Why is the prostate cancer death rate declining in the United States?

Factors affecting the diagnosis of prostate cancer through 12 quadrant guided prostate biopsy

PURPOSE

Investigate the factors affecting the efficacy of the widely used 12-quadrant prostate biopsy for the diagnosis of prostate cancer.

METHODS

The data of 1846 male patients between 45 and 75 years of age was evaluated. The patients were subdivided into groups according to age, blood prostate-specific antigen (PSA) levels prostate volume (PV), digital rectal examination (DRE) findings, and pathology results. The tumour detection rates in the 12-quadrant biopsies were compared with PV, PSA levels, and DRE results of the grouped patients.

RESULTS

The tumour detection rate decreased with increasing PV in patients 45-75 years of age and with a PSA level ≤ 14.5. No decrease was detected in patients 45-60 years of age or those aged 61-75 years with a PSA ≤ 6.99 and suspicious DRE findings. A decrease in the tumour detection rate with increasing PV was observed in the other three subgroups of patients in this age group, who had a PSA ≤ 6.99, and normal DRE findings but a PV ≤ 40, PV 41-80, or PV ≥ 81.

CONCLUSIONS

Even though there is no statistically significant relationship between PV and the prostate cancer detection rate in patients 45-60 years of age, the cancer detection rate decreased with increasing PV in three of the four subgroups of patients between the ages of 61 and 75 years. Our study results have demonstrated that an individualised approach can play an important role in the diagnosis and treatment of prostate cancer.

Regional Estimates of Prostate Cancer Burden in Italy

Aims and background

Prostate cancer is one of the most common cancers in developed countries and the most common among men in industrialized countries. The introduction of new diagnostic procedures caused an increase in new diagnoses in Italy starting from the early 1990s, while the prognosis of prostate cancer improved due to the use of hormonal treatments. The aim of this paper is to present estimates of prostate cancer mortality, incidence and prevalence over the period 1970-2005 for the Italian regions and for Italy as a whole, and to assess the changes that opportunistic screening and the diffusion of more effective treatments introduced.

Methods

Estimated figures for incidence, prevalence and mortality were obtained with the MIAMOD method. Starting from the knowledge of mortality in the period 1970-1999 and of the relative survival in the period of diagnosis 1978-1994, we derived incidence and prevalence estimates up to the year 2005 by means of a statistical back-calculation approach. Survival at regional and national levels was modelled on the basis of published survival data from the Italian cancer registries.

Results

The incidence trend showed a steep increase all over the country during the entire estimation period 1970-2005 with a more pronounced increase in the Center-North then in the South of Italy. Incidence of northern and central regions was about twice as high as that of southern regions. Mortality trends were however constant or declining in the majority of northern-central regions, while they still increased in the South. A total of around 43,000 incident cases, 174,000 prevalent cases and 9,000 deaths were estimated for Italy in 2005.

Discussion

The effects of opportunistic screening are reflected in an earlier diagnosis for many patients. The existing North-South gradient in incidence seems to be associated with the different spread of the PSA test in different parts of the country. Prostate cancer remains a great health problem in terms of both incidence and prevalence.

Changes in pathologic outcomes and operative trends with robot-assisted laparoscopic radical prostatectomy

Introduction:

We hypothesized that there is a reverse stage migration, or a shift toward operating on higher-risk prostate cancer, in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). We therefore evaluated the stage of disease at the time of surgery for patients with prostate cancer at a large tertiary academic medical center.

Materials and Methods:

After institutional review board approval, we reviewed all patients that had undergone robotic prostatectomy. These patients were separated into three categories: An early era of 2005-2008, intermediate era of 2009-2010, and a current era of 2011-2012.

Results:

A total of 3451 patients underwent robotic prostatectomy from 2005 to 2012. The proportion men with clinical T1 tumors declined from 88.3% in the early era to 72.2% in the current era (P < 0.0001). Men with preoperative biopsy Gleason 6 disease decreased from the early to the current era (P < 0.0001), while men with preoperative biopsy Gleason ≥ 8 showed the opposite trend, increasing from the early to the current era (P = 0.0002). From the early to the current era, the proportion of patients with National Comprehensive Cancer Network (NCCN) low risk prostate cancer decreased, while those with NCCN intermediate and high-risk disease increased. The proportion of pathologic T3 disease increased from 15.5% in the early to 30.6% in the current era (P < 0.0001). On the other hand, the proportion of pathologic T2/+ SMS (surgical margin status) decreased from 6.6% in the early era to 3.1% in the current era (P = 0.0002).

Conclusions:

We have demonstrated a reverse stage migration in men undergoing robotic prostatectomy. Despite the increasing proportion of men with extra-capsular disease undergoing RALP, the surgical margin status has remained similar. This could reflect both the changing dynamics of the population opting for surgery as well as the learning curve of the surgeons.

