with the patient. When discussing the need to perform a screening, the risks of using screening (lack of specificity of PSA, overdiagnosis) must be weighed against the risks of not performing it (increased rate of patients with initial diagnosis of metastasis). In the recent years, a number of authors have advocated the use of personalized screening, which could change the risk/benefit evaluation, thereby making screening necessary on the basis of a set of individual factors.

Prostate Cancer and Asbestos: A Systematic Review and Meta-Analysis

INTRODUCTION

Asbestos-related diseases and cancers represent a major public health concern.

OBJECTIVE

To conduct a systematic review and meta-analysis to demonstrate that asbestos exposure increases the risk of prostate cancer.

METHODS

The PubMed, Cochrane Library, Embase, and ScienceDirect databases were searched using the keywords (prostate cancer OR prostatic neoplasm) AND (asbestos* OR crocidolite* OR chrysotile* OR amphibole* OR amosite*). To be included, articles needed to describe our primary outcome: Risk of prostate cancer after any asbestos exposure.

RESULTS

We included 33 studies with 15,687 cases of prostate cancer among 723,566 individuals. Asbestos exposure increased the risk of prostate cancer (effect size = 1.10, 95% confidence interval [CI] = 1.05-1.15). When we considered mode of absorption, respiratory inhalation increased the risk of prostate cancer (1.10, 95% CI = 1.05-1.14). Both environmental and occupational exposure increased the risk of prostate cancer (1.25, 95% CI = 1.01-1.48; and 1.07, 1.04-1.10, respectively). For type of fibers, the amosite group had an increased risk of prostate cancer (1.12, 95% CI = 1.05-1.19), and there were no significant results for the chrysotile/crocidolite group. The risk was higher in Europe (1.12, 95% CI = 1.05-1.19), without significant results in other continents.

DISCUSSION

Asbestos exposure seems to increase prostate cancer risk. The main mechanism of absorption was respiratory. Both environmental and occupational asbestos exposure were linked to increased risk of prostate cancer.

CONCLUSION

Patients who were exposed to asbestos should possibly be encouraged to complete more frequent prostate cancer screening.

Post-SELEX Optimization and Characterization of a Prostate Cancer Cell-Specific Aptamer for Diagnosis

The RNA aptamer A4 binds specifically to tumor prostate cells. A4 was modified (mA4) by adding deoxyribonucleotides to its ends to remove the reactive 2' hydroxyl groups of RNA's sugar at the ends of the aptamer and to make it more stable to widespread RNase contamination in laboratories. Thus, mA4 would be more suitable to use in the clinical settings of prostate cancer (PCa). We aimed to characterize this optimized oligonucleotide to verify its potential as a diagnostic tool. The sequences and structures of A4 and mA4 were compared through in silico approaches to corroborate their similarity. Then, the degradation of mA4 was measured in appropriate media and human plasma for in vitro tests. In addition, the binding abilities of A4 to prostate cells were contrasted with those of mA4. The effects of mA4 were assessed on the viability, proliferation, and migration of human prostate cell lines RWPE-1 and PC-3 in three-dimensional (3D) cell cultures. mA4 showed configurational motifs similar to those of A4, displayed a half-life in plasma substantially higher than A4, and exhibited a comparable binding capacity to that of A4 and unaltered viability, proliferation, and migration of prostatic cells. Therefore, mA4 maintains the crucial 3D structures of A4 that would allow binding to its target, as suggested by in silico and binding analyses. mA4 may be a good PCa reporter as it does not change cellular parameters of prostate cells when incubated with it. Its additional deoxyribonucleotides make mA4 inherently more chemically stable than A4, avoiding its degradation and favoring its storage and handling for clinical applications. These characteristics support the potential of mA4 to be used in diagnostic systems for PCa.

Age-related urologic problems in the complex urologic patient

PURPOSE

Improved medical care throughout childhood and adolescence has enabled patients with complex urological abnormalities to live longer into adulthood. These patients are now at risk of developing common, age-related, urological conditions. This review aims to review existing data and make recommendations in areas where expert opinion is currently lacking METHODS: This review represents the joint SIU-ICUD (Société Internationale d'Urologie-International Consultation on Urological Disease) consultation on congenital lifelong urology. The results of this analysis were first presented at a joint consultation of the ICUD and SIU at the 2018 SIU annual conference in Seoul, South Korea.

RESULTS

BPH may present differently in patients with neurogenic bladder. Thorough assessment of neurological status, bladder and sphincter function is required before offering any bladder outlet surgery. Prostate specific antigen screening should be offered to men aged 50-69 with neurogenic bladders if they have good life expectancy. Multi-parametric MRI and transperineal biopsy would be the investigations of choice if feasible. Surgery for localized disease should only be done by surgeons with the relevant expertise. Bladder cancer in this patient group is more likely to present at a later stage and have a worse prognosis. Parenthood is achievable for most, but often requires assistance with conception. Pregnant women who have had previous urogenital reconstructive surgery should be managed in appropriate obstetric units with the involvement of a reconstructive urologist.

CONCLUSIONS

Most evidence regarding complex urogenital abnormalities comes from the pediatric population. Evidence regarding common, age-related urological issues is generally from the 'normal' adult population. As patients with complex congenital urological conditions live longer, more data will become available to assess the long-term benefits of intervention.

Prostate-Specimen Antigen (PSA) Screening and Shared Decision Making Among Deaf and Hearing Male Patients

Some deaf men who use American Sign Language (ASL) experience barriers in patient-physician communication which may leave them at disparity for shared decision making compared to hearing men. Transparent communication accessibility is needed between deaf male ASL users and their physicians to maximize the benefit to risk ratio of using the prostate-specific antigen (PSA) as a screening tool for early detection. The objective is to compare shared decision-making outcomes between deaf and hearing males who are (1) age-eligible for PSA screening and (2) younger than 45 years old with a family history of cancer. An accessible health survey including questions about PSA test, PCC, modes of communication, and cancer history was administered in ASL to a nationwide sample of deaf adults from February 2017 to April 2018. Two subsamples were created: (1) 45- to 69-year-old men who were age-eligible for PSA testing and (2) 18- to 44-year-old men with a family history of cancer. Age-eligible and younger deaf men with a family history of cancer are at disparity for shared decision making compared to their hearing peers. Regardless of age and PSA testing status, deaf men felt significantly less engaged in shared decision making with their health care providers compared to hearing men. Participation in shared decision making requires not only accessible communication but also cultural competency in working with deaf patients. This is critical in the shared decision-making era in maximizing the benefit of prostate cancer screening in deaf male patient population.

Epistemic risks in cancer screening: Implications for ethics and policy

Cancer screening is the subject of much debate; while screening has the potential to save lives by identifying and treating cancers in early stages, it is also the case that not all cancers cause symptoms, and the diagnosis of these cancers can lead to unnecessary treatments and subsequent side-effects and complications. This paper explores the relationships between epistemic risks in cancer diagnosis and screening, the social organization of medical research and practice, and policy making; it does this by examining 2018 recommendations by the United States Preventative Services Task Force that patients make individualized, autonomy-based decisions about cancer screening on the basis of discussions with their physicians. While the paper focuses on prostate cancer screening, the issues that it raises are relevant to other cancer screening programs, especially breast cancer. The paper argues that prostate cancer screening-and, more generally, the process of risk assessment for prostate cancer-is pervaded by epistemic risks that reflect value judgments and that the pervasiveness of these epistemic risks creates significant and under-explored difficulties for physician-patient communication and the achievement of autonomous patient decision making.

