Cancer surveillance series: interpreting trends in prostate cancer--part I: Evidence of the effects of screening in recent prostate cancer incidence, mortality, and survival rates

Radical prostatectomy for clinical stage T3a disease

BACKGROUND

Men with clinical stage T3a disease are at high risk and are often encouraged to undergo radiation therapy with concomitant hormonal therapy. The long-term outcomes among men treated with radical prostatectomy for clinical stage T3a disease were examined.

METHODS

Among 3397 men treated by radical prostatectomy by 1 surgeon between 1987 and 2003, 62 (1.8%) men were identified who had clinical stage T3a disease. Among the 56 men not treated with neoadjuvant or adjuvant therapies before prostate-specific antigen (PSA) recurrence, the long-term outcomes of PSA-free survival, metastasis-free survival, and prostate cancer specific survival were examined. Median and mean follow-up after surgery were 10.3 and 13 years, respectively (range, 1-17).

RESULTS

Ninety-one percent of men in this group had pathological T3 disease. PSA-free survival at 15 years after surgery was 49%. Metastasis-free survival and cause-specific survival at 15 years after surgery were 73% and 84%, respectively. Among men with a PSA recurrence, 46% received secondary therapy before metastasis. The only preoperative or pathological feature that predicted risk of prostate cancer death was lymph node metastasis (hazard ratio [HR]: 9.22, 95% confidence interval [CI]: 1.06-80.02, P = .044). Among the 28 men with a PSA recurrence, PSA doubling time (PSADT) data were available for 23, of which 11 (48%) has a PSADT >/=9 months. No patient with a PSADT >/=9 months died of prostate cancer. A PSADT <9 months was significantly associated with increased risk of prostate cancer death (log-rank, P = .004).

CONCLUSIONS

In a select cohort of men with clinical stage T3a disease, radical prostatectomy alone provides long-term cancer control in about half of the men and results in a prostate cancer-specific survival of 84%. Among men with a PSA recurrence, PSADT at the time of recurrence is a useful determinant of risk of prostate cancer death.

The changing age distribution of prostate cancer in Canada

BACKGROUND

Prostate cancer incidence rates are still increasing steadily; mortality rates are levelling, possibly decreasing; and hospitalization rates for many diagnoses are decreasing. Our objective is to examine changes in age distributions of prostate cancer during these times of change.

METHODS

Prostate cancer cases were derived from the Canadian Cancer Registry, prostate cancer deaths from Vital Statistics, hospitalizations from the Hospital Morbidity File. Age-standardized rates were calculated based on the 1991 Canadian population. A prevalence correction for incidence rates was calculated.

RESULTS

Age-specific incidence rates increased until 1995 for all ages, but a superimposed peak (1991-94) was greatest between ages 60-79. After 1995, increases in incidence continued for the under-70 age groups. Prevalence correction indicated the greatest underestimation of incidence rates for the oldest ages, but was less in Canada than in the United States. Mortality rates increased until 1994, then levelled and slowly decreased; age-specific mortality rates showed the greatest increase for the oldest ages but the earliest downturn for younger age groups. While hospitalizations dropped drastically after 1991, this drop was confined to elderly men (70+).

CONCLUSIONS

Dramatic changes in age distributions of prostate cancer incidence, mortality and hospitalizations altered age profiles of men with prostate cancer. This illustrated the changing nature of prostate cancer as a public health issue and has important implications for health care provision, e.g., the increased numbers of younger new patients have different needs from the increasing numbers of elderly long-term patients who now spend less time in hospital.

Specificity of serum prostate-specific antigen determination in the Finnish prostate cancer screening trial

Specificity constitutes a component of validity for a screening test. The number of false-positive (FP) results has been regarded as one of major shortcomings in prostate cancer screening. We estimated the specificity of serum prostate-specific antigen (PSA) determination in prostate cancer screening using data from a randomised, controlled screening trial conducted in Finland with 32 000 men in the screening arm. We calculated the specificity as the proportion of men with negative findings (screen negatives, SN) relative to those with negative and FP results (SN/(SN+FP)). A SN finding was defined as either PSA</=4 ng ml(-1) or PSA 3.0-3.9 ng ml(-1) combined with a negative ancillary test (digital rectal examination, DRE or free/total, F/T PSA ratio). False positives were those with positive screening test followed by a negative diagnostic examination. Of the 30 194 eligible men, 20 794 (69%) attended the first screening round and 1968 (9.5%) had a screen-positive finding. A total of 508 prostate cancers were detected at screening (2.4%). Hence, the number of SN findings was 18 825 and the number of FP results 1358. Specificity was estimated as 0.933 (18 825 out of 20 183) with 95% confidence interval (CI) 0.929-0.936. Specificity decreased with age. Digital rectal examination as ancillary examination had similar or higher specificity than F/T PSA. In the second screening round, specificity was slightly lower (0.912, 95% CI 0.908-0.916). The specificity of PSA screening in the Finnish screening trial is acceptable. Further improvement in specificity could, however, improve acceptability of screening and decrease screening costs.

Lack of Progress in Early Diagnosis of Bladder Cancer

OBJECTIVES

The stage of presentation of prostate cancer has changed dramatically in the past two decades, largely because of prostate-specific antigen screening and increased public awareness regarding the disease. Recently, strides have been made in the validation, development, and approval of bladder cancer (BC) markers. We sought to evaluate whether any stage migration has occurred for patients with BC during the same period.

METHODS

A total of 351 and 1262 patients underwent radical cystectomy and radical retropubic prostatectomy, respectively, between 1992 and 2005 by one surgeon. The patients were divided into two consecutive groups: group 1 (1992 to 1998) and group 2 (1999 to 2005). The baseline and pathologic characteristics of the patients were compared.

RESULTS

No differences were found in the clinical or pathologic staging between the two groups of patients undergoing radical cystectomy. The 5-year overall and disease-specific survival also was not different between the two groups. For patients with prostate cancer, those in group 2 presented at a younger age, with a lower prostate-specific antigen level, and had a lower clinical stage. Group 2 patients had a decrease in the incidence of extracapsular extension, a decreased tumor volume, and a decrease in the incidence of Gleason 8 to 10 tumors.

CONCLUSIONS

During two consecutive periods, our patients with prostate cancer presented with the cancer at an earlier stage and had more favorable pathologic features after radical retropubic prostatectomy. However, our patients with BC did not demonstrate any stage migration. Physicians need to be more aggressive in diagnosing BC, especially in patients at high risk of the disease. Risk factors must be emphasized, urine markers should be used in a screening strategy, and the indications for radical cystectomy should be liberalized.

Cancer detection and cancer characteristics in the European Randomized Study of Screening for Prostate Cancer (ERSPC)--Section Rotterdam. A comparison of two rounds of screening

OBJECTIVES

To evaluate the features, rates, and characteristics of prostate cancer detected during two subsequent screening rounds.

METHODS

Data were retrieved from the database of European Randomized Study of Screening for Prostate Cancer (ERSPC), section Rotterdam. Men, ages 55-74 yr were screened with a 4-yr interval. Different biopsy indications were used in the first and second screens in the PSA range <4.0 ng/ml. Clinical features and a total of 1548 sextant biopsies were recorded for Gleason score and tumour extent, and 550 radical prostatectomy specimens were evaluated for Gleason score, pathologic T category, and tumour volume.

RESULTS

Clinical stage, Gleason score, involvement of biopsy by tumour, and PSA levels were more favourable in patients of the second round compared with those of the first round. The number of men chosen for watchful waiting increased from 98 (10%) to 123 (22%) in the second round (p<0.0001). In patients undergoing radical prostatectomy, median tumour volume in the first and second screening round was 0.65 and 0.45 ml (p=0.001). Minimal cancer (cancer <0.5 ml, organ-confined, no Gleason pattern 4 or 5) was found in 122 (31.6%) in the first and 60 (42.6%) in the second screening round (p=0.03). The 5-yr PSA progression-free survival after radical prostatectomy was 87%.

CONCLUSIONS

Despite the 4-yr interval an important shift of all prognostic factors occurred in favour of round 2. In those men who underwent radical prostatectomy, 42.6% fulfilled the criteria of minimal cancer. These data suggest that overdiagnosis increases with repeat screening.