A randomised, wait-list controlled trial: evaluation of a cognitive-behavioural group intervention on psycho-sexual adjustment for men with localised prostate cancer

OBJECTIVE

To examine the effectiveness of a cognitive-behavioural therapy (CBT) group intervention to facilitate improved psycho-sexual adjustment to treatment side effects in prostate cancer survivors post-radical prostatectomy.

METHODS

A randomised, wait-list controlled trial was conducted with a total of 60 men who participated in a manualised 8-week cognitive-behavioural group intervention 6 months to 5 years post-radical prostatectomy for localised prostate cancer. Participants completed standardised questionnaires pre-intervention and post-intervention, which assessed mood state, stress, general and prostate cancer anxiety, quality of life and areas of sexual functioning.

RESULTS

Paired samples t-tests identified a significant improvement in sexual confidence, masculine self-esteem, sexual drive/relationship and a significant decline in sexual behaviour from pre-intervention to post-intervention. Hierarchical regression analyses revealed that after controlling for covariates, participation in the group intervention significantly improved sexual confidence, sexual intimacy, masculine self-esteem and satisfaction with orgasm.

CONCLUSIONS

This group-based CBT intervention for men post-radical prostatectomy for localised prostate cancer shows promising results in terms of improving quality of life.

PSA mass screening: is there enough evidence?

Prostate cancer plays an important role in widely understood aspects of men's health, and is becoming a growing problem in terms of public life. Prostate cancer is one of the most common neoplasms among men. Male patients can live with prostate cancer for a long time so it is important to offer appropriate males adequate diagnostic tools and treatments. Prostate cancer and PSA potentially represent a “pair” of a disease and an appropriate indicator to be used in mass screening, but regardless of that there is still active debate about it. Extensive use of PSA screening has modified epidemiology of the diseases. Randomized controlled studies provided sufficient results regarding a reduction in mortality through PSA mass screening, while all agreed on risks of overdiagnosis and overtreatment. New and accurate screening tools are necessary, along with adequate counseling and risk stratification.

Racial and geographic disparities in late-stage prostate cancer diagnosis in Florida

Abstract:Disparities in prostate cancer diagnosis among racial/ethnic groups and across Florida were mapped for the period 1996-2002 and their relationship with putative factors (individual, census tract and county level) was investigated using multilevel modeling and contingency analysis. More counties had higher rates of late-stage diagnosis for Black men than for White men and the location of these racial disparities changed with time. An important finding was the substantially larger correlation between county-level rates for Black and White men in 2002 relatively to 1996, which suggests a convergence in their spatial patterns. Major significant factors for late-stage diagnosis included lack of insurance, low household income, smoking, not being married and presence of farm house. These findings should help the design of intervention programs to target counties with the greatest racial disparities in health outcomes. Additional analysis is needed to disentangle the observed racial/ethnic and geographic differences.

Radical retropubic prostatectomy: a review of outcomes and side-effects

BACKGROUND

Radical prostatectomy (RP) is worldwide probably the most common procedure to treat localized prostate cancer (PC). Due to a more widespread use of Prostate-Specific Antigen (PSA) testing, patients operated today are often younger and have organ confined disease justifying a more preservative surgery. At the same time, surgical technique has improved resulting in lower risk of permanent side-effects. This paper aims to give an overview of results from modern surgery regarding cancer control and side-effects. A brief overview of the history is given.

MATERIAL AND METHODS

A literature research identified recently published papers focusing on outcome and side-effects after RP.

RESULTS

One large randomized study (SPCG-4) compared RP and watchful waiting (WW). The study showed that RP was superior to WW in preventing local progression (RR = 0.36), distant metastasis (RR = 0.65) and death from PC (RR = 0.65). Observational studies also show a better outcome for men treated with RP compared to WW. Peri-operative mortality after RP is low in most material around 0.1%. The risk of stricture of the vesico-urethral anastomosis has decreased with improved technique from historically 10-20% to a low incidence of around 2-9% today. Also the risk of incontinence has declined with improved technique. However, while the rates of severe incontinence is usually very low, as many as 30% still report light incontinence after long-term follow-up. Erectile dysfunction (ED) is still a frequent side-effect after RP. This risk is dependent on age, pre-operative sexual function, surgical technique and other risk factors for ED such as smoking, diabetes, etc. In selected subgroups the risk of ED is low. Inguinal hernia is a more recently described complication after open retropubic RP with a postoperative incidence of 15-20% within three years of surgery.

CONCLUSION

RP is an effective method to achieve cancer control in selected patients. With modern technique it is a safe procedure with a low risk of permanent side-effects except for ED.