Merging new-age biomarkers and nanodiagnostics for precision prostate cancer management

The accurate identification and stratified treatment of clinically significant early-stage prostate cancer have been ongoing concerns since the outcomes of large international prostate cancer screening trials were reported. The controversy surrounding clinical and cost benefits of prostate cancer screening has highlighted the lack of strategies for discriminating high-risk disease (that requires early treatment) from low-risk disease (that could be managed using watchful waiting or active surveillance). Advances in molecular subtyping and multiomics nanotechnology-based prostate cancer risk delineation can enable refinement of prostate cancer molecular taxonomy into clinically meaningful and treatable subtypes. Furthermore, the presence of intertumoural and intratumoural heterogeneity in prostate cancer warrants the development of novel nanodiagnostic technologies to identify clinically significant prostate cancer in a rapid, cost-effective and accurate manner. Circulating and urinary next-generation prostate cancer biomarkers for disease molecular subtyping and the newest complementary nanodiagnostic platforms for enhanced biomarker detection are promising tools for precision prostate cancer management. However, challenges in merging both aspects and clinical translation still need to be overcome.

Total Medicare Costs Associated With Diagnosis and Treatment of Prostate Cancer in Elderly Men

Importance

Localized prostate cancer diagnosis and treatment among elderly men who are not likely to benefit represents a potential source of low-value health care services.

Objective

To quantify the costs to the Medicare program associated with detection and treatment of prostate cancer among elderly men in the United States.

Design, Setting, and Participants

This nationwide, population-based, retrospective cohort study uses the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database to identify men 70 years or older diagnosed with localized prostate cancer between 2004 and 2007 and to ascertain Medicare costs associated with diagnosis and workup, treatment, follow-up, and morbidity management of the disease. National Medicare costs were estimated using per-person costs, stage-adjusted prostate cancer incidence rates by age from SEER 2007 through 2011, and 2010 Census population estimates by age.

Main Outcomes and Measures

Estimated costs to the Medicare program overall, and in each (mutually exclusive) category related to diagnosis and workup, treatment, follow-up, and morbidity management.

Results

This nationwide, population-based, retrospective cohort study included 49 692 men with nonmetastatic prostate cancer from the SEER-Medicare database (all participants were 70 years or older; 25 981 [52.3%] were 76 years or older). The median per-patient cost within 3 years after prostate cancer diagnosis was $14 453 (interquartile range [IQR], $4887-$27 899). The majority of this cost was attributable to treatment costs (median, $10 558; IQR, $1990-$23 718). Patients with a Gleason score of 6 or lower who pursued initial conservative management (no treatment within 12 months of diagnosis) had a 3-year median total cost of $1914 per patient. The estimated total 3-year cost to the Medicare program associated with the annual detection of prostate cancer in men 70 years or older is approximately $1.2 billion. Increasing active surveillance use in those with Gleason score of 6 or lower could reduce this cost by $320 million.

Conclusions and Relevance

There is substantial cost to the Medicare program associated with the diagnosis and treatment of localized prostate cancer among elderly men in the United States, despite the fact that these men are unlikely to die of prostate cancer. The majority of costs are related to treatment. Reducing provision of low-value health care services among this patient population could result in significant health care savings.

Association of Aspirin Use With Mortality Risk Among Older Adult Participants in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial

IMPORTANCE

Aspirin use has been associated with reduced risk of cancer mortality, particularly of the colorectum. However, aspirin efficacy may be influenced by biological characteristics, such as obesity and age. With the increasing prevalence of obesity and conflicting data regarding the effect of aspirin in older adults, understanding the potential association of aspirin use with cancer mortality according to body mass index (BMI) and age is imperative.

OBJECTIVES

To investigate the association of aspirin use with risk of all-cause, any cancer, gastrointestinal (GI) cancer, and colorectal cancer (CRC) mortality among older adults and to perform an exploratory analysis of the association of aspirin use with mortality stratified by BMI.

DESIGN, SETTING, PARTICIPANTS

This cohort study evaluated aspirin use among participants aged 65 years and older in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial at baseline (November 8, 1993, to July 2, 2001) and follow-up (2006-2008). Analysis began in late 2018 and was completed in September 2019.

MAIN OUTCOMES AND MEASURES

All-cause, any cancer, GI cancer, or CRC mortality. Multivariable hazard ratios (HRs) and 95% CIs were calculated using time-varying Cox proportional hazards regression modeling, adjusting for additional factors.

RESULTS

A total of 146 152 individuals (mean [SD] age at baseline, 66.3 [2.4] years; 74 742 [51.1%] women; 129 446 [88.6%] non-Hispanic white) were included in analysis. The median (interquartile range) follow-up time was 12.5 (8.7-16.4) years, encompassing 1 822 164 person-years. Compared with no use, aspirin use 1 to 3 times per month was associated with reduced risk of all-cause mortality (HR, 0.84; 95% CI, 0.80-0.88; P < .001) and cancer mortality (HR, 0.87; 95% CI, 0.81-0.94; P < .001). Aspirin use 3 or more times per week was associated with decreased risk of mortality of all causes (HR, 0.81; 95% CI, 0.80-0.83; P < .001), any cancer (HR, 0.85; 95% CI, 0.81-0.88; P < .001), GI cancer (HR, 0.75; 95% CI, 0.66-0.84; P < .001), and CRC (HR, 0.71; 95% CI, 0.61-0.84; P < .001). When stratified by BMI (calculated as weight in kilograms divided by height in meters squared), aspirin use 3 or more times per week among individuals with BMI 20 to 24.9 was associated with reduced risk of all-cause mortality (HR, 0.82; 95% CI, 0.78-0.85; P < .001) and any cancer mortality (HR, 0.86; 95% CI, 0.79-0.82; P < .001). Among individuals with BMI 25 to 29.9, aspirin use 3 or more times per week was associated with reduced risk of all-cause mortality (HR, 0.82; 95% CI, 0.79-0.85; P < .001), any cancer mortality (HR, 0.86; 95% CI, 0.81-0.91; P < .001), GI cancer mortality (HR, 0.72; 95% CI, 0.60-0.86; P < .001), and CRC mortality (HR, 0.66; 95% CI, 0.51-0.85; P = .001).

CONCLUSIONS AND RELEVANCE

In this cohort study, aspirin use 3 or more times per week was associated with a reduction in all-cause, cancer, GI cancer and CRC mortality in older adults.

Digital rectal examination and its associated factors in the early detection of prostate cancer: a cross-sectional population-based study

BACKGROUND

Digital rectal examination (DRE) is one of the most common strategies for prostate cancer early detection. However, the use for screening purposes has a controversial benefit and potential harms can occur due to false-positive results, overdiagnosis and overtreatment. The objective of this study is to calculate the prevalence and identify factors associated with the receipt of DRE in Brazilian men.

METHODS

We selected men older than 40 from a nationwide population-based survey (13,625 individuals) excluding those with prostate cancer diagnosis. Information was extracted from the most recent database of the Brazilian National Health Survey (PNS 2013). Statistical analysis was carried out to calculate incidence rate ratios, with 95% confidence intervals and p values, through multivariate analysis with Poisson regression and robust variance.

RESULTS

Men having private health insurance (63.3%; CI = 60.5-66.0) presented higher prevalence of DRE than those in the public health system (41.6%; CI = 39.8-43.4). The results show a positive association between DRE and men having private health insurance, aged 60-69, living with a spouse, never smokers, and living in urban areas. Among public health services users, this positive association was observed among men aged 70-79, living with a spouse, having bad/very bad health self-perception, abstainers, ex-smokers, with undergraduate studies, presenting four or more comorbidities, and residing in urban areas.

CONCLUSIONS

Prostate cancer screening with DRE is quite frequent in Brazil, specially among men with private health plans and better access to health services, healthier lifestyle and at more advanced ages, characteristics which increase the risk of overdiagnosis and overtreatment.

Contemporary Radiation Treatment of Prostate Cancer in Africa: A Ghanaian Experience

Purpose

Data on prostate cancer (PCa) treatment in Africa remains under-reported. We present a review of the management of PCa at the cancer center of the largest tertiary referral facility in Ghana, with emphasis on curative treatment.

