Advanced prostate cancer: course, care, and cost implications

Authentication of Algorithm to Detect Metastases in Men with Prostate Cancer Using ICD-9 Codes

Background

Metastasis is a crucial endpoint for patients with prostate cancer (PCa), but currently lacks a validated claims-based algorithm for detection.

Objective

To develop an algorithm using ICD-9 codes to facilitate accurate reporting of PCa metastases.

Methods

Medical records from 300 men hospitalized at Robert Wood Johnson University Hospital for PCa were reviewed. Using the presence of metastatic PCa on chart review as the gold standard, two algorithms to detect metastases were compared. Algorithm A used ICD-9 codes 198.5 (bone metastases), 197.0 (lung metastases), 197.7 (liver metastases), or 198.3 (brain and spinal cord metastases) to detect metastases, while algorithm B used only 198.5. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the two algorithms were determined. Kappa statistics were used to measure agreement rates between claim data and chart review.

Results

Algorithm A demonstrated a sensitivity, specificity, PPV, and NPV of 95%, 100%, 100%, and 98.7%, respectively. Corresponding numbers for algorithm B were 90%, 100%, 100%, and 97.5%, respectively. The agreement rate is 96.8% for algorithm A and 93.5% for algorithm B.

Conclusions

Using ICD-9 codes 198.5, 197.0, 197.7, or 198.3 in detecting the presence of PCa metastases offers a high sensitivity, specificity, PPV, and NPV value.

Upregulation of MAPK pathway is associated with survival in castrate-resistant prostate cancer

Background:

Recent evidence has implicated the MAP kinase (MAPK) pathway with the development of castrate-resistant prostate cancer (CRPC). We have previously reported gene amplification of critical members of this pathway with the development of castrate-resistant disease. In addition, we have shown that rising Raf-1 expression, with the development of CRPC, influences time to biochemical relapse. We therefore sought to further analyse the role of both Raf-1 and its downstream target MAPK in the molecular pathogenesis of CRPC.

Methods:

Protein expression of Raf-1 and MAPK, including their activation status, was analysed using immunohistochemistry in a database of 65 paired tumour specimens obtained before and after the development of CRPC and correlated with other members of the pathway.

Results:

Patients whose nuclear expression of MAPK rose with the development of CRPC had a significantly shorter median time to death following biochemical relapse (1.40 vs 3.00 years, P=0.0255) as well as reduced disease-specific survival when compared with those whose expression fell or remained unchanged (1.16 vs 2.62 years, P=0.0005). Significant correlations were observed between protein expression of Raf-1 and MAPK with the type 1 receptor tyrosine kinases, Her2 and epidermal growth factor receptor, as well as the transcription factor AP-1 in CRPC tumours.

Conclusion:

We conclude that the Her2/Raf-1/MAPK/AP-1 axis may promote the development of CRPC, leading to early relapse, and reduced disease-specific survival. In addition, members of the pathway may act as novel therapeutic and/or diagnostic targets for prostate cancer.

Disease-specific mortality may underestimate the total effect of prostate cancer screening

OBJECTIVES

To study the difference between the disease-specific and excess mortality rate in the European Randomized Study of Screening for Prostate Cancer section Rotterdam.

METHODS

A total of 42,376 men were randomized to systematic screening or usual care. The excess number of deaths was defined as the difference between the observed number of deaths in the prostate cancer (PC) patients and the expected number of deaths up to 31 December 2006. The expected number was derived from mortality of all study participants before a possible diagnosis with PC. The disease-specific mortality rate was based on the number of men who died from PC. The excess mortality rate based on the arm-specific excess number of deaths and the disease-specific mortality rate were compared between the two study arms.

RESULTS

The overall mortality rate was not significantly different between the intervention and the control arms of the study: RR 1.02 (95% CI 0.98-1.07). The disease-specific mortality rate was 0.42 men per 1000 person-years in the intervention and 0.48 men per 1000 person-years in the control arm: RR 0.86 (95% CI 0.64-1.17). The excess mortality rate was 0.40 per 1000 person-years in the intervention arm and 0.61 men per 1000 person-years in the control arm, and the RR for excess mortality was 0.66 (95% CI 0.39-1.13).

CONCLUSIONS

In contrast to the disease-specific mortality rates an increased difference in the excess mortality rates was observed between the two arms. This observation may be due to a systematic underestimation of the disease-specific deaths, and/or an additional disease-related mortality that is measured by an excess mortality analysis but not by a disease-specific mortality.