Spurious prostate-specific antigen (PSA) recurrence after radical prostatectomy: Interference by human antimouse heterophile antibodies

Human antimouse heterophile antibodies (HAMA) are naturally occurring antibodies that can interfere with modern serum assays. We report a case of HAMA interference with a commonly used prostate-specific antigen (PSA) assay, leading to false elevation (2.17-2.46 ng/mL) after radical prostatectomy. Pre-operative PSA was 4.4 ng/mL, and final pathology was Gleason 3 + 3, pT2cNXMX. This markedly elevated postoperative PSA led to unnecessary imaging for metastasis and psychological distress to the patient. Direct measurement of HAMA in the patient's serum yielded a value of 440 ng/mL (<74 ng/mL). An alternate PSA assay using goat detection antibody eliminated interference, with all values 0.05 ng/mL. When a patient's PSA is inconsistent with the clinical scenario, one should consider immunological interference by HAMA in PSA assays.

A population model of prostate cancer incidence

Introduction of screening for prostate cancer using the prostate-specific antigen (PSA) marker of the disease led to remarkable dynamics of the incidence of the disease observed in the last two decades. A statistical model is used to provide a link between dissemination of PSA and the observed transient population responses. The model is used to estimate lead time, overdiagnosis and other relevant characteristics of prostate cancer screening.

The role of prevalence in the diagnosis of prostate cancer

BACKGROUND

The worldwide incidence of prostate cancer has been rising rapidly, likely due to intensified effort in early detection and screening. Intense effort is also directed at novel schemas of chemoprevention and therapy. Incidence data are insufficient to identify the true magnitude of prostate cancer in a given population. The true prevalence of prostate cancer must be identified.

METHODS

We reviewed the latest worldwide epidemiologic data and clinical studies on prostate cancer studying the true prevalence of this disease.

RESULTS

The incidence of prostate cancer is increasing worldwide, with strong variation among regions. Prevalence studies based on autopsy data have confirmed a high frequency of latent prostate cancer in men of all ages. More aggressive screening measures using a lower prostate-specific antigen (PSA) threshold, together with an increasing number of biopsies, have escalated the detection of these latent cancers.

CONCLUSIONS

Recent improvements in prostate cancer detection narrow the gap between the incidence and true prevalence of prostate cancer. This, however, raises concerns about the risk of over detection of latent cancers and thus identifying a need for improvement in screening strategies to better identify clinically significant disease.

Survival results in patients with screen-detected prostate cancer versus physician-referred patients treated with radical prostatectomy: Early results

OBJECTIVE

Screening using a standardized protocol may improve outcomes of patients undergoing treatment for prostate cancer. We compared the 7- year progression-free survival rates after radical retropubic prostatectomy in patients whose prostate cancer was detected through a formal screening program with those of patients referred for treatment by other physicians who did not use a standardized screening/referral protocol.

METHODS

A single surgeon (W.J.C.) performed radical retropubic prostatectomy in 3,177 consecutive patients between 1989 and 2003. Of these patients, 464 had cancer detected in a screening study, and 2,713 were referred from outside institutions. We compared the screened and referred cohorts for age at surgery, clinical stage, pathologic stage, Gleason sum, preoperative prostate-specific antigen (PSA) levels, and adjuvant radiation therapy. Kaplan-Meier product limit estimates were used to calculate 7-year progression-free probabilities, and Cox proportional hazards models were used to determine the clinical and pathologic parameters associated with cancer progression in each group.

RESULTS

The overall 7-year progression-free survival rates were 83% for the screened patients compared with 77% for the referred patients (P = 0.002). Preoperative PSA, Gleason sum, clinical stage, pathologic stage, and adjuvant radiotherapy were all significantly associated with cancer progression. There was a significantly higher proportion of referred patients with a preoperative PSA > or =10, Gleason sum > or =7, and nonorgan-confined disease.

CONCLUSIONS

Patients with screened-detected prostate cancer have more favorable clinical and pathologic features, and 7-year progression-free survival rates than referred patients. On multivariate analysis, including other clinical variables, screening status was a significant independent predictor of biochemical outcome.

Die Skelettszintigraphie beim neu diagnostizierten Prostatakarzinom

BACKGROUND

The indication for a radionuclide bone scan in patients with newly diagnosed, untreated prostate cancer remains controversial.

PATIENTS AND METHODS

In this retrospective study we examined 406 patients who had received a staging bone scan irrespective of their PSA serum level and histology. We evaluated different guidelines and recommendations with respect to their usefulness. The costs were calculated according to EBM and GOA. We evaluated the classification systems of bone metastases according to Soloway, Crawford, and Rigaud.

RESULTS

The bone scan was positive in 41 (10%) of 406 patients. The EAU guidelines turned out to be useful with respect to both clinical value and cost efficiency. The Rigaud classification of bone metastases predicted outcome better than the Soloway or Crawford classification.

CONCLUSIONS

The EAU guidelines from 2005 are a useful tool to decide whether to perform a bone scan in patients with newly diagnosed, untreated prostate cancer. A bone scan should be performed if PSA levels exceed 20 ng/ml in patients with a G1/G2 histology, and in patients with G3 histology and locally advanced disease irrespective of PSA level. Bone scan metastases should be classified according to Rigaud.

Risk of cardiovascular mortality in prostate cancer patients in the Rotterdam randomized screening trial

PURPOSE

To estimate the risk of cardiovascular disease (CVD) mortality in prostate cancer patients in the Rotterdam section of European Randomized Study of Screening for Prostate Cancer, in both arms, and to compare this with the risk in the general population.

METHODS

Standardized mortality ratios (SMRs) of cardiovascular mortality for 2,211 prostate cancer patients were calculated including analyses for treatment subgroups (surgery, radiotherapy, watchful waiting, and hormone therapy). Cardiovascular mortality was defined as death as a result of all CVD and as a result of coronary heart disease, acute myocardial infarction, other diseases of the heart, and cerebrovascular accidents. The prevalence of self-reported comorbidities at entry of the trial was evaluated as well.

RESULTS

After a mean follow-up of 5.5 years, 258 prostate cancer patients (12%) had died. The SMR of all-cause mortality was 0.90 (95% CI, 0.79 to 1.01). The risk for cardiovascular mortality was low compared with that in the general population; the SMRs varied between 0.37 and 0.49. Low cardiovascular mortality risks were also seen within each treatment subgroup. CVD was the most frequently self-reported comorbidity at entry and prostate cancer patients undergoing radical prostatectomy reported the lowest rates (24%) compared with those receiving other therapies (40% to 42%).

CONCLUSION

Although some self-selection has occurred, prostate cancer treatment did not increase the risk of dying as a result of cardiovascular causes in our cohort. The risk was significantly lower for all primary treatment modalities, suggesting that less emphasis should be put on CVD as a contraindication for aggressive (surgical) treatment for prostate cancer patients.

Progress in chemoprevention drug development: the promise of molecular biomarkers for prevention of intraepithelial neoplasia and cancer--a plan to move forward

This article reviews progress in chemopreventive drug development, especially data and concepts that are new since the 2002 AACR report on treatment and prevention of intraepithelial neoplasia. Molecular biomarker expressions involved in mechanisms of carcinogenesis and genetic progression models of intraepithelial neoplasia are discussed and analyzed for how they can inform mechanism-based, molecularly targeted drug development as well as risk stratification, cohort selection, and end-point selection for clinical trials. We outline the concept of augmenting the risk, mechanistic, and disease data from histopathologic intraepithelial neoplasia assessments with molecular biomarker data. Updates of work in 10 clinical target organ sites include new data on molecular progression, significant completed trials, new agents of interest, and promising directions for future clinical studies. This overview concludes with strategies for accelerating chemopreventive drug development, such as integrating the best science into chemopreventive strategies and regulatory policy, providing incentives for industry to accelerate preventive drugs, fostering multisector cooperation in sharing clinical samples and data, and creating public-private partnerships to foster new regulatory policies and public education.

Clinical Approach to the Prostate: An Update

Prostatic disease continues to present clinicians with challenges. Although giant strides have been made in the medical and surgical management of benign prostatic hyperplasia, many fundamental questions about its pathogenesis, progression, and treatment efficacy remain unanswered. Prostate cancer also continues to be an area in which progress is needed despite major recent advancements. Numerous debates that include the value of prostate-specific antigen screening and appropriate roles for each of the numerous therapeutic modalities await resolution. For millions of patients who suffer from prostatitis, a major breakthrough is yet to come. Current treatment regimens for prostatitis remain ineffective at best. Contemporary approaches to the pathogenesis, diagnosis, and treatment of benign prostatic hyperplasia, prostate cancer, and prostatitis are discussed in this review.