Is social support from family associated with PSA testing? An exploratory analysis using the Health Information National Trends Survey (HINTS) 2005

African American and White men have the highest rates of prostate cancer in the United States. Families represent important social contexts within which illness occurs.The purpose of this study is to explore whether prostate-specific antigen (PSA) testing is associated with instrumental and informational social support from family members among a sample of Black and White men aged 45 and older. Data from the 2005 Health Information National Trends Survey were analyzed using logistic regression. The dependent variable was having a PSA test within the past year or less. The independent variables consisted of selected demographic and family informational and instrumental social support variables. The statistically significant variables included age and having a family member with cancer. Additional studies to elucidate the mechanisms of social support from family for prostate cancer are needed.

Population-based prostate-specific antigen testing in the UK leads to a stage migration of prostate cancer

OBJECTIVE

To determine, within the UK, the stage and grade of prostate cancers that would be found through population-based prostate specific antigen (PSA) testing and biopsy.

SUBJECTS AND METHODS

In the 'Prostate Testing for Cancer and Treatment' trial (ProtecT), men aged 50-69 years were recruited from nine cities in the UK and from randomly selected practices of general practitioners. Those with a PSA level of >3 ng/mL were offered a prostate biopsy. Age, PSA, stage and grade at diagnosis of ProtecT participants with cancer were compared with contemporaneous incident cases aged 50-69 years (age-restricted Cancer Registry cases) registered with the Eastern Cancer Registration and Information Centre (ECRIC).

RESULTS

Within ProtecT, 94,427 men agreed to be tested (50% of men contacted), 8807 ( approximately 9%) had a raised PSA level and 2022 (23%) had prostate cancer; 229 ( approximately 12%) had locally advanced (T3 or T4) or metastatic cancers, the rest having clinically localized (T1c or T2) disease. Within ECRIC, 12,661 cancers were recorded over the same period; 3714 were men aged 50-69 years at diagnosis. Men in ProtecT had a lower age distribution and PSA level, and the cancers were of lower stage and grade (P < 0.001 for all comparisons). If population-based PSA testing were introduced in the UK, approximately 2660 men per 100,000 aged 50-69 years would be found to have prostate cancer, compared to current rates of approximately 130 per 100,000. If half of men accepted PSA testing, approximately 160,000 cancers would be found, compared to 30,000 diagnosed each year at present.

CONCLUSIONS

Population-based PSA testing resulted in a significant downward stage and grade migration, and most such cancers were of low stage and grade, which could lead to risks of over-treatment for some men.

Secular trends in prostate cancer mortality, incidence and treatment: England and Wales, 1975-2004

OBJECTIVE

To aid the interpretation of the trends in prostate cancer mortality, which declined in the UK in the early 1990 s for unknown reasons, by investigating prostate cancer death rates, incidence and treatments in England and Wales in 1975-2004.

METHODS

Join-point regression was used to assess secular trends in mortality and incidence (source: Office of National Statistics), radical prostatectomy and orchidectomy (source: Hospital Episode Statistics database) and androgen-suppression drugs (source: Intercontinental Medical Statistics).

RESULTS

Prostate cancer mortality declined from 1992 (95% confidence interval, CI, 1990-94). The relative decline in mortality to 2004 was greater and more sustained amongst men aged 55-74 years (annual percentage mortality reduction 2.75%; 95% CI 2.33-3.18%) than amongst those aged >or=75 years (0.71%, 0.26-1.15%). The use of radical prostatectomy increased between 1991 (89 operations) and 2004 (2788) amongst men aged 55-74 years. The prescribing of androgen suppression increased between 1987 (33,000 prescriptions) and 2004 (470,000).

CONCLUSIONS

The decrease in prostate cancer mortality was greater amongst men aged 55-74 years than in those aged >or=75 years, but pre-dated the substantial use of prostate-specific antigen screening and radical prostatectomy in the UK. An increase in radical therapy amongst younger groups with localized cancers and screen-detected low-volume locally advanced disease as a result of stage migration, as well as prolonged survival from increased medical androgen suppression therapy, might partly explain recent trends.

Inverse correlation between body mass index and clinical outcomes in men with advanced castration–recurrent prostate cancer

BACKGROUND

Obesity has a variety of adverse health outcomes, but to the authors' knowledge, the effect of obesity on outcome in patients with advanced prostate cancer is not known. For this reason, the correlation between an elevated body mass index (BMI) and clinical outcomes in patients with metastatic, castration-recurrent prostate cancer (CRPC) was evaluated.