Overdetection, overtreatment and costs in prostate-specific antigen screening for prostate cancer

Background:

Prostate cancer screening with prostate-specific antigen (PSA) has shown to reduce prostate cancer mortality in the European Randomised study of Screening for Prostate Cancer (ERSPC) trial. Overdetection and overtreatment are substantial unfavourable side effects with consequent healthcare costs. In this study the effects of introducing widespread PSA screening is evaluated.

Methods:

The MISCAN model was used to simulate prostate cancer growth and detection in a simulated cohort of 100 000 men (European standard population) over 25 years. PSA screening from age 55 to 70 or 75, with 1, 2 and 4-year-intervals is simulated. Number of diagnoses, PSA tests, biopsies, treatments, deaths and corresponding costs for 100 000 men and for United Kingdom and United States are compared.

Results:

Without screening 2378 men per 100 000 were predicted to be diagnosed with prostate cancer compared with 4956 men after screening at 4-year intervals. By introducing screening, the costs would increase with 100% to €60 695 000. Overdetection is related to 39% of total costs (€23 669 000). Screening until age 75 is relatively most expensive because of the costs of overtreatment.

Conclusion:

Introduction of PSA screening will increase total healthcare costs for prostate cancer substantially, of which the actual screening costs will be a small part.

Interventions for sexual dysfunction following treatments for cancer

BACKGROUND

The proportion of people living with and surviving cancer is growing. This has led to increased awareness of the importance of quality of life including sexual function in people with cancer. Sexual dysfunction (SD) is a potential long-term complication of cancer treatments.

OBJECTIVES

Evaluate effectiveness of interventions for SD following treatments for cancer and their adverse effects.

SEARCH STRATEGY

The Cochrane Pain, Palliative & Supportive Care Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycInfo, AMED, CINAHL, Dissertation Abstracts and NHS Research Register were searched.

SELECTION CRITERIA

Randomised controlled trials (RCTs) were included that assessed the effectiveness of a treatment for SD. The trial population comprised of adults of either sex who at trial entry had developed SD as a consequence of cancer treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed trial quality. Meta-analysis was considered for trials with comparable key characteristics.

MAIN RESULTS

Eleven RCTs with a total of 1743 participants were identified. The quality of the trials was poor. Ten trials explored interventions for SD in men following treatments for non-metastatic prostate cancer. One trial explored effectiveness in women of a lubricating vaginal cream following radiotherapy for cervical cancer. The strongest evidence (from four trials) was on oral phosphodiesterase type 5 (PDE5) inhibitors for erectile dysfunction (ED) following radiotherapy of the prostate or radical prostatectomy. The results using validated measures in all trials significantly favoured those in the PDE5 inhibitor group(s). The combined results of two trials indicated a significantly greater improvement in ED in the PDE5 inhibitor groups (odds ratio (OR) 10.09 95% confidence interval (CI) 6.20 to 16.43). Negative effects were few and usually mild to moderate headaches or flushing. One trial reported more clinically serious events including six events of tachycardia and six of chest pain. Following prostate cancer treatments there was some evidence that PDE5 inhibitors are more effective in combination with acetyl-L-carnitine and propionyl-L-carnitine and that sexual counselling improves self-administration of prostaglandin intra-cavernous injection for SD. There was some evidence following treatment for prostate cancer that transurethral alprostadil and vacuum constriction devices reduce SD, although in both trials negative effects were fairly common. There is some evidence that vaginal lubricating creams reduce SD.

AUTHORS' CONCLUSIONS

PDE5 inhibitors are an effective treatment for SD secondary to treatments for prostate cancer. Other interventions identified need to be tested in further RCTs. The SD interventions in this review are not representative of the range available for men and women. Further evaluations are needed for these interventions for SD following cancer treatments.