Methods

We retrospectively reviewed data on 1,074 patients seen at the National Center for Radiotherapy and Nuclear Medicine from 2003 to 2016. Patient and disease characteristics at presentation are presented using descriptive statistics. The χ² and Fisher’s exact tests and Mann-Whitney U test were used to analyze differences between categorical and continuous variables, respectively. Methods of survival analysis were used to evaluate the relative risk of biochemical disease-free survival (bDFS).

Results

Seventy percent of the study population presented with localized disease. High-risk disease presentation accounted for 64.4% of these patients. Only 57.6% of patients with localized disease received curative radiotherapy. The 5-year overall survival for the curative cohort was 96% (interquartile range, 93% to 98%). The 5-year bDFS rates for low-, intermediate-, and high-risk groups were 95%, 70%, and 48%, respectively. Both Gleason score and pretreatment prostate-specific antigen were significant predictors for bDFS in multivariable analysis.

Conclusion

We show that the majority of patients with PCa have locally advanced disease at the time of presentation for radiotherapy. bDFS was significantly better for low- and intermediate-risk than for high-risk disease. These data emphasize the dire need to re-evaluate screening and patient education of PCa in regions of the world with high incidence and mortality as well as the need for improved access to care and treatment delivery.

PROSTATE CANCER DIAGNOSIS IN 2019 - CHANGES IN EUROPEAN GUIDELINES AND IMPACT ON DAILY PRACTICE

Changes in the diagnostic pathway for prostate cancer advised in the most recent Guidelines of the European Association of Urology bring many endeavors for everyday practice. Availability, costs and radiological expertise are still representing a challenge for the adoption of these guidelines in everyday clinical practice. In this article we discuss the current situation regarding these issues and future options.

Stratification based on adverse laboratory/pathological features for predicting overall survival in patients undergoing radical prostatectomy: A K-CaP registry-based analysis

When making clinical decisions concerning additional treatment for patients who have undergone radical prostatectomy (RP), adverse laboratory/pathological features are considered major factors. We investigated and compared the prognostic efficacy of adverse laboratory/pathological features in predicting overall survival (OS) and biochemical failure (BCF) in these patients.The Korean Prostate Cancer Database was used to identify patients undergoing RP between May 2001 and April 2013. Patients with incomplete clinicopathological data or positive lymphadenectomy results were excluded. Finally, 4486 patients included in the final analysis were categorized based on their adverse laboratory/pathological features.Adverse pathological features and detectable prostate-specific antigen (PSA) levels 6 weeks after surgery were observed in 1977 (44.1%) and 634 (14.1%) patients, respectively. PSA levels, pathological Gleason score ≥8, adverse pathological features [positive surgical margin (PSM), seminal vesicle invasion (SVI), and extracapsular extension (ECE)], and adverse laboratory features (detectable PSA levels after 6 weeks) together were significant predictors of BCF-free survival (BCFFS). SVI was identified as a predictor of OS. Additionally, patients with ECE, PSM, and detectable PSA levels after 6 weeks, but without SVI, showed similar OS to those without ECE, PSM, and detectable PSA levels after 6 weeks and with SVI (log-rank test, P = .976).We successfully stratified patients based on adverse laboratory/pathological features after RP and demonstrated that these are important prognostic factors for OS and BCFFS. Additionally, we identified the criteria for selecting appropriate patients for undergoing additional treatment based on OS and BCFFS.

Quality of life among symptomatic compared to PSA-detected prostate cancer survivors - results from a UK wide patient-reported outcomes study

Background

Quality of life among prostate cancer survivors varies by socio-demographic factors and treatment type received; however, less in known about differences in functional outcomes by method of presentation. We investigate differences in reported urinary, bowel, sexual and hormone-related problems between symptomatic and PSA-detected prostate cancer survivors.

Methods

A UK wide cross-sectional postal survey of prostate cancer survivors conducted 18-42 months post-diagnosis. Questions were included on presentation method and treatment. Functional outcome was determined using the EPIC-26 questionnaire. Reported outcomes were compared for symptomatic and PSA-detected survivors using ANOVA and multivariable log-linear regression.

Results

Thirty-five thousand eight hundred twenty-three men responded (response rate: 60.8%). Of these, 31.3% reported presenting via PSA test and 59.7% symptomatically. In multivariable analysis, symptomatic men reported more difficulty with urinary incontinence (Adjusted mean ratio (AMR): 0.96, 95% CI: 0.96-0.97), urinary irritation (AMR: 0.95, 95% CI: 0.95-0.96), bowel function (AMR: 0.97, 95% CI: 0.97-0.98), sexual function (AMR: 0.90, 95% CI: 0.88-0.92), and vitality/hormonal function (AMR: 0.96, 95% CI: 0.96-0.96) than PSA-detected men. Differences were consistent across respondents of differing age, stage, Gleason score and treatment type.

Conclusion

Prostate cancer survivors presenting symptomatically report poorer functional outcomes than PSA-detected survivors. Differences were not explained by socio-demographic or clinical factors. Clinicians should be aware that men presenting with symptoms are more likely to report functional difficulties after prostate cancer treatment and may need additional aftercare if these difficulties persist. Method of presentation should be considered as a covariate in patient-reported outcome studies of prostate cancer.

Translation and cultural adaptation of the web and printed versions of a decision aid to support men's prostate cancer screening choice: a protocol

INTRODUCTION

Prostate cancer is one of the most frequent cancers among men. However, screening for prostate cancer carries many risks and a small benefit. Thus, based on the available evidence, most medical organisations advocate a shared decision-making process, in which decision aids may play an important role. Nevertheless, to date there is no such instrument to be used by Portuguese men. Our goal is to translate and perform the cultural adaptation of an English language prostate cancer screening decision aid called 'Making the best choice', in web and printed formats, which has been developed and tested by a workgroup from Georgetown University (USA).

METHODS AND ANALYSIS

Culturally and technically inappropriate recommendations in the original decision aid will be reviewed by the process coordinator and a linguistic expert. Two forward translations from English to Portuguese will be done, followed by a back-translation and an independent expert review. We will further improve the decision aid through an iterative process of data collection, data analysis and decision aid review. Individual semistructured cognitive interviews will be conducted and audiotaped with 55-69-year-old men recruited from the local community (urban and suburban) of Oporto district. We plan a total sample size of 30 participants (15 interviews per format). All participants will receive written information about the study and will sign individual consent forms. After verbatim transcription of the audiofiles, a thematic categorical analysis will be conducted using Ligre Software.

ETHICS AND DISSEMINATION

The study protocol was approved by the Health Ethics Committee from Centro Hospitalar de São João/Faculdade de Medicina da Universidade do Porto. Results from this study will be disseminated in peer-reviewed publications and the Portuguese decision aid will available to Portuguese men.

Observational Studies That Seek to Emulate a Randomized Trial of Screening to Reduce the Incidence of Cancer: Do They Address the Question to Which We'd Like to Have an Answer?

Some forms of cancer screening have the potential to reduce cancer incidence, if the screening modality can identify not only a malignancy but a treatable premalignant condition (such as a colon polyp) as well. Cohort studies of the efficacy of these forms of screening in reducing the incidence of cancer face many challenges, notably the difficulty in distinguishing whether a test performed in a given individual was screening or diagnostic in nature. Downward bias in the estimated efficacy of screening resulting from misclassification of test indication is a particular problem in cohort studies that seek to gauge cancer incidence beginning at the time of screening (and a corresponding point in time among unscreened persons). The downward bias is accentuated in those cohort studies that have sought to mimic the "intention-to-treat" analytical approach used in randomized trials, in which initially unscreened persons are retained in this category even if later they themselves undergo screening.

Prostate Health Index outperforms other PSA derivatives in predicting a positive biopsy in men with tPSA <10 ng/mL: Largest prospective cohort in Taiwan

BACKGROUND

Few prospective studies have focused on the performance of the Prostate Health Index (PHI) in Asian populations. Therefore, we aimed to evaluate the performance of the PHI in predicting prostate cancer (PCa) compared with standard prostate-specific antigen (PSA) tests.