METHODS

A total of 1226 men with CRPC who were enrolled in 9 prospective clinical trials conducted by the Cancer and Leukemia Group B (CALGB) for the treatment of metastatic disease were considered. Eligible patients had progressive prostate cancer during androgen deprivation therapy (with documented castrate levels of testosterone); an Eastern Cooperative Oncology Group performance status of 0 to 2; and adequate hematologic, renal, and hepatic function. Patients were classified based on BMI as normal (18.5-24.9 kg/m(2)), overweight (25-29.9 kg/m(2)), and mildly to severely obese (> or =30 kg/m(2)).

RESULTS

Approximately 24% of the patients had a normal BMI, 43% were overweight, and 33% were mildly to severely obese. On multivariable analysis, BMI was found to be a statistically significant predictor of overall survival and prostate cancer-specific mortality. Compared with men with normal BMIs, the hazard ratios for death for overweight men and mildly to severely obese men were 0.80 (95% confidence interval [95% CI], 0.68-0.93; P = .001) and 0.80 (95% CI, 0.68-0.94; P = .010), respectively.

CONCLUSIONS

In patients with metastatic CRPC, obesity (as defined by an elevated BMI) appears to have a protective effect against overall mortality and prostate cancer-specific mortality. Alternatively, a higher BMI may reflect different cancer biology (ie, the lack of cachexia-producing substances). Further studies to gain a more comprehensive understanding of the mechanisms behind these clinical observations are needed.

Excess risk of subsequent primary cancers among colorectal carcinoma survivors, 1975-2001

BACKGROUND

Studies of persons with colorectal cancer have reported increased risk of subsequent primary cancers. Results have not been consistent, however, and there is little information about such risk in specific races and ethnic populations.

METHODS

Using 1975-2001 data from the Surveillance, Epidemiology, and End Results (SEER) Program, we assembled 262,600 index cases of colorectal carcinoma to assess the occurrence of subsequent primary cancers in 13 noncolonic sites. Observed (O) subsequent cancers were compared with those expected (E) based on age-/sex-/race-/year-/site-specific rates in the SEER population. The standardized incidence ratio (SIR) and the absolute excess risk (AER) represent 'O / E' and 'O - E,' respectively.

RESULTS

Colorectal carcinoma patients had significantly elevated SIRs for small gut, stomach (males), kidney, and corpus uteri cancers, ranging from 1.13 for stomach cancer in males to 3.45 for small gut cancer in females. Elevated SIRs for additional sites were seen in certain population subgroups: pancreas and ovary in persons aged <50 years, and prostate in black males. The excess burden, as assessed by AER, was notable for prostate cancer in black males and for corpus uteri cancer in females aged <50 years (26.5 and 9.5 cancers per 10,000 person-years, respectively), and it persisted beyond 5 years of follow-up.

CONCLUSIONS

Although significantly elevated SIRs were found for several cancers, the excess burden was notable only for cancer of the prostate in black males and of the corpus uteri in females under age 50.

Prostate cancer screening decision making under controversy: implications for health promotion practice

Prostate cancer is a major health problem for U.S. men and is characterized by paradoxes and controversies. Despite the wide availability of the prostate-specific antigen (PSA) test, prostate cancer screening remains a controversial practice mainly because the direct impact of screening on mortality is not yet proven. As the relative value of screening, early detection, and treatment strategies continue to be debated, glaring racial-ethnic disparities persist with African American men experiencing excess morbidity and mortality and demonstrating the lowest screening rates among racial-ethnic groups. Given the prevailing controversy, uncertainty, and known disparities, how can health education messages be framed to assist men and their family members? This article highlights the ethnic disparities, paradoxes, and controversies of prostate cancer and identifies critical challenges and opportunities for health educators and clinical practitioners. Implications for health promotion communications and informed decision making in this era of uncertainty are discussed.

Quantitative PSA mRNA determination in blood: a biochemical tool for scoring localized prostate cancer

OBJECTIVES

Our aim was to verify whether the quantitative determination of PSA mRNA in circulating cells is helpful in diagnosing and scoring localized prostate cancer (PC).

DESIGN AND METHODS

The study included 145 patients with benign prostatic hyperplasia (BPH), 138 with localized PC and 28 healthy controls (CS). PSA cDNA was amplified by real-time PCR from circulating mononuclear cells. Serum total and free PSA were determined. Prostate cancers were histologically scored according to the Gleason criteria.

RESULTS

The most sensitive index of PC was tPSA (70%), and the most specific was f/t PSA (80%). High PSA mRNA was found more frequently in PC patients with poorly differentiated (23.1%) than in those with well (4.5%) or moderately (4.3%) differentiated tumors.

CONCLUSIONS

tPSA and f/t PSA are the best available tools for discriminating between localized PC and BPH. The quantitative assessment of PSA mRNA in blood might be helpful in the biochemical grading of prostate cancer.