Expression levels of the JAK/STAT pathway in the transition from hormone-sensitive to hormone-refractory prostate cancer

The main cause of prostate cancer-related mortality is the development of hormone-refractory disease. Circulating serum levels of IL-6 are raised in hormone-refractory prostate cancer patients and evidence from cell line studies suggests that the IL-6R/JAK/STAT3 pathway may be involved in development of this disease. In the current study we investigate if expression levels of these family members are implicated in the development of hormone-refractory prostate cancer. Immunohistochemistry using IL-6R, JAK1, STAT3, pSTAT3(Tyr705) and pSTAT3(Ser727) antibodies was performed on 50 matched hormone-sensitive and hormone-refractory tumours pairs. An increase in expression of cytoplasmic IL-6 receptor, with the development of hormone-refractory prostate cancer was associated with reduced time to relapse (P=0.0074) while an increase in expression of cytoplasmic pSTAT3(Tyr705) was associated with reduced patient survival (P=0.0003). In addition, those patients with high expression of cytoplasmic pSTAT3(Tyr705) in their hormone-refractory tumours had significantly shorter time to death from biochemical relapse and overall survival in comparison to those patients with low expression of cytoplasmic pSTAT3(Tyr705) (P=0.002 and P=0.0027, respectively). Activation of STAT3, via phosphorylation is associated with reduced patient survival, suggesting that activation of the IL-6R/JAK/STAT3 pathway is involved with development of hormone-refractory prostate cancer.

Overall survival in the intervention arm of a randomized controlled screening trial for prostate cancer compared with a clinically diagnosed cohort

OBJECTIVES

This population-based study provides comparisons of prostate cancer characteristics at diagnosis of two cohorts of men from two well-defined geographical areas exposed to different intensities of prostate cancer screening. Overall survival in both cohorts was compared with that in the general population.

METHODS

A cohort of 822 men randomized to the intervention arm of a prostate cancer screening trial and subsequently diagnosed with prostate cancer was compared with a nonrandomized cohort of 947 men who were clinically diagnosed with prostate cancer in a geographically neighboring region. In both cohorts, cases were diagnosed with prostate cancer between January 1989 and December 1997. A partitioning of overall survival by variables associated with cancer onset such as age at diagnosis, stage at diagnosis, and grade at diagnosis was performed.

RESULTS

Age at diagnosis, tumor extent at diagnosis, and grade at diagnosis were significantly different between the screened and clinically diagnosed cohort. The 5- and 10-yr survival rates were higher in the screened cohort than in the clinically diagnosed cohort (88.8% vs. 52.4%, and 68.4% vs. 29.6%, respectively). Significant differences in survival were evident for all age, stage, and grade subgroups, except for metastatic disease at diagnosis.

CONCLUSIONS

Differences in overall survival favoring the screened population were observed for all baseline characteristics (age, stage, and grade of disease), and these variables may all explain differences in overall survival because screening achieves early diagnosis as well as a stage and grade shift. As observed survival rates in the screened population mirrored those within the general population, the contribution of lead time and overdiagnosis to final patient outcome is considered to be large as well.

Pharmacoeconomics of available treatment options for metastatic prostate cancer

The resources devoted to managing metastatic prostate cancer are enormous, yet little attention has been given to directly measuring the economic consequences of treatment alternatives. The purpose of this article was to evaluate the pharmacoeconomics of available treatments for metastatic prostate cancer, including hormone-sensitive disease, androgen-independent prostate cancer and locally advanced/progressive disease. We identified 58 articles addressing economic issues related to metastatic prostate cancer. Treatment alternatives with considerably different costs are available in many areas of disease management, most notably, medical androgen deprivation therapy (ADT) versus surgical castration; combined androgen blockage (CAB) versus monotherapy for initial treatment of hormone-sensitive disease; as well as bisphosphonates and bone-targeted radioisotopes for palliation. The few available pharmacoeconomic studies indicate that the additional costs are not supported by clear and compelling evidence of differences in survival or quality-of-life (QOL) outcomes. Our review revealed that authors often use considerably different assumptions about efficacy and survival outcomes in their analyses, which may be due to the inconsistency of available clinical evidence. Although there have been many clinical trials comparing various therapies, we identified only three trials that included economic assessments. Thus, few sources of economic data are available and most pharmacoeconomic studies rely on information mined from indirect sources. We note that, while there has been considerable enthusiasm about the role of docetaxel regimens in the past 2 years, no study has yet examined the costs of these therapies. Survival remains poor for metastatic disease, thus QOL is the primary consideration for many therapies. However, QOL for treatment of metastatic disease is poorly measured and, in most analyses, the impact of therapy on QOL was inferred based on speculation by the authors. Given the large cost burdens of these treatments, it is essential that we more fully understand the true QOL gains potentially offered by more expensive therapies. The economic studies of advanced prostate cancer highlight several aspects of clinical care that are filled with considerable uncertainty and remain guided by forces other than optimal resource allocation. It is essential that we address the weaknesses in our understanding of the economic consequences of therapies for prostate cancer, and find ways to include economic information into the process of determining optimal therapy.