Pathological outcomes and biochemical progression in men with T1c prostate cancer undergoing radical prostatectomy with prostate specific antigen 2.6 to 4.0 vs 4.1 to 6.0 ng/ml

PURPOSE

Recent studies have suggested that the cut point for recommending prostate biopsy among men with a normal digital rectal examination should be greater than 2.5 ng/ml as opposed to the more traditional greater than 4.0 ng/ml. We compared outcomes between men with clinical stage T1c disease undergoing radical prostatectomy who had a low vs slightly increased prostate specific antigen.

MATERIALS AND METHODS

The study population consisted of 2,896 men treated with radical prostatectomy between 1985 and 2004 at a tertiary care referral center with clinical stage T1c disease and a pre-biopsy prostate specific antigen between 2.6 and 6.0 ng/ml. Using multivariate analysis we evaluated the association between pre-biopsy prostate specific antigen 2.6 to 4.0 ng/ml (784) vs 4.1 to 6.0 ng/ml (2,112), and pathological outcomes and biochemical progression.

RESULTS

After adjusting for multiple clinical and pathological characteristics, lower preoperative serum prostate specific antigen values were associated with decreased odds of Gleason score 7 or greater in the surgical specimen (p = 0.004), positive surgical margins (p = 0.02) and extraprostatic extension (p = 0.001). There was no significant association between these preoperative prostate specific antigen groups and odds of seminal vesicle invasion (p = 0.47) or lymph node metastasis (p = 0.90). Among the 1,534 men with followup information available there was a trend for increased risk of biochemical progression associated with a higher preoperative prostate specific antigen, although this trend did not reach statistical significance (relative risk 1.48, 95% CI 0.69-3.19, p = 0.31).

CONCLUSIONS

In the current study of men with clinical stage T1c treated with radical prostatectomy a lower preoperative prostate specific antigen was associated with significantly more favorable pathological findings. Whether this degree of improved outcomes justifies the limitations associated with decreasing the prostate specific antigen cut point (eg increased biopsies performed and diagnosis of insignificant cancers) remains to be determined.

Reduction of prostate cancer mortality in Tyrol, Austria, after introduction of prostate-specific antigen testing

The objective of this study was to analyze in detail the time trend in prostate cancer mortality in the population of Tyrol, Austria. In Tyrol, prostate-specific antigen tests were introduced in 1988-1989 and, since 1993, have been offered to all men aged 45-74 years free of charge. More than three quarters of all men in this age group had at least one such test in the last decade. The authors applied the age-period-cohort model by Poisson regression to mortality data covering more than three decades, from 1970 to 2003. For Tyrol, the full model with age and period and cohort terms fit fairly well. Period terms showed a significant reduction in prostate cancer mortality in the last 5 years, with a risk ratio of 0.81 (95% confidence interval: 0.68, 0.98) for Tyrol; for Austria without Tyrol, no effect was seen, with a risk ratio of 1.00 (95% confidence interval: 0.95, 1.05). Each was compared with the mortality rate in the period 1989-1993. Although the results of randomized screening trials are not expected until 2008-2010, these findings support the evidence that prostate-specific antigen testing offered to a population free of charge can reduce prostate cancer mortality.

Trends in prostate cancer incidence, hospital utilization and surgical procedures, Canada, 1981-2000

BACKGROUND

Numbers of new prostate cancer cases in Canada continue to increase because of increasing prostate cancer incidence, population growth, aging of the population, and earlier detection methods such as PSA (prostate-specific antigen) testing. Concern has been expressed that PSA-related increases in incidence will make unaffordable demands on Canadian hospital resources. Our objective is to relate increases in prostate cancer incidence to trends in hospitalizations and in- patient treatment.

METHODS

Hospitalizations with prostate cancer as primary diagnosis were obtained from the Hospital Morbidity Database, estimates of prostate cancer day surgery from the Discharge Abstract Database, newly diagnosed cases from the Canadian Cancer Registry, and prostate cancer deaths from the Vital Statistics Mortality Databases--all for the years 1981-2000.

RESULTS

Between 1981-2000, the number of new cases rose from 7,000 to 18,500 with a transient peak, 1991-1994. Hospitalizations rose parallel to the incidence until 1991 but then fell sharply in spite of further increasing incidence. The use of radical prostatectomy (RP) increased steadily, but transurethral prostatectomy and bilateral orchiectomy decreased in the 1990s. Decreases in length of stay and in number of hospitalizations resulted in considerably decreased annual hospital days for all prostate cancer in-patient procedures except RP, which remained level since 1993.

CONCLUSIONS

A net decrease in number of in-patient days occurred, despite the increasing number of new prostate cancer cases and the increasing use of radical prostatectomy. We concluded that increases in hospital utilization due to early detection programs, such as PSA testing, are unlikely to overwhelm in-patient services of Canadian hospitals.

Genetic variation in the COX-2 gene and the association with prostate cancer risk

COX-2 is a key enzyme in the conversion of arachidonic acid to prostaglandins. The prostaglandins produced by COX-2 are involved in inflammation and pain response in different tissues in the body. Accumulating evidence from epidemiologic studies, chemical carcinogen-induced rodent models and clinical trials indicate that COX-2 plays a role in human carcinogenesis and is overexpressed in prostate cancer tissue. We examined whether sequence variants in the COX-2 gene are associated with prostate cancer risk. We analyzed a large population-based case-control study, cancer prostate in Sweden (CAPS) consisting of 1,378 cases and 782 controls. We evaluated 16 single nucleotide polymorphisms (SNPs) spanning the entire COX-2 gene in 94 subjects of the control group. Five SNPs had a minor allele frequency of more than 5% in our study population and these were genotyped in all case patients and control subjects and gene-specific haplotypes were constructed. A statistically significant difference in allele frequency between cases and controls was observed for 2 of the SNPs (+3100 T/G and +8365 C/T), with an odds ratio of 0.78 (95% CI=0.64-0.96) and 0.65 (95% CI=0.45-0.94) respectively. In the haplotype analysis, 1 haplotype carrying the variant allele from both +3100 T/G and +8365 C/T, with a population frequency of 3%, was also significantly associated with decreased risk of prostate cancer (p=0.036, global simulated p-value=0.046). This study supports the hypothesis that inflammation is involved in prostate carcinogenesis and that sequence variation within the COX-2 gene influence the risk of prostate cancer.

The North Carolina-Louisiana Prostate Cancer Project (PCaP): methods and design of a multidisciplinary population-based cohort study of racial differences in prostate cancer outcomes

BACKGROUND

The North Carolina-Louisiana Prostate Cancer Project (PCaP) is a multidisciplinary study of social, individual, and tumor-level causes of racial differences in prostate cancer aggressiveness.

METHODS

A population-based sample of incident prostate cancer cases from North Carolina and Louisiana will include 1,000 African Americans and 1,000 Caucasian Americans. Study nurses administer structured questionnaires and collect blood, adipose tissue, urine, and toenail samples during an in-home visit. Clinical data are abstracted from medical records, diagnostic biopsies are reviewed and assayed, and tissue microarrays are constructed from prostatectomy samples. Prostate cancer aggressiveness is classified based on PSA, clinical stage, and Gleason grade.

RESULTS

Preliminary data demonstrate between- and within-group differences in patient characteristics, screening, and treatment by race and state. Participation exceeds 70% in all groups.

CONCLUSIONS

Preliminary data support the feasibility of this comprehensive study to help determine the focus of public health efforts to reduce racial disparities in prostate cancer mortality.

Bladder calculi: did the clinical picture change?

OBJECTIVES

Recent improvements in socioeconomic conditions have changed the clinical picture of urinary stones, including bladder calculi. With the ongoing changes in these predisposing factors, it is possible that the clinical picture of bladder calculi will show additional changes. Nevertheless, few contemporary series of bladder calculi in published English reports have addressed these issues.

METHODS

We retrospectively reviewed the records of 328 patients who underwent surgical therapy for bladder calculi at our institution from January 1995 to June 2005.