Cambio en el patrón de presentación del cáncer de próstata en Oviedo en los últimos 10 años: patrón de presentación, manifestaciones clínicas y anatomo-patológicas (Parte I)

OBJECTIVES

To describe the clinical and pathological factors of prostate adenocarcinomas diagnosed in our department in the years 1995 and 2004.

MATERIAL AND METHOD

We review the 216 patients diagnosed in both years, recording several features.

RESULTS

The mean age was significatively lower in the year 2004. In that year, the increments of the PSA levels was the main reason for the diagnosis of the prostate cancer, followed by low urinary tract symptons (LUTS), while the LUTS was the main reason in 1995. There was a greater proportion of high grade tumors in 1995 and also in this year, high risk tumors were the most frequently found, while in 2004 low risk and low grade tumors were predominant.

CONCLUSIONS

Due to the general determinations of PSA levels in asymptomatic patients in 2004, we found a greater proportion of high grade tumors in 1995 and lower grade tumors in 2004.

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.

Prospective Observational Study to Assess Value of Prostate Cancer Diagnostic Methods

The purpose of this article is to evaluate the efficiency and effectiveness of analytical and imaging methods for diagnosing prostate cancer in northwest Spain. The authors investigated prospectively two groups of patients with a pathological digital rectal examination (DRE) or prostate-specific antigen (PSA). Sensitivity, specificity, positive predictive value, negative predictive value, receiver operating characteristics curves, and other analyses were performed to determine the relative contributions of PSA, DRE, gray-scale transrectal ultrasonography (TRUS), color Doppler ultrasound (CDUS), symptoms, and patient age to cancer prediction. The presence of prostatic disease symptoms did not distinguish between subjects with and without cancer. The most sensitive (98%) was total PSA (> 4 ng/mL), and the most specific (78%) was DRE and TRUS (65%). The contribution of PSA, DRE, and TRUS to the diagnosis of prostate cancer was significant. In patients with a PSA between 4 and 10 ng/mL, PSA specificity increased, using a free/total PSA ratio of 15%. The PSA continues to be the most sensitive method for prostate cancer diagnosis. DRE tends to be more negative at early stages of cancer detection. Comparing the conventional TRUS echography with the CDUS, the latter is a better detector in the diagnosis of cancer.

Can Power Doppler Enhanced Transrectal Ultrasound Guided Biopsy Improve Prostate Cancer Detection on First and Repeat Prostate Biopsy?

OBJECTIVE

To determine the utility of Power Doppler enhanced transrectal ultrasound (PD-TRUS) and its guided prostate biopsies in men with prostate specific antigen (PSA) levels between 2.5 and 10 ng/ml and to evaluate its impact on prostate cancer (PCa) detection in men undergoing first and repeat biopsies.

METHODS

A total of 136 consecutive referred men with serum total PSA (Abbott Laboratories, Abbott Park, IL, USA) levels between 2.5 and 10 ng/ml (mean age 64 +/- 9 years, range 45-82) and a normal digital rectal examination were included. 101 underwent a first biopsy whereas 35 had repeat biopsy. Gray-scale transrectal ultrasound (TRUS), and PD-TRUS (B&K Medical, Denmark) were performed in lithotomy position before and during the biopsy procedure. Vascularity accumulation and perfusion characteristics were recorded and graded as normal or abnormal in the peripheral zone of the prostate. A Vienna-nomogram based biopsy regime was performed in all patients on first biopsy and a special biopsy regime on repeat biopsy plus additional biopsies from abnormal sites on PD-TRUS.

RESULTS

Overall PCa detection rate was 34.7% and 25.7% and abnormal accumulation on PD-TRUS was identified in 42.3% and 48.6% on first and repeat biopsy, respectively. The PCa detection rate, on first and repeat biopsy in patients with and without PD-TRUS accumulation were 67.4% versus 10.3% (p < 0.001) and 47.05% versus 5.6% (p = 0.0049), respectively. PD-TRUS directed biopsies were positive in 5.7% and 11.1% on first and repeat biopsy whereas PCa detection using the routine prostate biopsy regime was 94.3% and 88.9% on first and repeat biopsy. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of PD-TRUS signal alone for PCa detection on first biopsy was 82.8%, 78.8%, 87.9% and 89.7%, respectively, and 88.8%, 68.0%, 47.0% and 94.4% on repeat biopsy, respectively. In comparison, the results PD-TRUS guided biopsies were 53.8%, 59.1%, 16.7%, and 89.5%, on first biopsy, respectively, and 20.0%, 13.3%, 23.5%, 11.1% on repeat biopsy, respectively.

CONCLUSION

Negative PD-TRUS signal is able to exclude most of the patients without PCa in the PSA range of 2.5-10 ng/ml. As an additional tool at TRUS biopsy PD-TRUS has a high negative predictive value and may help to reduce the number of unnecessary biopsies.