Raf-1 expression may influence progression to androgen insensitive prostate cancer

BACKGROUND

Recent evidence has implicated the MAP kinase pathway with the development of androgen insensitive prostate cancer (AIPC). We have previously reported gene amplification of critical members of this pathway with the development of androgen insensitive disease.

METHODS

Protein expression of Raf-1 was analyzed using immunohistochemistry (IHC) in a database of 65 paired tumor specimens obtained before and after the development of AIPC and correlated with other members of the pathway.

RESULTS

Patients whose Raf-1 expression rose with development of AIPC had a significantly shorter median time to biochemical relapse compared to those whose expression fell or remained unchanged (1.16 vs. 2.62 years, P = 0.0005). In AIPC tumors, expression of Raf-1 correlated significantly with expression of HER2 and with expression of c-fos.

CONCLUSIONS

We conclude that the HER2/Raf-1/AP-1 axis may promote the development of AIPC, leading to early relapse. Members of the pathway may act as novel therapeutic targets for patients.

Medical care cost of patients with prostate cancer

OBJECTIVE

To analyze variations in direct medical care cost of patients with prostate across two racial groups after controlling for age, disease stage, and comorbidity.

METHODS

In this retrospective cohort control study, we randomly selected 120 newly diagnosed prostate cancer patients (60 African Americans and 60 White) from the administrative database of a large urban academic hospital. Medical care costs data and clinical data were obtained. The control group consisted of 240 men without cancer, and matched by age and race. Demographics, clinical variables and treatment patterns were compared across race using t-test and chi2. Mean medical care costs for prostate cancer patients were compared by race, using bootstrap and log t-test. Regression models were used to estimate the incremental cost of prostate cancer, and to analyze the association between race and direct medical care cost.

RESULTS

Whites were more likely to receive radical prostatectomy, whereas African Americans were more likely to receive radiation therapy. The incremental cost of prostate cancer was 1.30 times higher than controls. Charlson comorbidity was a significant predictor of type of treatment received and cost. Race was not associated with total direct medical care cost after controlling for age, Charlson comorbidity and stage of cancer at diagnosis.

CONCLUSIONS

Charlson Comorbidity score was a predictor of type of treatment and direct medical care cost. While analyzing the association between race and cost of care, potential bias-inducing factors such as clinical characteristics at diagnosis and provider characteristics (physician and hospital) must be addressed.

The truth is out there: an overall perspective on androgen deprivation

Androgen deprivation therapy (ADT) is a mainstay in the treatment of prostate cancer. The ideal timing, duration and composition of ADT remains undefined. At the present time, first-line therapy consists of orchiectomy, LHRH agonists, or combined androgen blockade (CAB). However, new combinations and treatment settings show promise for improving outcomes and decreasing toxicity.

Adenocarcinoma of the prostate: an expensive way to die

The costs of radical prostatectomy and radiation therapy for localized carcinoma of the prostate are well known, the costs of terminal care for men with metastatic disease less so. We sought to determine the costs of terminal care incurred with prostate cancer in the last year of life. A retrospective chart review was conducted at five military medical centers identifying 32 patients who had died from prostate cancer from 1995 to 1997. The data investigated were: duration of metastatic disease, days hospitalized in the last year of life, palliative procedures (surgery or radiation), chemotherapy and need for transfusions. The mean duration of symptomatic metastatic disease was 3.4 y. The mean duration of hospitalization in the last year of life was 19 days. Seven patients (22%) required channel transurethral resection of the prostate (TURP). Three patients (9%) required either percutaneous nephrostomies or stenting. The mean number of transfusions required was 5.4. Eighteen patients (56%) underwent bilateral simple orchiectomy (BSO), 14 (44%) used LHRH agonists and 11 (34%) used anti-androgens. The mean total cost of hospitalization, studies, outpatient visits to physicians, palliative procedures and hormonal therapy was US dollars 24660 in the last year of life. Comparatively, the cost of radical prostatectomy is US dollars 12250 and three-dimensional conformal radiation therapy is US dollars 13823. Our estimation of costs due to metastatic disease is at best an underestimation. Men dying of prostate cancer incur significant costs in the last year of life. Based upon recent epidemiological data the cost of death due to prostate cancer in the US is over three quarters of a billion dollars a year.