RESULTS

Acute urinary retention was the most common presenting symptom (n = 221, 67%). Patients who presented with urinary retention were younger (37 versus 48 years, P <0.001), had a greater incidence of recent renal colic (40% versus 19%, P <0.01), and had a lower incidence of bladder outlet obstruction (14% versus 37%, P <0.001) compared with the nonretention group. However, previous stone passage did not influence the probability of presenting with urinary retention. Small bladder stones were associated with a greater likelihood of presenting with urinary retention. The retention group had greater incidence of stones less than 1 cm in diameter compared with the nonretention group (72% versus 39%, P <0.001). Finally, calcium oxalate was found in 78% of patients with bladder calculi.

CONCLUSIONS

Acute urinary retention was the main mode of presentation in patients with bladder calculi. Younger age, a history of recent renal colic, and smaller stones appeared to increase the likelihood for patients to present with urinary retention.

A multilevel analysis of socioeconomic status and prostate cancer risk

PURPOSE

We investigated whether prostate cancer was associated with socioeconomic status (SES) at the individual level, area level, or a combination of both levels.

METHODS

This population-based case-control study of prostate cancer in men aged 65 to 79 years was conducted between 2000 and 2002 in South Carolina. Complete interviews were available for 407 incident prostate cancer cases and 393 controls (with respective response rates of 61% and 64%). We used educational level to measure individual-level SES and a composite variable capturing income and education from 2000 Census data to measure area-level SES.

RESULTS

After adjustment for race, age, geographic region, and prostate-specific antigen testing, men with some college were at reduced risk for prostate cancer (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.27-0.72), as were men in the highest quartile of area-level SES (OR, 0.52; 95% CI, 0.34-0.80). When assessing individual-level and area-level SES simultaneously and accounting for their nonindependence, the independent negative associations persisted and appeared to be more striking for men with a diagnosis of localized disease, rather than advanced disease.

CONCLUSION

The independent effects of area-level and individual-level SES on prostate cancer risk seen in our study may help explain the conflicting results of previous studies conducted at both levels.

Prostate cancer in Alaska Native men, 1969-2003

OBJECTIVES

The incidence of prostate cancer differs significantly between US race groups. In prior reviews of cancer in Alaska Natives, the incidence of prostate cancer has been observed to occur at a low rate compared to US Whites and Blacks. However, a detailed report of prostate cancer in this population has not been previously published.

STUDY DESIGN

Incidence of prostate cancer in Alaska Native men was determined for the time period 1969-2003 using data from the Alaska Native Tumor Registry. The registry is a population-based registry which participates in the National Cancer Institute Surveillance, Epidemiology and End Results Program, and has collected cancer information on Alaska Natives since 1969.

METHODS

Incidence rates were calculated for all Alaska Natives and for each of the three major ethnic groups (Aleut, Eskimo, Indian). Comparisons of incidence rates between Alaska Natives and US Whites were performed using odds ratios. Temporal changes were identified by a Chi square analysis for trend.

RESULTS

During the 35-year period of review, 332 Alaska Native men were diagnosed with prostate cancer. The age-adjusted incidence rate of 69.5 per 100 000 in Alaska Native men during 1994-2003 was significantly higher than the rate of 45.5 per 100 000 for the earlier period 1969-1983. The US White rate for 1994-2002 of 169.5 per 100 000 was significantly higher than the rate for Alaska Native men for 1994-2003. Results of comparisons between Alaska Native ethnic groups for 1969-2003 showed that prostate cancer was highest in Indians and Aleuts and lowest among Eskimos.

CONCLUSIONS

Compared to the US White population, the incidence of prostate cancer in Alaska Native men is significantly lower. Prostate cancer rates among Alaska Native ethnic groups differ. The reason for these differences remains undetermined.

Inadequacies of the current American Joint Committee on cancer staging system for prostate cancer

BACKGROUND

Two major objectives of the American Joint Committee on Cancer (AJCC) staging system are to ensure appropriate treatments for patients and to determine prognosis. AJCC stage for distant prostate cancer includes patients with regional lymph node involvement. In the current study, the authors assessed whether patients with lymph node involvement and patients with distant metastasis, as determined using the Surveillance, Epidemiology, and End Results (SEER) staging system, had similar treatment and survival duration and, thus, were grouped together appropriately in the AJCC system.

METHODS

In total, 4141 patients were selected from The University of Texas M. D. Anderson Cancer Center's Tumor Registry who initially had registered at the center between January 1, 1982, and December 31, 2001, with a diagnosis of prostate cancer; had received no treatment before presentation; and had received treatment at the center. Patients with unknown stage and patients with any other primary malignancies were excluded. Descriptive analyses of demographic and disease variables were performed. Using SEER stage groups, survival analyses and Cox proportional hazards regression analyses were performed.

RESULTS

Treatments differed between patients with lymph node involvement and patients with distant metastasis. The median survival was 134 months for patients with lymph node involvement and 42 months for patients with distant metastasis. When these 2 groups were combined, as in the AJCC scheme, the median survival was 86 months.

CONCLUSIONS

The treatment and median survival of patients with lymph node involvement differed substantially from those of patients with distant metastasis. The current AJCC scheme for prostate cancer appeared to be inappropriate when considering its purpose, and the authors concluded that it should be revised.

Versorgung der erektilen Dysfunktion nach radikaler Prostatektomie in Deutschland

INTRODUCTION

The aim of this national study was to evaluate ED management after RPX (without any postoperative adjuvant therapy or tumor relapse) from the patient's view compared to the urologist's view.

MATERIAL AND METHODS

In May 2003 we queried 1063 urologists and 801 patients following radical prostatectomy without adjuvant therapy. They were asked about preserved potency without erectile aid, existing wish for ED therapy, recommended or tested erectile aid (oral, transurethral, intracorporal, vacuum constriction device[VCD], penile implant) as well as the long-term use. Return rate: patients 80.1%, urologists 26.7%.

RESULTS

According to the urologists' view 9.1% of their affected patients were potent postoperatively without a device, but according to the polled patients only 4.7%. The wish to be treated for erectile dysfunction existed in the urologists' opinion in 46.1% of their patients, while they considered that 44.8% had no wish for treatment. On the other hand, 59.3% of the patients would like to be treated and only 28.5% did not want any kind of treatment. Regarding the long-term use of therapy for ED, the urologists thought that 26.1% of their patients did not receive therapy for the problem, and 69.7% of the patients stated they received no long-term therapy. Only 30.3% of the patients confirmed long-term therapy, while the urologists thought that 73.9% of the patients used an erectile aid. Definite therapy in the urologists' opinion involved: oral medication in 38.4%, MUSE in 3.6%, (SKAT) in 37.3%, VCD in 20.4%, and a prosthesis in 0.3%. Indeed 19.8% of the patients used oral medication, 1.7% MUSE, 26.7% SKAT, 50.9% VCD, and 0.9% penile implant. Considering the satisfaction of patients, urologists thought that 46.2% of the patients were satisfied with their treatment of ED, but only 28.9% of the patients were actually satisfied themselves.

CONCLUSIONS

The comparison of patients' and urologists' views shows a clearly different description of the ED situation after RPX. The proportion of patients with a wish for treatment and the proportion of dissatisfied patients are much higher from the patients' view. This demonstrates an undertreatment of ED patients after RPX, which should also be taken into account under the current changes in the German health care system.

The increased rate of prostate specific antigen testing has not affected prostate cancer presentation in an inner city population in the UK

OBJECTIVE

To assess whether the increased use of prostate-specific antigen (PSA) testing over the last 15 years has changed the way prostate cancer presents in an inner city UK population, where PSA screening rates might be expected to be lower than in epidemiological studies based in North America, where there is a significant tendency to a localized stage and earlier age at diagnosis.

PATIENTS AND METHODS

The study comprised a 5-year retrospective and 5-year prospective analysis of data on 704 men diagnosed with prostate cancer over the 10-year period since the introduction of PSA testing (1994-2003).

RESULTS

The median (range) age at presentation remained unchanged, at 72 (45-94) years; the PSA level at diagnosis was 20-46 microg/L, with a steady decline after 1997. There was no significant change in stage at diagnosis; overall, 38 (20-44)% presented with clinically localized disease, 37 (31-48)% with locally advanced and 25 (18-29)% with metastatic disease. The Gleason grade changed significantly, with more moderately differentiated tumours and a decline in well-differentiated cancers. Closer examination showed this to have been due to a change in diagnostic practice rather than a true population trend. PSA testing increased over the 10 years of the study (2.35 times), with requests from general practitioners rising seven times, compared with urologists or other hospital doctors (1.25 and 2.3 times, respectively). Community PSA testing remained lower than in other reported UK series, which may be explained in part by the lower socio-economic status of the population assessed.