Survellaince Program for Prostate Carcinoma: Preliminary Results on 585 Blood Donors

Population screening for prostatic carcinoma (CP) is a struggled subject, and we don't know the real utility of it. Nowadays the Authors suggest only survey on little groups. In this study the male population of blood donors of our hospital between 45 and 65 years underwent a complete valutation for CP.

From this study we hope to obtain the following results: a) early diagnosis of CP (eradicable); b) eliminate keeper of neoplastic pathology from blood donations (theoretic risk of transmission of neoplastic cells in immunodepressed patients); c) studying the practicability, if we achieve a high percentage of ahdesions at this program, our model could be exportable.

Decreasing mortality rates for prostate cancer: possible role of hormonal therapy?

Within the last decade prostate cancer mortality rates have started to decrease in some countries. Although it is tempting to assume that these trends are a result of earlier diagnosis and aggressive therapeutic intervention, as a consequence of prostate-specific antigen screening, definitive results from randomized trials of screening will not be available for several years. Moreover, there is mounting evidence that the effects of screening cannot be entirely responsible for this reduction in mortality rates. This review explores the possibility that other factors, particularly the increased uptake of early hormonal therapy, are contributing to the observed changes in mortality.

Prostate cancer mortality in Connecticut, Iowa and New Mexico African American men

We sought to assess trends in prostate cancer incidence, treatment and mortality in African American men by means of analysis of prostate cancer data from three states, Connecticut, Iowa and New Mexico, all participants in the Surveillance, Epidemiology, and End Results (SEER) Program. Compared with levels before prostate specific antigen (PSA) testing, prostate cancer incidence increased in all three states after widespread testing. For men diagnosed with localized or regional prostate cancer, the respective increases in radical prostatectomy in Connecticut, Iowa, and New Mexico were 3.2, 2.3, and 4.9 times pre-test levels. Age-standardized mortality in Connecticut and Iowa increased slightly; in New Mexico the 104.7 deaths per 100,000 in 1979-1986, 62.1 in 1987-1990, dropped to 47.6 in 1991-1998, an amount of decline that was statistically significant. Introduction of PSA testing influenced early detection and treatment of prostate cancer in all three states. Although decline in prostate cancer mortality in New Mexico over time may be linked with use of the PSA test and definitive therapy, the relationship among these factors, and thus the proper treatment for the early stages of this condition, is unclear on the basis of these data.

Epidemiology of prostate cancer in the Umbria region of Italy: evidence of opportunistic screening effects

OBJECTIVES

To examine the impact of prostate-specific antigen-based screening on prostate cancer incidence, mortality, and survival in the Umbria region of Italy for the period 1978 to 1999.

METHODS

Incidence rates were derived from an ad hoc survey and from cancer registry records for the period 1978 to 1982 and 1994 to 1999, respectively. The mortality trend was assessed by joinpoint analysis using data from the official publications. The observed, relative, and age-adjusted relative survival rates were also calculated.

RESULTS

The number of newly diagnosed cases in 1997 to 1999 was almost four times greater than in 1978 to 1982, the crude incidence rate was more than three times, and the age-adjusted incidence rate increased by about 125%. No trend was apparent for mortality. The survival rates also showed a large increase. The 5-year relative survival rate was 37% and 74% for 1978 to 1982 and 1994 to 1998 incident cases, respectively. People older than 75 years showed the same striking increase in incidence and survival rates as the younger age groups.

CONCLUSIONS

As in many other developed countries, prostate cancer screening activities are the likely cause of the increase in incidence and survival rates observed in the study area, but a decreasing mortality trend is not yet evident. Opportunistic screening is likely to be performed among all age groups, including the elderly, although the latter are unlikely to benefit from intervention. The evaluation of opportunistic screening is difficult and a lack of evaluation implies a high risk of ineffective interventions and inequality of care.

The timing of hormone therapy for men with asymptomatic advanced prostate cancer

The most appropriate time to introduce hormonal therapy for patients with advanced prostate cancer is a contentious issue. Recent prospective studies comparing immediate and deferred hormonal therapy (medical or surgical castration) on survival outcome are reviewed with the aim of redefining the most appropriate time to initiate hormonal therapy for individual patients. The evidence supports the use of immediate hormonal therapy in previously untreated patients with advanced disease (M1) and also the use of adjuvant hormonal therapy after radical prostatectomy and lymphadenectomy for node-positive (but clinically localized) disease. Immediate hormonal therapy may also be advantageous in advanced local/regional disease when it is the primary treatment contemplated (i.e., without any definitive curative therapy to the prostate), although not all studies show this. Adjuvant hormonal therapy has significantly improved survival in some studies in the radiotherapy setting; the lack of statistically significant benefits in other studies may be a result of the timing of hormonal therapy in relation to the administration of external beam irradiation. Decisions on the immediate initiation of hormonal therapy should also take into account the patient's life expectancy and the side effects and long-term complications of androgen deprivation therapy. Recent epidemiological studies indicate that prostate cancer mortality has fallen in the USA. This decline in prostate cancer mortality is likely to be multifactorial with early application of hormonal therapy being one potential contributory factor. It is recommended that after an assessment of their disease risk, patients should be informed about the benefits and side effects of all potential treatment options and allowed to make an informed choice about their treatment.