METHODS

We prospectively enrolled patients with suspected PCa with a total PSA (tPSA) level 4 to 10 ng/mL or tPSA <4 ng/mL and a suspicious digital rectal examination between February 2017 and September 2018. All of the patients underwent a 12-core transrectal ultrasound-guided prostate biopsy. Prebiopsy blood samples were analyzed for tPSA, free PSA (fPSA), percentage of fPSA (%fPSA), [-2]proPSA (p2PSA), and percentage of p2PSA (%p2PSA). The PHI was calculated as (p2PSA/fPSA) × √tPSA. The areas under the receiver operating characteristic curve (AUCs) were estimated for the PSA derivatives in addition to their specificities at a prespecified sensitivity of 90%.

RESULTS

Of the 307 enrolled patients, 95 (30.9%) had PCa on biopsy. Excluding fPSA, all of the PSA derivatives were significantly different between the positive and negative biopsy groups. Of the various derivatives, the PHI (AUC: 0.783) showed the best performance in predicting the results of the initial biopsy compared with tPSA (AUC: 0.611). At a sensitivity of 90%, the PHI had the best specificity of 46.7% compared with 23.2% for tPSA. Using a PHI cutoff value of 35.15 for biopsy, 108 (35.2%) patients could have avoided undergoing a biopsy. To detect Gleason score ≥ 7 disease at 90% sensitivity, the threshold for PHI was 36.96 with a specificity of 52.1%.

CONCLUSION

PHI was the best biomarker among the PSA derivatives in predicting PCa at biopsy in men with tPSA < 10 ng/mL. The risk of a Gleason score ≥ 7 increased with increasing PHI.

Relationship between Socioeconomic Status and Prevalent Prostate Cancer in the South Korea

BACKGROUND

Prostate cancer prevalence recently has increased among male adults in South Korea. But, few study has evaluated the reason. Therefore, we investigated the relationship between socioeconomic status and prevalent prostate cancer.

METHODS

This study enrolled 16,215 males aged 40 years and over who took part in the Korean National Health and Nutrition Examination Survey 2007-2016. In addition, we obtained the 2000-2016 age-standardized incidence rate and age-standardized mortality rate of prostate cancer from the Korean Statistical Information Service.

RESULTS

After adjusting for other covariates, prevalent prostate cancer was significantly associated with monthly household income (OR 3.71, 95% confidence interval [CI] 1.48-9.30, for highest vs. lowest) and significantly associated with education level (OR 3.66, 95% CI 1.54-8.70, for ≥ 13 vs. ≤ 6). In the analysis of the age-standardized incidence rate and the age-standardized mortality rate, the age-standardized incidence rate has soared from 2000 to 2011 and then decreased gradually, but the age-standardized mortality rate did not change.

CONCLUSION

In our results, prevalent prostate cancer increased significantly with socioeconomic status and the increase in prevalent prostate cancer may be attributable to earlier detection rather than to a real increase in prevalence.

Metastatic prostate cancer at diagnosis and through progression in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial

BACKGROUND

The Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial assessed the effect of screening with prostate-specific antigen and a digital rectal examination on prostate cancer mortality. Another endpoint of interest was the burden of total metastatic disease.

METHODS

All men in PLCO were assessed for metastatic prostate cancer at diagnosis; men with clinical stage I/II disease were assessed for metastatic progression. The rate of total metastatic disease was defined as metastases found either at diagnosis or through progression divided by person-years (PYs) of follow-up for all men in the trial. Metastatic progression rates were computed among men with clinical stage I/II prostate cancer. Survival among men with metastases at diagnosis was compared with survival among men with metastatic progression.

RESULTS

Among 38,340 men in the intervention arm and 38,343 men in the control arm in PLCO, there were 4974 and 4699 prostate cancer cases, respectively. The rates of total metastatic disease were 4.72 and 4.83 per 10,000 PYs in the intervention and control arms, respectively (rate ratio, 0.98; 95% CI, 0.81-1.18). The rates of metastatic progression among men with clinical stage I/II prostate cancer were 43.7 and 50.5 per 10,000 PYs in the intervention and control arms, respectively (P = .30). Prostate cancer-specific 5- and 10-year survival rates were significantly worse for men with metastatic progression (24% and 19%, respectively) than men with metastases at diagnosis (40% and 26%, respectively).

CONCLUSIONS

Rates of total metastatic disease and metastatic progression were similar across arms in PLCO. Survival was worse for men with metastatic progression in comparison with those with metastatic disease at diagnosis.

Systematic evaluation of written health information on PSA based screening in Germany

Background

Prostate-specific antigen (PSA) based screening for early detection of prostate cancer is common although it is associated with both benefits and potential harms (e.g., the risk of overdiagnosis). Evidence-based health information could help individuals make informed decisions about whether to undergo PSA testing or not. This evaluation aimed to determine whether the written health information materials available in Germany provide appropriate information for informed decision-making on PSA based screening.

Methods

A list of criteria was developed and used to systematically assess the quality of information on the benefits and harms of prostate cancer screening included in written health information materials. Fourteen information materials identified by information requests and online searches were evaluated independently by two of three reviewers. Consensus was achieved with a third reviewer.

Results

Of the 14 information materials evaluated, 10 (71%) list the ability to reduce the absolute risk of death from prostate cancer as a benefit of PSA testing, 9 (64%) point out the risks of follow-up diagnostics, 13 (93%) describe the risks of the available prostate cancer treatments, and all 14 specify the risk of overdiagnosis. The minority provide numerical data on benefits and risks. Partially mismatched framing was identified in four cases: two information materials report only the relative frequencies of benefits, and two report only the absolute frequencies of harms. Half of the materials encouraged participation using downplaying or frightening language.

Conclusions

The majority of health information materials in Germany describe the benefits and harms of PSA based screening, including overdiagnosis, but often lack adequate balance, neutrality and numbers.

SERS-based differential diagnosis between multiple solid malignancies: breast, colorectal, lung, ovarian and oral cancer

PURPOSE

Surface-enhanced Raman scattering (SERS) spectroscopy on serum and other biofluids for cancer diagnosis represents an emerging field, which has shown promising preliminary results in several types of malignancies. The purpose of this study was to demonstrate that SERS spectroscopy on serum can be employed for the differential diagnosis between five of the leading malignancies, ie, breast, colorectal, lung, ovarian and oral cancer.

PATIENTS AND METHODS

Serum samples were acquired from healthy volunteers (n=39) and from patients diagnosed with breast (n=42), colorectal (n=109), lung (n=33), oral (n=17), and ovarian cancer (n=13), comprising n=253 samples in total. SERS spectra were acquired using a 532 nm laser line as excitation source, while the SERS substrates were represented by Ag nanoparticles synthesized by reduction with hydroxylamine. The classification accuracy yielded by SERS was assessed by principal component analysis-linear discriminant analysis (PCA-LDA).

RESULTS

The sensitivity and specificity in discriminating between cancer patients and controls was 98% and 91%, respectively. Cancer samples were correctly assigned to their corresponding cancer types with an accuracy of 88% for oral cancer, 86% for colorectal cancer, 80% for ovarian cancer, 76% for breast cancer and 59% for lung cancer.

CONCLUSION

SERS on serum represents a promising strategy of diagnosing cancer which can discriminate between cancer patients and controls, as well as between cancer types such as breast, colorectal, lung ovarian and oral cancer.

Are We Choosing Wisely? Older Adults' Cancer Screening Intentions and Recalled Discussions with Physicians About Stopping

BACKGROUND

National guidelines recommend against cancer screening for older individuals with less than a 10-year life expectancy, but it is unknown if this population desires ongoing screening.