Costs of prostate cancer, metastatic to the bone, in the Netherlands

OBJECTIVE

To quantify medical costs associated with bone metastases in patients with prostate cancer. Bone metastases in patients with prostate cancer are associated with considerable morbidity, negatively impact quality of life, and can add substantially to medical costs, given a median survival of 30-35 months from diagnosis of bone metastases.

METHODS

A retrospective cost analysis from both a community and university hospital in The Netherlands was conducted. Twenty-eight patient records (14 from each hospital) were investigated to assess the impact of skeletal-related events (SREs), including fractures, spinal cord compression, and radiotherapy, on total direct medical costs and cost of hospitalization. Costs are given in EUROS (Euros).

RESULTS

The average total cost of treatment was Euros 13,051 per patient over the 24-month follow-up period, which includes an average cost of Euros 6973 per patient to treat SREs. Treatment of SREs more than doubled total treatment costs. Patients in this analysis experienced, on average, one SRE per year, and the cost of SREs varied from Euros 1187 to Euros 40,948.

CONCLUSIONS

Occurrence of SREs contributes significantly to the cost of care for patients with advanced prostate cancer. These data suggest that bisphosphonates, which can reduce pain and SREs, may reduce healthcare costs.

Early prostate cancer: is there a need for new treatment options?

Improvements in diagnostic techniques have led to prostate cancer being diagnosed in younger patients and at an earlier stage of disease. The question therefore arises as to what is the best treatment for early prostate cancer. The main issues to be considered are whether the cancer is likely to progress quicker if these patients do not receive early treatment and what the quality of life implications are for patients receiving early treatment. As yet, due to the lack of valid comparisons of treatments, there is no clear "best treatment" for early prostate cancer. A number of clinical trials, comparing current treatments or investigating potential new treatment options for early prostate cancer, are in progress. The results of these should clarify the relative benefits of currently available treatments. This article reviews the latest information on the incidence, prognosis and current treatments for early prostate cancer and discusses the need for new treatments. Potential clinical benefits and cost implications of new treatments for early prostate cancer, such as improved surgical and radiotherapy techniques and adjuvant medical therapy, are also evaluated.

An economic overview of prostate carcinoma

BACKGROUND

In the United States in 2000, 180,400 new cases of prostate carcinoma were expected to occur, with 31,900 men expected to die from this illness. In addition, prostate carcinoma is the cause of over half a million disability-adjusted life-years. This study summarizes the current body of published literature about the economics of prostate carcinoma.

METHODS

The authors used a MEDLINE-based literature review for relevant articles from 1990 to the present.

RESULTS

The authors' search returned 216 articles, 56 of which met the criteria of interest. Prostate carcinoma is costly to treat, currently averaging above $20,000 per case. Cost of care is directly related to stage of disease and comorbidity. Substantial geographic variation exists, even within small locales, with regard to care patterns and cost. In-hospital mortality, length of stay, and cost are inversely related to case volume. Care rendered in health maintenance organizations is generally less technologically intensive than in the fee-for-service sector. Out of the 18 cost studies examined, 13 were cost-minimization analyses and five assessed cost-effectiveness. From a cost perspective, laparoscopic pelvic node dissection was favored over an open pelvic procedure; 3D conformal radiation therapy was favored over 2D; and radiation therapy was favored over radical prostatectomy. Cost-effectiveness analyses favored the use of metastron, mitroxantone plus prednisone over prednisone alone, flutamine with either medical or surgical castration, and orchiectomy as the androgen suppression therapy.

CONCLUSIONS

The literature on the economics of prostate carcinoma is relatively meager. Most cost studies were done on small samples, had short follow-up periods, used charges rather than cost data, and did not include adequate representation of all stages of disease. Additional research is needed.

Health-related quality of life and cost-effectiveness studies in the European randomised study of screening for prostate cancer and the US Prostate, Lung, Colon and Ovary trial

Decisions on policies for screening for prostate cancer require that information upon health-related quality of life (HRQL) and cost-effectiveness (CE) be available, as the lead time for some of the cases detected by screening will be very long and detriments in quality of life could have a major impact on the subjects remaining life-span. A framework within which both HRQL and cost-effectiveness of prostate cancer screening can be assessed is presented. Studies of both are ongoing in the European Randomised Study of screening for prostate cancer and the US Prostate, Lung, Colon and Ovary trial. Preliminary information confirms that it is important to study screened subjects and controls, and not to assume that inferences derived from study of prostate cancer outside screening trials can be extrapolated to the trials. However, it will require prolonged study to enable the overall effects on quality of life, and on cost-effectiveness to be determined. Such studies are ongoing for the two trials.