Insignificant prostate cancer in radical prostatectomy specimen: time trends and preoperative prediction

OBJECTIVES

We analysed systematically a consecutive series of radical prostatectomy specimens performed between January 1992 and June 2002 with emphasis to time trends, tumour characteristics and preoperative prediction of insignificant prostate cancers (cancer volume < or =0.5 cm(3) and Gleason pattern < or =6).

METHODS

In a total of 1254 patients, prostate cancers (PC) were divided by a cancer volume of 0.5 cm(3). The two groups were compared in their clinical and pathological tumour characteristics. Correlation was determined between yearly incidence rates of T1c and insignificant PC. Furthermore, a logistic regression analysis was performed to calculate the ability to predict insignificant PC and a statistical model was established.

RESULTS

Overall, 73 (5.8%) of 1254 men presented with insignificant PC. The incidence of insignificant PC showed no significant linear correlation with that of T1c PC (p<0.61). PSA density and percentage of cancer per biopsy set were assessed as independent prognosticators predicting insignificant PC. Using a threshold of 1% of cancer per biopsy set and a PSA density < or =0.10, positive and negative predictive values were 45.0% and 93.3%, respectively.

CONCLUSION

In our series, only few men undergoing radical prostatectomy were affected by insignificant PC. Their incidence showed no statistically significant correlation with that of T1c tumours. Furthermore, insignificant PC was predictable by PSA density and percentage of cancer per biopsy set. Mainly elderly patients facing different treatment options for localized PC may benefit from this information.

Prostate cancer in Italy before and during the 'PSA era': survival trend and prognostic determinants

The aim of the study was to investigate the variations in prostate cancer prognosis during a period of major diagnostic change, such as the introduction of the prostate-specific antigen (PSA) test. Data were provided by 14 Italian cancer registries (CRs). Incidence and follow-up information was collected for patients diagnosed from 1978 to 1994. Relative survival was computed taking into account incidence period, age, tumour stage and grade at diagnosis. A multivariate analysis was carried out to evaluate the independent simultaneous effect on survival of some prognostic determinants. A large geographical variability was observed: in 1993-1994 Italian survival rates ranged from 76% to 52%, with a north-south gradient. A striking prognostic improvement (up to +27 percentage points) between the late 1980s and the early 1990s occurred in almost all CRs, particularly with regard to younger patients. Multivariate analysis showed a strong influence of incidence period on survival, also after correction by tumour stage. The slowdown of metastatic cancers suggests that the survival improvement could be due both to the introduction of an effective opportunistic screening and to a quantitative change in the application of clinical treatment, even if the effect of the lead-time bias phenomenon has to be taken into account.

Screening for prostate cancer

Epidemiologically, screening is justified by the importance of the disease and the lack of prospects for primary prevention, but evidence from natural history is unhelpful since men are more likely to die with, rather than from, prostate cancer. The available screening tests do not always detect men whose lesions could result in future morbidity or mortality. Evidence is limited for the benefits of treatment for localised cancers detected through screening, whereas the evidence for harm is clear. Observational evidence for the effect of population screening programmes is mixed, with no clear association between intensity of screening and reduced prostate cancer mortality. Screening for prostate cancer cannot be justified in low-risk populations, but the balance of benefit and harm will be more favourable after risk stratification. Prostate cancer screening can be justified only in research programmes designed to assess its effectiveness and help identify the groups who may benefit.

Trends in prostate cancer mortality among black men and white men in the United States

BACKGROUND

Prostate cancer mortality rates in the United States declined sharply after 1991 in white men and declined after 1992 in black men. The current study was conducted to investigate possible mechanisms for the declining prostate cancer mortality rates in the United States.

METHODS

The authors examined and compared patterns of prostate cancer incidence, survival rates, and mortality rates among black men and white men in the United States using the 1969-1999 U.S. prostate cancer mortality rates and the 1975-1999 prostate cancer incidence, survival, and incidence-based mortality rates from the Surveillance, Epidemiology, and End Results (SEER) Program for the U.S. population. The SEER data represent approximately 10% of the U.S. population.