OBJECTIVE

To determine (1) if older individuals with < 10-year life expectancy have future intentions for cancer screening, (2) if they recall a doctor previously suggesting that screening is no longer needed, and (3) individual characteristics associated with intentions to seek screening.

DESIGN

National Social life Health and Aging Project (2015-2016), a nationally representative, cross-sectional survey.

PARTICIPANTS

Community-dwelling adults 55-97 years old (n = 3816).

MAIN MEASURES

Self-reported: (1) mammography and PSA testing within the last 2 years, (2) future intentions to be screened, and (3) discussion with a doctor that screening is no longer needed. Ten-year life expectancy was estimated using the Lee prognostic index. Multivariate logistic regression analysis examined intentions to pursue future screening, adjusting for sociodemographic and health covariates.

KEY RESULTS

Among women 75-84 with < 10-year life expectancy, 59% intend on future mammography and 81% recall no conversation with a doctor that mammography may no longer be necessary. Among men 75-84 with < 10-year life expectancy, 54% intend on future PSA screening and 77% recall no discussions that PSA screening may be unnecessary. In adjusted analyses, those reporting recent cancer screening or no recollection that screening may not be necessary were more likely to want future mammography or PSA screening (p < 0.001).

CONCLUSION

Over 75% of older individuals with limited life expectancy intend to continue cancer screening, and less than 25% recall discussing with physicians the need for these tests. In addition to public health and education efforts, these results suggest that older adults' recollection of being told by physicians that screening is not necessary may be a modifiable risk factor for reducing overscreening in older adults with limited life expectancy.

Bias-corrected estimates of effects of PSA screening decisions on the risk of prostate cancer diagnosis and death: Analysis of the Finnish randomized study of screening for prostate cancer

More information is needed about effects of prostate-specific antigen (PSA) screening for informed decision making. The objective of our study is to evaluate the effects of an implemented screening decision on the risk of prostate cancer (PC) diagnosis and PC death. In a randomized trial, 31,867 Finnish men aged 55-67 years were allocated to the screening arm and 48,282 to the control arm during 1996-1999. Two to three screening rounds were offered to the screening arm with a PSA cut-off of 4.0 ng/ml. A counterfactual exclusion method was used to adjust for the effects of screening noncompliance and PSA contamination on risk of PC death and PC incidence by prognostic group at 15 years of follow up. After correcting for noncompliance and contamination, PSA screening led to 32.4 (95% CI 26.4, 38.6) more PC diagnoses per 1,000 men after 15 years and 1.4 (95% CI 0.0, 2.8) fewer PC deaths compared to the control arm. The corresponding results of an intention-to-screen analysis were 16.5 (95% CI 12.3, 20.7) and 0.8 (95% CI 0.5, 2.0), respectively. These results can be used for patient counseling in informed decision making about PC screening. A limitation of the study was the lack of comprehensive data on contamination.

Decision Aids for Prostate Cancer Screening Choice: A Systematic Review and Meta-analysis

IMPORTANCE

US guidelines recommend that physicians engage in shared decision-making with men considering prostate cancer screening.

OBJECTIVE

To estimate the association of decision aids with decisional outcomes in prostate cancer screening.

DATA SOURCES

MEDLINE, Embase, PsycINFO, CINAHL, and Cochrane CENTRAL were searched from inception through June 19, 2018.

STUDY SELECTION

Randomized trials comparing decision aids for prostate cancer screening with usual care.

DATA EXTRACTION AND SYNTHESIS

Independent duplicate assessment of eligibility and risk of bias, rating of quality of the decision aids, random-effects meta-analysis, and Grading of Recommendations, Assessment, Development and Evaluations rating of the quality of evidence.

MAIN OUTCOMES AND MEASURES

Knowledge, decisional conflict, screening discussion, and screening choice.

RESULTS

Of 19 eligible trials (12 781 men), 9 adequately concealed allocation and 8 blinded outcome assessment. Of 12 decision aids with available information, only 4 reported the likelihood of a true-negative test result, and 3 presented the likelihood of false-negative test results or the next step if the screening test result was negative. Decision aids are possibly associated with improvement in knowledge (risk ratio, 1.38; 95% CI, 1.09-1.73; I2 = 67%; risk difference, 12.1; low quality), are probably associated with a small decrease in decisional conflict (mean difference on a 100-point scale, -4.19; 95% CI, -7.06 to -1.33; I2 = 75%; moderate quality), and are possibly not associated with whether physicians and patients discuss prostate cancer screening (risk ratio, 1.12; 95% CI, 0.90-1.39; I2 = 60%; low quality) or with men's decision to undergo prostate cancer screening (risk ratio, 0.95; 95% CI, 0.88-1.03; I2 = 36%; low quality).

CONCLUSIONS AND RELEVANCE

The results of this study provide moderate-quality evidence that decision aids compared with usual care are associated with a small decrease in decisional conflict and low-quality evidence that they are associated with an increase in knowledge but not with whether physicians and patients discussed prostate cancer screening or with screening choice. Results suggest that further progress in facilitating effective shared decision-making may require decision aids that not only provide education to patients but are specifically targeted to promote shared decision-making in the patient-physician encounter.

A Metabolomics Analysis of Body Mass Index and Postmenopausal Breast Cancer Risk

Background

Elevated body mass index (BMI) is associated with increased risk of postmenopausal breast cancer. The underlying mechanisms, however, remain elusive.

Methods

In a nested case-control study of 621 postmenopausal breast cancer case participants and 621 matched control participants, we measured 617 metabolites in prediagnostic serum. We calculated partial Pearson correlations between metabolites and BMI, and then evaluated BMI-associated metabolites (Bonferroni-corrected α level for 617 statistical tests = P < 8.10 × 10-5) in relation to invasive breast cancer. Odds ratios (ORs) of breast cancer comparing the 90th vs 10th percentile (modeled on a continuous basis) were estimated using conditional logistic regression while controlling for breast cancer risk factors, including BMI. Metabolites with the lowest P values (false discovery rate < 0.2) were mutually adjusted for one another to determine those independently associated with breast cancer risk.

Results

Of 67 BMI-associated metabolites, two were independently associated with invasive breast cancer risk: 16a-hydroxy-DHEA-3-sulfate (OR = 1.65, 95% confidence interval [CI] = 1.22 to 2.22) and 3-methylglutarylcarnitine (OR = 1.67, 95% CI = 1.21 to 2.30). Four metabolites were independently associated with estrogen receptor-positive (ER+) breast cancer risk: 16a-hydroxy-DHEA-3-sulfate (OR = 1.84, 95% CI = 1.27 to 2.67), 3-methylglutarylcarnitine (OR = 1.91, 95% CI = 1.23 to 2.96), allo-isoleucine (OR = 1.76, 95% CI = 1.23 to 2.51), and 2-methylbutyrylcarnitine (OR = 1.89, 95% CI = 1.22 to 2.91). In a model without metabolites, each 5 kg/m2 increase in BMI was associated with a 14% higher risk of breast cancer (OR = 1.14, 95% CI = 1.01 to 1.28), but adding 16a-hydroxy-DHEA-3-sulfate and 3-methylglutarylcarnitine weakened this association (OR = 1.06, 95% CI = 0.93 to 1.20), with the logOR attenuating by 57.6% (95% CI = 21.8% to 100.0+%).

Conclusion

These four metabolites may signal metabolic pathways that contribute to breast carcinogenesis and that underlie the association of BMI with increased postmenopausal breast cancer risk. These findings warrant further replication efforts.