CONCLUSION

There was no apparent change in patient age or tumour stage in men presenting with prostate cancer over a 10-year period after the introduction of PSA testing. While there was an increase in PSA testing during the study period, the testing rate remains much lower than in other reported series from the UK.

Cancer survivorship: a new challenge in comprehensive cancer control

Cancer survivors are a growing population in the United States because of earlier cancer diagnosis, the aging of society, and more effective risk reduction and treatment. Concerns about the long-term physical, psychosocial, and economic effects of cancer treatment on cancer survivors and their families are increasingly being recognized and addressed by public, private, and non-profit organizations. The purpose of this paper is to discuss how survivorship fits within the framework of comprehensive cancer control. We summarize three national reports on cancer survivorship and highlight how various organizations and programs are striving to address the needs of cancer survivors through public health planning, including the challenges these groups face and the gaps in knowledge and available services. As cancer survivorship issues are being recognized, many organizations have objectives and programs to address concerns of those diagnosed with cancer. However, better coordination and dissemination may decrease overlap and increase the reach of efforts and there is limited evidence for the effectiveness and impact of these efforts.

Glutathione S-transferase M1, T1, and P1 polymorphisms and prostate cancer risk in middle-aged men

BACKGROUND

The glutathione S-transferase (GST) enzymes detoxify several carcinogens. Genetic polymorphisms in GSTM1, T1, and P1 (Ile105Val) have been associated with prostate cancer, however, results have been inconsistent across studies.

METHODS

Data from a population-based case-control study in King County, Washington, were used to further evaluate the relationships between these GST polymorphisms and prostate cancer. Incident cases (n = 590) were 40-64 years old, diagnosed from 1993 through 1996, and identified via the SEER cancer registry. Controls (n = 538) were identified via random digit dialing, and frequency age-matched to cases. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Risk of prostate cancer was moderately increased among Caucasians with the GSTM1-null genotype (OR = 1.54; 95% CI 1.19-2.01). There were no associations for either GSTT1 or P1(Ile105Val). The association between the GSTM1-null genotype and prostate cancer was not different according to cancer aggressiveness defined by stage at diagnosis and Gleason score. Among GSTM1-null Caucasians, the relative risk of prostate cancer increased linearly with increasing pack-years of smoking (P-value for trend = 0.007), with the highest ORs observed for smokers of >30 pack-years.

CONCLUSIONS

Findings suggest that the GSTM1-null genotype defines a subgroup of men at higher risk of prostate cancer, particularly if they are heavy smokers.

Recent changes in the spatial pattern of prostate cancer in the U.S

INTRODUCTION

Spatial-temporal trends in prostate cancer mortality are of interest because of the introduction and increasing use of the prostate-specific antigen (PSA) screening test after 1986. This article describes spatial-temporal changes in U.S. prostate cancer mortality from 1968 to 1998.

METHODS

Prostate cancer mortality data were obtained from Compressed Mortality Files available from the National Center for Health Statistics. To minimize potential problems such as small numbers or missing data, the analysis was limited to white males aged 25 and over, and located in 2970 counties with complete data. Statistical analyses included the global distance between observed and expected multinomial probabilities, Hoover's Index of Concentration, and a retrospective test for change in spatial patterns.

RESULTS

Fairly steady declines were observed in prostate cancer mortality from 1968 until 1993, with an increasing tendency toward spatial uniformity. Spatial concentration increased from 1994 to 1998, and by 1998 the level of spatial concentration had returned to levels that prevailed during the early to mid-1980s. Comparing 1991-1998 to 1968-1990, the observed number of prostate deaths increased the most rapidly with respect to the expected number in western Appalachia and the south central U.S. Recent relative declines in mortality were observed in southern California and parts of Florida.

CONCLUSIONS

The observed results are generally consistent with prior evaluations of prostate cancer spatial-temporal patterns. However, the current study identified a heretofore unnoticed recent pattern of change in western Appalachia and the south central U.S. Recent declines in Florida and southern California may have contributed to recent increases in spatial concentration of prostate cancer mortality, and may possibly be associated with realized benefits from screening programs.

Racial/ethnic patterns in lifetime and age-conditional risk estimates for selected cancers

BACKGROUND

Estimates of the probability of developing or dying from cancer, either over a lifetime or over a specified number of years, are useful summary measures of the burden of cancer in a population.

METHODS

The authors used publicly available DevCan software and new, detailed, racial/ethnic data bases that were developed in the Surveillance Research Program of the National Cancer Institute to produce risk estimates for selected major cancers among American Indian/Aleut/Eskimo, black, Chinese, Filipino, native Hawaiian, Japanese, white (total, non-Hispanic), and Hispanic populations.

RESULTS

Japanese and non-Hispanic white men had the highest lifetime risk for developing cancer (47.94% and 47.41%, respectively), and the American Indian/Eskimo/Aleut population (excluding Alaska) had the lowest lifetime risk among men (24.30%). Among women, white and American Indian/Eskimo/Aleut (in Alaska) populations had higher lifetime risks than Japanese women, whereas American Indian/Eskimo/Aleut (excluding Alaska) women had the lowest risk. The age-conditional probabilities of developing cancer within the next 10 years among men and women age 60 years and the lifetime probabilities of dying from cancer also were reported by racial/ethnic group.

CONCLUSIONS

Racial/ethnic disparities in the lifetime risk of cancer may be because of differences in cancer incidence rates, but they also may reflect differential mortality rates from causes other than the cancer of interest. Furthermore, because cross-sectional incidence and mortality rates are used in calculating the DevCan lifetime risk estimates, results must be interpreted with caution when events, such as the widespread and rapid implementation of a new screening test, are known to have influenced disease rates.

More favorable tumor features and progression-free survival rates in a longitudinal prostate cancer screening study: PSA era and threshold-specific effects

OBJECTIVES

To describe the changes in pathologic outcomes and progression-free survival (PFS) rates after radical retropubic prostatectomy for clinically localized prostate cancer in men whose cancers were detected in a 12-year longitudinal prostate cancer screening study.

METHODS

Between 1989 and 2001, more than 36,000 men participated in a digital rectal examination-based and prostate-specific antigen (PSA)-based screening program. In 1995, the PSA cutoff for biopsy recommendation was lowered from 4.0 ng/mL to 2.6 ng/mL, and the biopsy protocol was changed from four to at least six-sector biopsies. From the screening study, 2952 men were diagnosed with cancer and 2241 of these men underwent radical retropubic prostatectomy. We analyzed the differences in clinical and pathologic stage and PFS after surgery, according to the greater PSA cutoff era (1989 to 1995) and lower PSA cutoff era (1996 to 2001).

RESULTS

A significant downward clinical and pathological stage migration was found toward T1c and organ-confined disease, respectively, in men whose cancer was detected in the lower PSA cutoff era. Furthermore, men with cancer diagnosed in the lower PSA cutoff era had improved PFS rates 5 and 8 years after radical retropubic prostatectomy (P = 0.007). These changes occurred without a significant increase in the proportion of unimportant tumors (organ confined, smaller than 0.5 cm3 without a Gleason pattern of 4 or 5).

CONCLUSIONS

These findings support the enhanced detection of favorable cancer and improved PFS rates with lower PSA cutoffs and more intensive biopsy regimens, although the follow-up and lead-time and length-time biases, as well as improvements in surgical technique, might also have affected these results.

A population-based survey of prostate-specific antigen testing among California men at higher risk for prostate carcinoma

BACKGROUND

Despite the lack of evidence demonstrating a survival benefit from prostate-specific antigen (PSA) screening, its use has become widespread, organizations have encouraged physicians to discuss early detection of prostate carcinoma, and two higher risk groups have been recognized. In the current study, the authors examined whether African-American men and men who had a family history of prostate carcinoma underwent PSA testing preferentially, and patterns of test use were examined according to age, race, and other factors.

METHODS

Data regarding self-reported PSA test use in the past year among men age 50 years and older without a history of prostate carcinoma (n = 8713 men) were analyzed from the 2001 California Health Interview Survey.