Health-related quality of life in patients with screen-detected versus clinically diagnosed prostate cancer preceding primary treatment

BACKGROUND

The purpose of this study was to evaluate baseline health-related quality of life (HRQOL) in patients with localized prostate cancer before primary treatment (radical prostatectomy or radiotherapy).

METHODS

Two hundred patients with newly diagnosed localized (screen-detected or clinically diagnosed) prostate cancer completed HRQOL questionnaires (generic and disease-specific measures). Clinical data were collected from patients' medical records in four Rotterdam hospitals.

RESULTS

Screen-detected tumors were of more favorable stages and grades than clinically diagnosed ones. The diagnostic groups did not differ significantly in bowel and sexual functioning. Differences were found in urinary functioning, favoring patients with screen-detected tumors of T2-T3 stages. Patients with screen-detected T2 cancer reported better generic HRQOL (physical aspects) than the clinical group, but HRQOL of the latter group was similar to the population norm. Radiotherapy patients were significantly older and had more comorbidity than subjects referred to prostatectomy. Urinary, bowel, and sexual problems were uncommon. Older (> 65 years) radiotherapy patients appeared to be less sexually active. Radiotherapy patients also reported poorer levels of generic HRQOL.

CONCLUSIONS

Screen-detected prostate cancer patients presented with more favorable cancer stage and grade. HRQOL was related to both the tumor stage and the detection method. Pre-treatment HRQOL differences between prostatectomy and radiotherapy patients were associated neither with tumor characteristics nor with the detection method. Baseline differences in HRQOL should be taken into account when evaluating post-treatment HRQOL.

Prostate-specific antigen-based early detection of prostate cancer--validation of screening without rectal examination

OBJECTIVES

The evaluation of the screening procedures for prostate cancer (PCa) was a part of the protocol of the European Randomized Study of Screening for Prostate Cancer (ERSPC), section Rotterdam, The Netherlands. We sought to establish an improved strategy for the early detection of PCa using a prostate-specific antigen (PSA) cutoff of 3.0 ng/mL or greater as the only indication for prostate biopsy with omission of the digital rectal examination (DRE).

METHODS

In June 1996, 8612 men, 55 to 74 years old, were randomized to screening and were screened within the ERSPC Rotterdam by a PSA level of 4.0 ng/mL or greater or positive DRE or transrectal ultrasound findings as the indication for biopsy. Four hundred thirty men had PCa. Those treated by radical prostatectomy provided the tumor characteristics considered essential for a change in the screening strategies. Various options were evaluated and predictions made by logistic regression analyses. The protocol change was implemented in February 1997. Another 7943 men were screened according to the new protocol (PSA 3.0 ng/mL or greater). The resulting data were used to compare the two protocols.

RESULTS

The detection rate (proportion of PCa in those screened) turned out to be very similar, with rates of 5.0 and 4.7 at a PSA cutoff of 4.0 ng/mL or greater and 3.0 ng/mL or greater, respectively. This was due to a much larger number of cases of PCa per biopsy in the PSA range of 3 to 3.9 ng/mL than expected. The positive predictive value of the PSA range 3.0 to 3.9 ng/mL in the two protocols was 18.0% and 6.4%, respectively. Tumor characteristics were studied on radical prostatectomy specimens from the original protocol. PCa detected with the new screening regimen had a similar distribution of Gleason scores but a larger proportion of confined disease. Tumor volumes were smaller in patients with PSA levels of less than 2.9 ng/mL; the proportion of "minimal disease" in that group was 50% compared with 28% in the group with a PSA level between 3.0 and 3.9 ng/mL.

CONCLUSIONS

Lowering the biopsy indication to a PSA cutoff of 3.0 ng/mL or greater without a DRE improved the positive predictive value from 18.2% to 24.3%. The number of biopsies necessary to detect 1 case of PCa accordingly changed from 5.2 to 3.4. The overall characteristics of the cases detected at that PSA cutoff differed very little from those detected with the regimen based on PSA, DRE, and transrectal ultrasound.