Circulating mRNA signature as a marker for high-risk prostate cancer

Prostate cancer (PCa) is the second most common cancer in men. The indolent course of the disease makes the treatment choice a challenge for physicians and patients. In this study, a minimally invasive method was used to evaluate the potential of molecular markers in identifying patients with aggressive disease. Cell-free plasma samples from 60 PCa patients collected before radical prostatectomy were used to evaluate the levels of expression of eight genes (AMACR, BCL2, NKX3-1, GOLM1, OR51E2, PCA3, SIM2 and TRPM8) by quantitative real-time PCR. Overexpression of AMACR, GOLM1, TRPM8 and NKX3-1 genes was significantly associated with aggressive disease characteristics, including extracapsular extension, tumor stage and vesicular seminal invasion. A trio of genes (GOLM1, NKX3-1 and TRPM8) was able to identify high-risk PCa cases (85% of sensitivity and 58% of specificity), yielding a better overall performance compared with the biopsy Gleason score and prostate-specific antigen, routinely used in the clinical practice. Although more studies are required, these circulating markers have the potential to be used as an additional test to improve the diagnosis and treatment decision of high-risk PCa patients.

Screening for prostate cancer: History, evidence, controversies and future perspectives toward individualized screening

Differences in the incidence and mortality rate of prostate cancer between the USA and Japan have been decreasing over time, and were only twofold in 2017. Therefore, countermeasures against prostate cancer could be very important not only in Western countries, but also in developed Asian countries. Screening for prostate cancer in the general population using transrectal ultrasonography, digital rectal examination and/or prostate acid phosphatase began in Japan in the early 1980s, and screening with prostate-specific antigen and digital rectal examination has been widespread in the USA since the late 1980s. Large- and mid-scale randomized controlled trials on screening for prostate cancer began around 1990 in the USA, Canada and Europe. However, most of these studies failed as randomized controlled trials because of high contamination in the control arm, low compliance in the screening arm or insufficient screening setting about screening frequency and/or biopsy indication. The best available level 1 evidence is data from the European Randomized Study of Screening for Prostate Cancer and the Göteborg screening study. However, several non-urological organizations and lay media around the world have mischaracterized the efficacy of prostate-specific antigen screening. To avoid long-term confusion about screening for prostate cancer, leading professional urological organizations, including the Japanese Urological Association, are moving toward the establishment of an optimal screening system that minimizes the drawbacks of overdetection, overtreatment and loss of quality of life due to treatment, and maximizes reductions in the risk of death as a result of prostate cancer and the development of metastatic prostate cancer.

Women's perception, attitudes, and intended behavior towards predictive epigenetic risk testing for female cancers in 5 European countries: a cross-sectional online survey

BACKGROUND

Epigenetic markers might be used for risk-stratifying cancer screening and prevention programs in the future. Although the clinical utility of consequent epigenetic tests for risk stratification is yet to be proven, successful adoption into clinical practice also requires the public's acceptance of such tests. This cross-sectional online survey study sought to learn for the first time about European women's perceptions, attitudes, and intended behavior regarding a predictive epigenetic test for female cancer (breast, ovarian, cervical, and endometrial) risks.

METHODS

1675 women (40-75 years) from five European countries (Czech Republic, Germany, United Kingdom, Italy, Sweden), drawn from online panels by the survey sampling company Harris Interactive (Germany), participated in an online survey where they first received online leaflet information on a predictive epigenetic test for female cancer risks and were subsequently queried by an online questionnaire on their desire to know their female cancer risks, their perception of the benefit-to-harm ratio of an epigenetic test predicting female cancer risks, reasons in favor and disfavor of taking such a test, and their intention to take a predictive epigenetic test for female cancer risks.

RESULTS

Most women desired information on each of their female cancer risks, 56.6% (95% CI: 54.2-59.0) thought the potential benefits outweighed potential harms, and 75% (72.0-77.8) intended to take a predictive epigenetic test for female cancer risks if freely available. Results varied considerably by country with women from Germany and the Czech Republic being more reserved about this new form of testing than women from the other three European countries. The main reason cited in favor of a predictive epigenetic test for female cancer risks was its potential to guide healthcare strategies and lifestyle changes in the future, and in its disfavor was that it may increase cancer worry and coerce unintended lifestyle changes and healthcare interventions.

CONCLUSIONS

A successful introduction of predictive epigenetic tests for cancer risks will require a balanced and transparent communication of the benefit-to-harm ratio of healthcare pathways resulting from such tests in order to curb unjustified expectations and at the same time to prevent unjustified concerns.

Interaction between leukocyte aldo-keto reductase 1C3 activity, genotypes, biological, lifestyle and clinical features in a prostate cancer cohort from New Zealand

Introduction

Aldo-keto reductase 1C3 (AKR1C3) is known for multiple functions including its catalytic activity towards producing extra-testicular androgen. The present study is towards understanding interaction between biological, lifestyle and genetic impacts of AKR1C3 and their influence on clinical factors in a prostate cancer (PC) cohort from New Zealand (NZ).

Method

Characteristics of 516 PC patients were collected from the Auckland Regional Urology Facility, NZ. These men were genotyped for the AKR1C3 rs12529 single nucleotide polymorphism (SNP). The leukocyte AKR1C3 activity was measured in a sub-cohort. Variability of leukocyte AKR1C3 activity between biological, lifestyle and clinical features as well as correlation between biological and clinical features were assessed with and without genetic stratification.

Results

The leukocyte AKR1C3 activity was associated with age at diagnosis (0.51 vs 0.34 μM coumberol units for >69y vs ≤69y, P = 0.03); and with anatomic stage/prognostic grouping among the AKR1C3 rs12529 CC genotype carriers (0.50 vs 28 μM coumberol units among low- and high-risk groups respectively, P = 0.02). Significant correlation between leukocyte AKR1C3 activity and age at PC diagnosis was also observed (correlation coefficient 0.20 and P = 0.02). Ever- smoking impacted both age and PSA at PC diagnosis among AKR1C3 rs12529 GG and CG genotype carriers respectively. Age at diagnosis significantly correlated with PSA at diagnosis in the main (correlation coefficient 0.29, and P<0.001) and sub-cohorts (correlation coefficient 0.24, and P = 0.01); and those carrying the AKR1C3 rs12529 CG and GG genotypes in both the main (correlation coefficient 0.30, and P<0.001 and correlation coefficient 0.35, and P<0.001 respectively) and sub-cohorts (correlation coefficient 0.43, and P<0.001 and correlation coefficient 0.39, and P = 0.06 respectively); but not with those carrying the CC genotype.

Conclusions

Age dependent PSA thresholds in PC screening could have been valid only in men carrying the AKR1C3 rs12529 CG and GG genotypes in this NZ cohort.

Prostate Cancer Incidence and Mortality in Relationship to Family History of Prostate Cancer; Findings From The PLCO Trial

BACKGROUND

The purpose of the study was to determine the relationship between family history of prostate cancer in a first-degree relative (FDR) and prostate cancer incidence and mortality.

PATIENTS AND METHODS

Deidentified data sets of men recruited in the Prostate, Lung, Colorectal, and Ovary (PLCO) trial were accessed. Men with complete information about family history of prostate cancer in an FDR were included. The effect of family history on prostate cancer incidence and mortality was assessed in a multivariate Cox regression model. Likewise, the effect of the number of FDRs with prostate cancer and the effect of youngest diagnosis age of an FDR with prostate cancer were assessed.

RESULTS

A total of 74,781 participants were included in the current analysis, including 5281 participants with family history of prostate cancer in an FDR and 69,500 participants without family history of prostate cancer in an FDR. Among participants without family history of prostate cancer in an FDR, a total of 7450 patients (10.5%) were subsequently diagnosed with prostate cancer; whereas among patients with family history of prostate cancer in an FDR, a total of 889 patients (16.5%) were subsequently diagnosed with prostate cancer. In an adjusted multivariate Cox regression model, family history of prostate cancer was associated with a higher probability of prostate cancer diagnosis (hazard ratio [HR], 1.590; 95% confidence interval [CI], 1.482-1.705; P < .001). The number of FDRs with prostate cancer proportionally correlated with higher prostate cancer incidence (HR, 1.529; 95% confidence interval [CI], 1.439-1.624; P < .001). Family history of prostate cancer in an FDR was not predictive of higher prostate cancer mortality in the PLCO screening (intervention) arm (HR, 0.829; 95% CI, 0.422-1.629; P = .587) whereas it was predictive of a higher prostate cancer mortality in the PLCO nonscreening (control) arm (HR, 1.894; 95% CI, 1.154-3.109; P = .012). Number of FDRs with prostate cancer was not associated with higher prostate cancer mortality in the PLCO screening (intervention) arm (HR, 0.956; 95% CI, 0.541-1.691; P = .878), whereas it was associated with higher prostate cancer mortality in the PLCO nonscreening (control) arm (HR, 1.643; 95% CI, 1.083-2.493; P = .020).