RESULTS

The overall rate of PSA use was 43.0%. Older age, higher socioeconomic status, having a usual source of healthcare, and a family history of prostate carcinoma were the strongest predictors of testing. Higher risk African-American men age 50 years and older were no more likely to be tested than white men. Men at higher risk who had a family history of prostate carcinoma were more likely to have been tested than men who had no such family history.

CONCLUSIONS

Rates of PSA use among higher risk men who had a family history of prostate carcinoma were higher compared with the rates among men without such a family history. However, PSA testing rates among higher risk African-American men were no different than the rates among lower risk white men, suggesting that some risk factors for prostate carcinoma (but not others) are associated with preferential testing. Testing in all groups was associated with access to care variables, highlighting the importance of removing barriers to preventive healthcare services.

Sex steroid hormones and the androgen receptor gene CAG repeat and subsequent risk of prostate cancer in the prostate-specific antigen era

OBJECTIVE

Sex steroid hormones are thought to contribute to the growth, differentiation, and progression of prostate cancer. We investigated plasma levels of sex steroid hormones and length of the androgen receptor gene CAG repeat in relation to incident prostate cancer diagnosed in the prostate-specific antigen (PSA) era.

METHODS

Using a nested case-control design, we included 460 prostate cancer cases diagnosed after providing a blood specimen in 1993 but before February 1998 among men in the Health Professionals Follow-up Study. Controls were 460 age-matched men without prostate cancer who had a screening PSA test after the date of providing a blood specimen. We measured plasma concentrations of total testosterone, free testosterone, dihydrotestosterone, androstanediol glucuronide, estradiol, and sex hormone binding globulin (SHBG) and determined the length of the androgen receptor gene CAG repeat. Conditional logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI) of prostate cancer.

RESULTS

Mean concentrations of the sex steroids adjusted for SHBG, and mean CAG repeat length did not differ significantly between the prostate cancer cases and controls. No significant associations with total prostate cancer were detected for plasma total testosterone concentration (comparing highest versus lowest quartiles: OR, 0.78; 95% CI, 0.48-1.28; P(trend) = 0.73) or the other sex hormones after adjusting for SHBG. However, plasma total testosterone concentration was positively associated with low-grade disease (Gleason sum < 7: OR, 1.91; 95% CI, 0.89-4.07; P(trend) = 0.02) and inversely associated with high-grade disease (Gleason sum > or = 7: OR, 0.26; 95% CI, 0.10-0.66; P(trend) = 0.01). Similar patterns for grade were observed for free testosterone. Short CAG repeat length was not associated with total prostate cancer (< or = 19 versus > or = 24: OR, 0.84; 95% CI, 0.57-1.23; P(trend) = 0.22) or grade of disease. No clear associations with regionally invasive or metastatic (> or = T3b, N1, or M1) were found for any of the hormones or the CAG repeat, although the number of these cases was small.

CONCLUSIONS

The overall lack of association of prostate cancer diagnosed in the PSA era with sex steroid hormones and the androgen receptor gene CAG repeat length is consistent with the hypothesis that these factors do not substantially contribute to the development of early prostate cancer in the PSA era. The influence of plasma total and free testosterone concentrations on prostate cancer grade merits further evaluation.

Cancer Surveillance Research: a Vital Subdiscipline of Cancer Epidemiology

Public health surveillance systems relevant to cancer, centered around population-based cancer registration, have produced extensive, high-quality data for evaluating the cancer burden. However, these resources are underutilized by the epidemiology community due, we postulate, to under-appreciation of their scope and of the methods and software for using them. To remedy these misperceptions, this paper defines cancer surveillance research, reviews selected prior contributions, describes current resources, and presents challenges to and recommendations for advancing the field. Cancer surveillance research, in which systematically collected patient and population data are analyzed to examine and test hypotheses about cancer predictors, incidence, and outcomes in geographically defined populations over time, has produced not only cancer statistics and etiologic hypotheses but also information for public health education and for cancer prevention and control. Data on cancer patients are now available for all US states and, within SEER, since 1973, and have been enhanced by linkage to other population-based resources. Appropriate statistical methods and sophisticated interactive analytic software are readily available. Yet, publication of papers, funding opportunities, and professional training for cancer surveillance research remain inadequate. Improvement is necessary in these realms to permit cancer surveillance research to realize its potential in resolving the growing cancer burden.

COMPARISON OF THE INCIDENCE OF LATENT PROSTATE CANCER DETECTED AT AUTOPSY BEFORE AND AFTER THE PROSTATE SPECIFIC ANTIGEN ERA

PURPOSE

Most data regarding the prevalence of latent prostate cancer found only at autopsy are from old reports. To determine if significant differences exist in the prevalence of latent prostate cancer between periods before and after the advent of screening for prostate cancer, we compared 2 groups of men undergoing autopsy during the 2 periods.

MATERIALS AND METHODS

Our institutional autopsy record database was searched to identify all men found to have prostate cancer before or after death between 1955 and 1960 (total 3,307 men and 1,578 men older than 40 years), and between 1991 and 2001 (total 2,938 men, 1,380 men older than 40 years). We calculated the age based incidence of latent prostate cancer detected only at autopsy in an at risk population of men (older than 40 years). We also compared Gleason grade distribution and proportion of stage cT3 or greater cancers between the 2 periods.

RESULTS

Between 1955 and 1960 the prevalence of latent prostate cancer detected only at autopsy in men older than 40 years was 4.8% compared to 1.2% (p < 0.0001) between 1991 and 2001. A significant decrease in the prevalence of latent, autopsy detected cancers was observed in men 70 to 89 years old at death. Autopsy detected cancers were found to be grossly invading adjacent structures (stage cT3 or greater) in 17 of 76 (22%) cancers discovered between 1955 and 1960, while none of the latent prostate cancers found in the 1991 to 2001 period were found to extend grossly beyond the prostate.

CONCLUSIONS

Autopsy rates are decreasing at our institution. With the more widespread use of screening, the prevalence of latent prostate cancer has decreased 3-fold. The decrease in the prevalence of latent prostate cancer is especially dramatic in men older than 70 years. Further study will determine the significance of many of the tumors currently detected clinically, which may have been latent and found at autopsy if not for screening.

Advancing cancer biotherapy with proteomics

Proteomics is becoming increasingly important for cancer biotherapy. The development of high-throughput platforms now allows the analysis of multiple proteins from small quantities of material. While these techniques are being used to discover new biomarkers, they are particularly important for assessing complex biologic processes such as immunotherapy for cancer. Recent advances in this field are reviewed, as well as the use of proteomics to assess the effectiveness and toxicities of high-dose IL-2 cancer therapy. Proteomics is becoming useful in assessing cancer biotherapies and in unraveling their mechanisms of action. High-throughput proteomic technologies have now advanced to a stage where they have the potential to become effective discovery tools for biomarkers/predictors of disease, disease recurrence, and response to therapy.

THE PROSTATIC SPECIFIC ANTIGEN ERA IS ALIVE AND WELL: PROSTATIC SPECIFIC ANTIGEN AND BIOCHEMICAL PROGRESSION FOLLOWING RADICAL PROSTATECTOMY

PURPOSE

Prostate specific antigen (PSA) has been shown to predict the presence of prostate cancer on biopsy, pathological stage, and biochemical progression following primary therapy. A recent study found only a weak association between PSA and tumor volume in the radical prostatectomy (RP) specimen and concluded that the PSA era is over. We examined the association between PSA and clinical progression in men undergoing RP.

MATERIALS AND METHODS

The study population consisted of 2,312 men treated with RP between 1992 and 2004 by a single surgeon. We evaluated the association between preoperative PSA and biochemical progression on multivariate analysis.

RESULTS

Men with higher preoperative PSA concentrations had higher grade cancers in the biopsy and RP specimen, and more adverse pathological features. After adjusting for the clinical covariates of age, race, grade, stage, and year of surgery, preoperative PSA was significantly associated with the risk of biochemical progression. When only men with PSA less than 10 ng/ml were examined, PSA remained a significant predictor of biochemical progression on multivariate analysis (RR 1.30, 95% CI 1.18 to 1.44, p <0.001). For each 2-point increase in PSA, the risk of biochemical progression increased approximately 2-fold.

CONCLUSIONS

Preoperative PSA was significantly associated with high grade disease and adverse pathological findings. After adjusting for clinical covariates, PSA was significantly associated with the risk of biochemical progression, even in men with PSA less than 10 ng/ml. Despite multiple limitations, PSA remains the best prostate cancer tumor marker available.

Prostate cancer in patients with an abnormal digital rectal examination and serum prostate-specific antigen less than 4.0 ng/mL

OBJECTIVES

To evaluate men with abnormal digital rectal examination (DRE) findings and a serum prostate-specific antigen (PSA) level less than 4.0 ng/mL who underwent prostate biopsy.

METHODS

A total of 986 patients undergoing prostate biopsy were documented to have DRE findings suspicious for prostate cancer and a serum PSA level of less than 4.0 ng/mL. We examined the serum PSA level, age, and race to see which patient characteristics were statistically significant predictors of prostate cancer on biopsy. The pathologic findings of the biopsy and prostatectomy specimens were examined to determine which patients had serendipitously diagnosed prostate cancer.

RESULTS

The positive predictive value of an abnormal DRE was 8.8%. The PSA level and increasing age were statistically significant predictors of a positive biopsy, but race was not. Well-differentiated cancer (Gleason score 6 or less) was diagnosed in 72.8% of the biopsies. Also, 87.5% of the patients undergoing radical prostatectomy had pathologic Stage T2 disease. Using specific pathologic criteria, prostate cancer was diagnosed serendipitously in 19% of the biopsies and in 43% of the radical prostatectomy specimens.

CONCLUSIONS

Higher serum PSA levels even if less than 4.0 ng/mL were associated with dramatic increases in prostate cancer detection. Age was also a statistically significant predictor of cancer. Although the overall positive predictive value of the DRE was poor, most patients diagnosed with prostate cancer had an abnormality on the DRE that corresponded either to the location of cancer detected on biopsy or had cancer volumes on prostatectomy specimens large enough to be palpable.

Screening for Prostate Cancer: Opportunities and Challenges

Prostate cancer screening with PSA and with digital rectal examination isa reality in the United States. Regardless of recent observations regarding the complexities of PSA interpretation, millions of U.S. men expect an annual PSA test and physicians have come to rely on the test, in combination with digital rectal examination, to assess for prostate cancer risk. What has become evident is that PSA can no longer be interpreted dichotomously as a simple yes or no. The test reflects a range of risk and PSA value must be merged with other risk factors of an individual man including ethnicity, family history, as well as the individual's risk aversion to complications from prostate cancer. The future of prostate cancer screening will be built upon incorporation of new biomarkers to the prediction of risk of disease. As these markers move forward in testing, it will no longer be acceptable to move these into clinical usage without formal validation studies and, because of the high frequency of prostate cancer in the general male population, these validation studies will almost certainly have to include measures of prognosis. It is the holy grail of cancer biomarker development to acquire a test that is positive in the man with clinically-aggressive prostate cancer but is negative in both the patient without disease and in the man with disease that will be of no clinical consequence over his lifetime.

The role of anxiety in prostate carcinoma: a structured review of the literature

Although the impact of anxiety on patients with some types of cancer is well recognized, to the authors knowledge its impact on patients with prostate carcinoma has not been studied as thoroughly. The authors conducted a systematic review of the medical literature for high-quality articles that quantified anxiety levels in men with prostate carcinoma and identified 29 articles. Using the clinical timeline of prostate carcinoma to organize the articles, cross-sectional studies that reflected anxiety prevalence in populations and longitudinal studies that reflected changes in anxiety over time were identified. Anxiety appeared to fluctuate over the clinical timeline in response to stressors and uncertainty (such as at the time of screening and/or biopsy), rising before these times and falling afterward. Although anxiety levels in men age > 55 years who were at risk for prostate carcinoma were modest (10-15%), multiple studies found that these levels were substantially higher in men who presented for screening (> 50%), and "seeking peace of mind" was the motivation cited most frequently for pursuing screening. Most studies demonstrated a significant decrease in anxiety levels after a normal screening or biopsy result, although the proportion of men who remained anxious afterward did not fall to baseline levels (20-36%). Men who presented for prostate-specific antigen monitoring after treatment had elevated anxiety levels at the time of testing (23-33%). Many years after therapy for localized disease, anxiety levels were lower after prostatectomy (23%) compared with the levels after watchful waiting (31%).

Prostate cancer and the Will Rogers phenomenon

BACKGROUND

Information on tumor stage and grade are used to assess cancer prognosis and to produce standardized comparisons of end results over time. Changes in the interpretation of classification schemes can alter the apparent distribution of cancer stage or grade in the absence of a true biologic change. Since the introduction of prostate-specific antigen testing, the reported incidence of low-grade prostate cancer has declined. To determine whether this decline is in part a result of Gleason score reclassification during the same time period, we documented the potential impact of reclassification between 1992 and 2002 on clinical outcomes.

METHODS

A population-based cohort of 1858 men who were < or = 75 years of age at diagnosis of prostate cancer in 1990-1992 was assembled retrospectively from the Connecticut Tumor Registry. Histology slides of the diagnostic prostate tissue were retrieved and reread in 2002-2004 by an experienced pathologist blinded to the original Gleason score readings. Prostate cancer mortality rates for the cohort calculated using the original Gleason score readings were compared with those calculated using the contemporary Gleason score readings. Statistical tests were two sided.

RESULTS

The contemporary Gleason score readings were statistically significantly higher than the original readings (mean score increased from 5.95 to 6.8; difference = 0.85, 95% confidence interval = 0.79 to 0.91; P < .001). Consequently, the Gleason score-standardized contemporary prostate cancer mortality rate (1.50 deaths per 100 person-years) appeared to be 28% lower than standardized historical rates (2.08 deaths per 100 person-years), even though the overall outcome was unchanged. This apparent improvement in mortality held for all Gleason score categories.

CONCLUSIONS

In this population, a decline in the reported incidence of low-grade prostate cancers appears to be the result of Gleason score reclassification over the past decade. This reclassification resulted in apparent improvement in clinical outcomes. This finding reflects a statistical artifact known as the Will Rogers phenomenon.

A case study of radiotherapy planning for a bilateral metal hip prosthesis prostate cancer patient

The purpose of this report is to communicate the observed advantage of intensity-modulated radiotherapy (IMRT) in a patient with bilateral metallic hip prostheses. In this patient with early-stage low-risk disease, a dose of 74 Gy was planned in two phases--an initial 50 Gy to the prostate and seminal vesicles and an additional 24 Gy to the prostate alone. Each coplanar beam avoided the prosthesis in the beam's eye view. Using the same target expansions for each phase, IMRT and 3D-conformal radiotherapy (CRT) plans were compared for target coverage and inhomogeneity as well as dose to the bladder and rectum. The results of the analysis demonstrated that IMRT provided superior target coverage with reduced dose to normal tissues for both individual phases of the treatment plan as well as for the composite treatment plan. The dose to the rectum was significantly reduced with the IMRT technique, with a composite V 80 of 35% for the IMRT plan versus 70% for 3D-CRT plan. Similarly, the dose to the bladder was significantly reduced with a V 80 of 9% versus 20%. Overall, various dosimetric parameters revealed the corresponding 3D-CRT plan would not have been acceptable. The results indicate significant success with IMRT in a clinical scenario where there were no curative alternatives for local treatment other than external beam radiotherapy. Therefore, definitive external beam radiation of prostate cancer patients with bilateral prosthesis is made feasible with IMRT. The work described herein may also have applicability to other groups of patients, such as those with gynecological or other pelvic malignancies.

SCREENING WITH PROSTATE SPECIFIC ANTIGEN AND METASTATIC PROSTATE CANCER RISK: A POPULATION BASED CASE-CONTROL STUDY

PURPOSE

Screening of asymptomatic men with prostate specific antigen (PSA) remains a controversial issue. There is limited evidence that screening is effective in reducing mortality from prostate cancer. In the current study we determined if screening with PSA reduces the risk of metastatic prostate cancer.

MATERIALS AND METHODS

We conducted a population based case-control study among the residents of Metropolitan Toronto and 5 surrounding counties in Ontario, Canada. Data were obtained from 236 cases of metastatic prostate cancer and 462 controls randomly sampled from the source population and frequency matched to cases for age and area of residence. History of PSA testing, digital rectal examination, symptoms and other data were obtained from medical records and a self-administered questionnaire. The association between PSA screening and metastatic prostate cancer was measured by the Mantel-Haenszel odds ratio stratified by exposure observation time and other potential confounding factors.