CONCLUSION

Family history of prostate cancer is associated with an increased risk of prostate cancer diagnosis in the overall cohort of patients as well as a higher risk of prostate cancer mortality in the nonscreened subcohort. Further prospective assessment of the role of screening among selected high-risk populations (including those with strong family history) is warranted.

Structured Population-based Prostate-specific Antigen Screening for Prostate Cancer: The European Association of Urology Position in 2019

Prostate cancer (PCa) is one of the first three causes of cancer mortality in Europe. Screening in asymptomatic men (aged 55-69yr) using prostate-specific antigen (PSA) is associated with a migration toward lower staged disease and a reduction in cancer-specific mortality. By 20yr after testing, around 100 men need to be screened to prevent one PCa death. While this ratio is smaller than for breast and colon cancer, the long natural history of PCa means many men die from other causes. As such, the nonselective use of PSA testing and radical treatments can lead to overdiagnosis and overtreatment. The European Association of Urology (EAU) supports measures to encourage appropriate PCa detection through PSA testing, while reducing overdiagnosis and overtreatment. These goals may be achieved using personalized risk-stratified approaches. For diagnosis, the greatest benefit from early detection is likely to come in men assessed using baseline PSA levels at the age of 45yr to individualize screening intervals. Multiparametric magnetic resonance imaging as well as risk calculators based on family history, ethnicity, digital rectal examination, and prostate volume should be considered to triage the need for biopsy, thus reducing the risk of overdiagnosis. For treatment, the EAU advocates balancing patient's life expectancy and cancer's mortality risk when deciding an approach. Active surveillance is encouraged in well-informed patients with low-risk and some intermediate-risk cancers, as it decreases the risks of overtreatment without compromising oncological outcomes. Conversely, the EAU advocates radical treatment in suitable men with more aggressive PCa. Multimodal treatment should be considered in locally advanced or high-grade cancers. PATIENT SUMMARY: Implementation of prostate-specific antigen (PSA)-based screening should be considered at a population level. Men at risk of prostate cancer should have a baseline PSA blood test (eg, at 45yr). The level of this test, combined with family history, ethnicity, and other factors, can be used to determine subsequent follow-up. Magnetic resonance imaging scans and novel biomarkers should be used to determine which men need biopsy and how any cancers should be treated.

Prostate biopsy: when and how to perform

Prostate cancer, unlike other cancers, has been sampled in a non-targeted, systematic manner in the past three decades. On account of the low volume of prostate sampled despite the multiple cores acquired, systematic transrectal (TRUS) biopsy suffered from low sensitivity in picking up clinically significant prostate cancer. In addition, a significant number of cancers of the anterior, lateral peripheral zone, and the apex were missed as these areas were undersampled or missed during this biopsy protocol. Subsequently, the number of cores acquired was increased with special focus given to targeting the previously undersampled areas. These procedures led to an increase in the complication rates as well as detection of more clinically insignificant cancers. The advent of multiparametric magnetic resonance imaging (MRI) and its high intrinsic tissue contrast enabled better detection of prostate cancer. This led to the introduction of MRI-targeted biopsies with either MRI-TRUS fusion or under direct (in-gantry) guidance. MRI-targeted biopsies increased the percentage of positive cores and detection of clinically significant prostate cancers; however, these are expensive, time-intensive, require significant capital investment and operator expertise. This article describes the indications, workflow, complications, advantages, and disadvantages of TRUS-guided biopsy followed by MRI-guided biopsies.

Conservative management and radical treatment in localised prostate cancer: A systematic review with meta-analysis and trial sequential analysis

Background:

Several randomised control trials comparing conservative management (watchful waiting/observation/active monitoring) and radical treatments (radical prostatectomy/radiotherapy) for localised prostate cancer with at least more than 10 years of follow-up (median) have been published with conflicting findings. The primary aim of this study was to determine all-cause mortality and prostate cancer-related mortality between conservative management and radical treatment for localised prostate cancer.

Methods:

All randomised clinical trials were searched in MEDLINE, EMBASE, PubMed and CENTRAL from their inception until September 2018.

Results:

Four trials were eligible ( n = 3211) for inclusion in the data synthesis. In patients who had radical treatment, the incidence of all-cause mortality and prostate cancer-related mortality (three trials, 3069 patients) were reduced (with odds ratio, i.e. 95% confidence interval (CI)), of 1.37 (1.14–1.64), ρ < 0.001, low quality of evidence and odd ratio (95% CI) of 1.74 (1.31–2.30), ρ < 0.001, low quality of evidence, respectively). The radical treatment group was associated with reduced incidence of distant metastases, the odds ratio (95% CI) being 1.87 (1.48–2.36), ρ < 0.001, low quality of evidence. However, patients who were randomised to radical treatment had a significantly higher incidence of erectile dysfunction (the odds ratio (95% CI) being 0.62 (0.39–0.98), ρ = 0.04, very low quality of evidence) and urinary incontinence (odds ratio (95% CI) of 0.42 (0.21–0.86), ρ = 0.02, very low quality of evidence).

Conclusions:

In summary, radical treatments reduce all-cause mortality, and prostate cancer-related and distant metastases, at the expense of higher incidence of erectile dysfunction and urinary incontinence. The general quality of evidence ranged from very low to low.

Level of evidence: 1a

PROSPERO Registration Number: CRD42017072687

Extended follow-up for prostate cancer incidence and mortality among participants in the Prostate, Lung, Colorectal and Ovarian randomized cancer screening trial

OBJECTIVE

To examine prostate cancer (PCa) incidence and mortality by arm in the randomized Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening trial.

PATIENTS AND METHODS

Patients aged 55-74 years at 10 screening centres were randomized between 1993 and 2001 to an intervention or usual care arm. Patients in the intervention arm received six annual prostate-specific antigen (PSA) tests and four annual digital rectal examinations. The patients were followed for PCa incidence and for mortality via active follow-up processes and by linkage to state cancer registries and the National Death Index. For cancers identified through active follow-up, trial abstractors recorded the mode of diagnosis (screen-detected, symptomatic, other).

RESULTS

A total of 38 340 patients were randomized to the intervention arm and 38 343 to a usual care arm. The median follow-up for mortality was 16.9 (intervention) and 16.7 years (usual care). There were 333 (intervention) and 352 (usual care) PCa cancer deaths, giving rates (per 10 000 person-years) of 5.5 and 5.9, respectively, and a rate ratio (RR) of 0.93 (95% confidence interval [CI] 0.81-1.08; P = 0.38). The RR for overall PCa incidence was 1.05 (95% CI 1.01-1.09). The RRs by Gleason category were 1.17 (95% CI 1.11-1.23) for Gleason 2-6, 1.00 (95% CI 0.93-1.07) for Gleason 7 and 0.89 (95% CI 0.80-0.99) for Gleason 8-10 disease. By mode of detection, during the trial's screening phase, 13% of intervention arm vs 27% of usual care arm cases were symptomatic; post-screening, these percentages were 18% in each arm.

CONCLUSION

After almost 17 years of median follow-up, there was no significant reduction in PCa mortality in the intervention compared with the usual care arm. There was a significant increase in Gleason 2-6 disease and a significant reduction in Gleason 8-10 disease in the intervention compared with the usual care arm.