RESULTS

In asymptomatic men, the frequency of PSA screening as determined from medical records was significantly lower among the cases compared with the controls (odds ratio 0.65, 95% confidence interval 0.45 to 0.93). The odds ratio was 0.52 (0.28 to 0.98) in men 45 to 59 years old and 0.67 (0.41 to 1.09) in those 60 to 84 years old.

CONCLUSIONS

In this case-control study screening of asymptomatic men with PSA was associated with a significantly reduced risk of metastatic prostate cancer. The results need to be confirmed in randomized controlled trials.

THIS ARTICLE HAS BEEN RETRACTED Trends in prostate cancer incidence and survival in various socioeconomic classes: A population-based study

OBJECTIVES

Prostate cancer is currently the commonest cancer in men of all ages in UK, but robust demographic data of its distribution in various socioeconomic classes is lacking. We aimed to analyze its incidence, mortality and survival trends in West Midlands, England, from 1986 to 2000 in terms of socioeconomic deprivation.

METHODS

Data were collated from the regional cancer registry database and a well-validated demographic score, the Townsend band, was employed as an indicator of social deprivation, including four variables as proxy indicators of socioeconomic status. Individual cases were allocated to one of five deprivation categories using postcode at diagnosis. Regression trend analysis at 1 and 5 years was performed and a P-value derived from the t-test statistic.

RESULTS

In the mid-1980s, the incidence rate ratio in affluent:deprived classes was 0.9, with age-standardized rates of 35.23 and 39.53 per 100 000 people. This ratio increased to 1.5 by 2000 with age-standardized rates of 95.98 and 63.13, respectively (172% increase in affluent compared with 60% in deprived). The affluent groups had a 7 and 13% survival advantage at 1 and 5 years; the survival advantage at 1 year was statistically significant (P=0.03).

CONCLUSIONS

The preferential changes in incidence and survival in the affluent social classes are likely to be due to heightened awareness, resulting in increased prostate-specific antigen testing, which captures early and relatively slow-growing tumors with a better overall prognosis. If these bipolar trends are allowed to persist, then the gap between the affluent and deprived will continue to widen.

Adenocarcinoma of the prostate: epidemiological trends, screening, diagnosis, and surgical management of localized disease

Prostate cancer is a leading cause of mortality and morbidity worldwide. Despite years of study and effort, certain key questions remain unanswered, including how prostate cancer is best detected and diagnosed, how it is best treated, and how best to minimize the complications of treatment. The aim of this article is to briefly address these topics to shed light on the current best practices in prostate cancer screening, diagnosis, and surgical treatment of localized disease. We examine current trends in prostate cancer epidemiology and screening, including genetic and dietary risk factors and the newer prostate-specific antigen-derived screening modalities. Methods of diagnosis, including an overview of prostate biopsy technique and indications, and a brief review of relevant pathologic findings are provided. An in-depth analysis of traditional prostate cancer surgical management highlights the relevant advantages and disadvantages of radical retropubic and perineal prostatectomy. Complications of surgery, prognostic factors, and the many risk prediction models currently available are discussed. In all, this article aims to give the reader a broad overview of the basic elements of prostate cancer diagnosis and surgical treatment in the modem era.

Role of transrectal ultrasound guided salvage cryosurgery for recurrent prostate carcinoma after radiotherapy

Despite improvements in treatment of localized prostate cancer, local recurrence remains a significant problem. A total of 46 patients with proven local cancer recurrence following external beam radiotherapy entered a prospective clinical trial using ultrasound-guided cryosurgery to ablate the residual prostate gland. Persistent complications included one urethra-rectal fistula, incontinence (2), retention (3), and treatment induced erectile dysfunction (7). Using the PSA definitions for biochemical failure as PSA>or=0.3 ng/ml, the Kaplan-Meier plots showed the incidence of patients to be free of biochemical recurrence at 51 and 44% at 1 and 2 y, respectively. For a PSA>or=1.0, the values at 1 and 2 y were 72 and 58%.

Prostate cancer relapse after therapy with curative intention: a diagnostic and therapeutic dilemma

Prostate cancer is the most common malignant disease and second in causes of cancer death among men in Western Europe and North America. Despite improved surgical and irradiation techniques tumor relapse after curatively intended therapy is not uncommon. Due to the difficulty in discriminating local and systemic progression, it is often difficult to decide what this means for the patient and what kind of second-line treatment has to be given. Modern imaging techniques (MRI with endorectal coil, Choline-PET-CT, ProstaScint-Scan) are used for diagnosis of prostate cancer relapse. Nevertheless, early detection of local tumor relapse and likewise the detection of disseminated tumor cells often fails. To differentiate between local and systemic progression, prognostic factors of the primary tumor (grading, surgical margins, infiltration of the seminal vesicles, lymph node metastases) and PSA kinetics are used. The time from initial treatment to biochemical relapse and PSA doubling time are of highest prognostic relevance. Local progression allows second-line local treatment with potentially curative results (local irradiation after radical prostatectomy, salvage-surgery / cryotherapy / HIFU after irradiation), while in the case of systemic progress a palliative systemic therapy (hormonal treatment, chemotherapy, bisphosphonates) is indicated. Before deciding on the most appropriate therapy, prognostic factors and the patient's individual situation (co-morbidity, life expectancy, individual wishes) should be taken into account.

Androgen deprivation for minimal metastatic disease: Threshold for achieving undetectable prostate-specific antigen

OBJECTIVES

To develop objective measures to select systemic therapies for study in large-scale trials for patients with lesser tumor burdens, we explored prostate-specific antigen (PSA) changes after androgen ablation in patients with disease progression after treatment of localized disease. Long-term follow-up of trials incorporating androgen-deprivation with local therapy have shown improved survival relative to local therapy alone. This suggests that the benchmark for treatment of minimal metastatic disease can be cure.

METHODS

Patients with a rising PSA level with or without clinical metastases after local therapy who received androgen deprivation at Memorial Sloan-Kettering Cancer were identified from two institutional databases. The primary outcome was the proportion achieving an undetectable PSA level, and the pretreatment parameters associated with this endpoint were evaluated.

RESULTS

A total of 130 patients who received androgen ablation and were followed up at Memorial Sloan-Kettering Cancer Center were identified. Overall, 31 (57%) of 54 (95% confidence interval 44% to 71%) patients with a rising PSA level alone and 28 (37%) of 76 (95% confidence interval 26% to 47%) patients with a rising PSA level and clinical metastases achieved an undetectable PSA level after androgen ablation (P = 0.02). The PSA level at the start of androgen ablation and the presence of metastases were the most significant predictive factors.

CONCLUSIONS

The probability of achieving an undetectable PSA level varied inversely with the disease extent. Although achieving an undetectable PSA level does not mean that a patient has been cured, it does establish an endpoint that can be used to identify approaches worthy of study in the Phase III setting.

Decline in the overall incidence of regional-distant prostate cancer in Olmsted County, MN, 1980-2000

OBJECTIVE

To describe trends in the incidence of regional-distant prostate cancer over the entire course of the disease, before and after the introduction of prostate-specific antigen screening in 1987.

PATIENTS AND METHODS

All residents of Olmsted County, MN, USA, with a diagnosis of prostate cancer from 1964 to 2000 were identified using the resources of the Rochester Epidemiology Project. Their community medical records were examined to identify men with documented evidence of locally advanced (T3/4 or N+ disease) or metastatic prostate cancer between 1980 and 2000.

RESULTS

In all, 407 men had regional-distant prostate cancer, based on clinical or pathological staging at the time of initial diagnosis of prostate cancer and/or on radiological information over the entire course of their illness. The age-adjusted incidence per 100,000 men increased from 47.4 in 1980-86 to 65.8 in 1987-93, and declined to 33.3 in 1994-2000 (P < 0.001). Based on clinical and radiological information over the entire course of illness (268 men) the age-adjusted incidence of regional-distant disease was 42.3 in 1980-86, 41.2 in 1987-93, and declined to 18.1 in 1994-2000 (P < 0.001). These latter rates were 27%, 32% and 47% higher for the three periods, respectively, than rates based on clinical staging at initial diagnosis of prostate cancer.

CONCLUSIONS

The overall incidence of regional-distant stages of prostate cancer has declined in recent years, regardless of the stage at initial diagnosis. This may be a result in part of early detection and curative treatments. These findings also indicate that assessing the incidence of regional-distant prostate cancer only at the initial diagnosis underestimates the full impact of the benefits of early detection and treatment.