Early detection of prostate cancer using prostate-specific antigen testing: an empirical evaluation among general practitioners and urologists

Background: Prostate cancer (PCa) is the most frequent cancer and the third leading cause of cancer death among German men. One option for PCa early detection is prostate-specific antigen (PSA) testing, which is still under debate regarding its risk benefits. Besides recommendations on the early PCa detection, daily practice on PSA testing varies in, for example, information communication and usage of the test. This pilot study assessed potential differences between general practitioners (GPs) and urologists in handling PSA testing and guidelines on early detection of PCa. Methods: 172 GPs belonging to the teaching network of the University of Oldenburg in Lower Saxony and Bremen and 128 practicing urologists were included in the online survey focusing on PSA testing. The questionnaire covered 43 questions on topics as the usage of the test, information communication, handling of test results and handling of/knowledge about national and international guidelines on PCa. Wether PSA testing is used in accordance with guidelines was also explored in four standardized case scenarios. Statistical analysis was done at a descriptive level. Results: In total, 65 doctors participated in the survey (response proportion: 21.7%, n=65; 27.9%, n=48 [GPs]; 13.2%, n=17 [urologists]). Results of 41 GPs and 14 urologists were analyzed. The PSA test was judged as useful by all urologists, while almost half of the GPs valued the test as ambivalent or not useful. Urologists showed a more proactive approach of informing men on PSA testing. Regarding guidelines and recommendations on PSA testing, GPs were less familiar with them compared to the urologists. Doctors of both specialties did not always treat men in consistence with the guidelines. This was partially in contradiction to their self-appraisal. Conclusion: This pilot study is highlighting differences in PSA testing practices between GPs and urologists in Germany. Urologists showed a more proactive approach. For further verification, we plan a more comprehensive study covering several German states.

Obstacles in prostate cancer screening: Current issues and future solutions

Prostate cancer is the most common cancer in men and is associated with unacceptably high mortality rates, yet an accurate and acceptable screening programme that detects clinically significant prostate cancer remains elusive. Although there is good evidence that prostate-specific antigen (PSA)-based screening lowers prostate cancer-specific mortality, especially when conducted at high intensity, the harm caused by overinvestigation, overdiagnosis and overtreatment of clinically insignificant cases arguably outweighs these benefits. Several attempts have therefore been made to improve screening, enhancing the diagnostic value of PSA and identifying novel modalities for screening. Here, we provide a comprehensive review of the benefits and harms, and analyse which of these novel screening methods show most promise.

Level of evidence: 5, expert opinion

Causes of death among women with epithelial ovarian cancer by length of survival post-diagnosis: a population-based study in British Columbia, Canada

OBJECTIVES

Little is known regarding the health of women who survive more than 5 years following their ovarian cancer diagnosis. To bridge an important gap in our knowledge about long term health of ovarian cancer survivors, we examined the causes of death among women diagnosed with epithelial ovarian cancer between 1990 and 2014 in British Columbia. These causes were stratified by years since diagnosis, and compared with age- standardized causes of death among women who have not been diagnosed with ovarian cancer.

METHODS

We examined all women with epithelial ovarian cancer in British Columbia 1990-2014 using population- based administrative datasets. We stratified women into three groups: all epithelial ovarian cancer patients; women surviving 5 to 9 years post-diagnosis, and women surviving 10 or more years since diagnosis. All- cause and cause specific standardized mortality ratios (SMRs) were calculated.

RESULTS

There were 4246 deaths among 6427 women with epithelial ovarian cancer. About 55.9% of deaths were from ovarian cancer. When compared with the general population, the highest SMRs (SMR of 5 or higher) were for deaths from other cancers and external causes (44.4% from falls) among women surviving 5-9 years and 10 or more years post-diagnosis. Mortality from other cancers can largely be explained by deaths from breast cancer (15.8%), lung cancer (12.3%), and colorectal cancer (11%).

CONCLUSIONS

While the majority of epithelial ovarian cancer patients continue to die from their ovarian cancer, our results suggest that long term ovarian cancer survivors are particularly vulnerable to deaths from other cancers and from falls in elderly survivors. These data could indicate closer surveillance for breast, lung, and colorectal cancer, and closer attention to bone health is warranted among women surviving for 5 or more years following their epithelial ovarian cancer diagnosis.

A 16-yr Follow-up of the European Randomized study of Screening for Prostate Cancer

BACKGROUND

The European Randomized study of Screening for Prostate Cancer (ERSPC) has previously demonstrated that prostate-specific antigen (PSA) screening decreases prostate cancer (PCa) mortality.

OBJECTIVE

To determine whether PSA screening decreases PCa mortality for up to 16yr and to assess results following adjustment for nonparticipation and the number of screening rounds attended.

DESIGN, SETTING, AND PARTICIPANTS

This multicentre population-based randomised screening trial was conducted in eight European countries. Report includes 182160 men, followed up until 2014 (maximum of 16yr), with a predefined core age group of 162389 men (55-69yr), selected from population registry.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The outcome was PCa mortality, also assessed with adjustment for nonparticipation and the number of screening rounds attended.

RESULTS AND LIMITATIONS

The rate ratio of PCa mortality was 0.80 (95% confidence interval [CI] 0.72-0.89, p<0.001) at 16yr. The difference in absolute PCa mortality increased from 0.14% at 13yr to 0.18% at 16yr. The number of men needed to be invited for screening to prevent one PCa death was 570 at 16yr compared with 742 at 13yr. The number needed to diagnose was reduced to 18 from 26 at 13yr. Men with PCa detected during the first round had a higher prevalence of PSA >20ng/ml (9.9% compared with 4.1% in the second round, p<0.001) and higher PCa mortality (hazard ratio=1.86, p<0.001) than those detected subsequently.

CONCLUSIONS

Findings corroborate earlier results that PSA screening significantly reduces PCa mortality, showing larger absolute benefit with longer follow-up and a reduction in excess incidence. Repeated screening may be important to reduce PCa mortality on a population level.

PATIENT SUMMARY

In this report, we looked at the outcomes from prostate cancer in a large European population. We found that repeated screening reduces the risk of dying from prostate cancer.

A natural history model for planning prostate cancer testing: Calibration and validation using Swedish registry data

Recent prostate cancer screening trials have given conflicting results and it is unclear how to reduce prostate cancer mortality while minimising overdiagnosis and overtreatment. Prostate cancer testing is a partially observable process, and planning for testing requires either extrapolation from randomised controlled trials or, more flexibly, modelling of the cancer natural history. An existing US prostate cancer natural history model (Gulati et al, Biostatistics 2010;11:707-719) did not model for differences in survival between Gleason 6 and 7 cancers and predicted too few Gleason 7 cancers for contemporary Sweden. We re-implemented and re-calibrated the US model to Sweden. We extended the model to more finely describe the disease states, their time to biopsy-detectable cancer and prostate cancer survival. We first calibrated the model to the incidence rate ratio observed in the European Randomised Study of Screening for Prostate Cancer (ERSPC) together with age-specific cancer staging observed in the Stockholm PSA (prostate-specific antigen) and Biopsy Register; we then calibrated age-specific survival by disease states under contemporary testing and treatment using the Swedish National Prostate Cancer Register. After calibration, we were able to closely match observed prostate cancer incidence trends in Sweden. Assuming that patients detected at an earlier stage by screening receive a commensurate survival improvement, we find that the calibrated model replicates the observed mortality reduction in a simulation of ERSPC. Using the resulting model, we predicted incidence and mortality following the introduction of regular testing. Compared with a model of the current testing pattern, organised 8 yearly testing for men aged 55–69 years was predicted to reduce prostate cancer incidence by 14% and increase prostate cancer mortality by 2%. The model is open source and suitable for planning for effective prostate cancer screening into the future.