RESULTS

Prostate cancer incidence and mortality rates showed transient increases after 1986, when the U.S. Food and Drug Administration approved the use of prostate specific antigen (PSA) testing. The age-adjusted prostate cancer mortality rates for men age 50-84 years, however, have dropped below the rate in 1986 since 1995 for white men and since 1997 for black men. In fact, for white men ages 50-79 years, the 1998 and 1999 rates were the lowest observed since 1950. Incidence-based mortality rates by disease stage revealed that the recent declines were due to declines in distant disease mortality. Moreover, the decrease in distant disease mortality was due to a decline in distant disease incidence, and not to improved survival of patients with distant disease.

CONCLUSIONS

Similar incidence, survival, and mortality rate patterns are seen in black men and white men in the United States, although with differences in the timing and magnitude of recent rate decreases. Increased detection of prostate cancer before it becomes metastatic, possibly reflecting increased use of PSA testing after 1986, may explain much of the recent mortality decrease in both white men and black men.

Differences in the epidemic rise and decrease of prostate cancer among geographical areas in Southern Europe. an analysis of differential trends in incidence and mortality in France, Italy and Spain

This is a population-based study aimed at evaluating incidence and mortality trends for prostate cancer in France, Italy and Spain, during the prostate-specific antigen (PSA) era, considering elderly people aged 70 years and over and younger adults aged between 40 and 69 years. Trends were estimated by a log-linear Poisson regression model and expressed as an Estimated Annual Percent Change (EAPC). Incidence increased sharply in almost all areas. Spain showed the lowest increases. Incidence started to rise around 1985 in France and after 1990 in Italy and Spain. Mortality increased until the late 1980s in all countries, then declined in France and Italy (-2.5% in 40-69 year age group), but not in Spain. Younger people showed a much higher rise in incidence than the elderly, while mortality decreased mainly in the younger adults. The decrease in mortality was more marked in those areas and the younger age group where the rise in incidence was higher and started earlier, i.e. in France and in younger people, suggesting that the PSA test may have had a positive effect on mortality, although other clinical advances also have to be taken into account.

Gleason scores of prostate biopsy and radical prostatectomy specimens over the past 10 years: is there evidence for systematic upgrading?

BACKGROUND

With the advent of the prostate specific antigen (PSA) assay, an increased detection rate of prostate carcinoma has ensued. This has been associated with a downward stage migration. In contrast, grade has shifted heavily toward moderate differentiation. The authors sought to test the hypothesis that such changes in grade in part may be because of trends among pathologists to upgrade similar specimens over time.

METHODS

Two expert genitourinary pathologists regraded 23 prostate biopsies and 15 radical prostatectomy specimens during a 3-year period (1989-1991). Each pathologist then regraded 32 prostate biopsies and 15 radical prostatectomies from 1998 to 2000. For both time periods, each pathologist regraded only specimens that they personally had graded initially. All specimens were scored using the Gleason system, the predominant system used in describing prostate carcinoma grade. In evaluating original and regraded scores, the authors classified score changes between less than or equal to 6 and greater than or equal to 7 or between 7 and greater than or equal to 8 as significant because such changes have a high probability of altering clinical management. The results were analyzed using the two-tailed Fisher exact test.

RESULTS

Of 23 prostate biopsies from 1989 to 1991, 10 of 23 (44%) had a clinically significant Gleason score change when regraded, whereas 2 of 15 (13%) radical prostatectomy specimens from the same period had a clinically significant Gleason score change. A significant change in the distribution of biopsy Gleason scores on regrading was observed (P < 0.04). In comparison, when the prostate biopsies from 1998-2000 were regraded, 10 of 32 (31%) had a clinically significant grade change. Radical prostatectomy specimens from the same period revealed 3 of 15 (20%) with a clinically significant grade change. After regrading the biopsies from 1989-1991, 8 of 23 (35%) of were upgraded, whereas 2 of 23 (9%) were downgraded. In comparison, of the biopsies with significant changes from 1998 to 2000, 3 of 32 (9%) were upgraded, whereas 7 of 32 (22%) were downgraded. Of the radical prostatectomy specimens with significant change, only 2 of 15 from each period were upgraded. Significant upgrading (P < 0.005) occurred only in the biopsy specimens from 1989 to 1991.

CONCLUSIONS

The authors' data suggest that rates of upgrading and downgrading of biopsy specimens differ between the 1989-1991 cases and the 1998-2000 cases, with the 1989-1991 samples exhibiting a significant change toward higher grades. Although not excluding the possibility of a change in the biology of prostate carcinoma over time, these findings suggest that the apparent trend toward higher biopsy grades in part may be because of how pathologists interpret these specimens today as compared with 10 years ago. Therefore, outcome studies including a biopsy Gleason score from older specimens as a risk variable have a significant chance of being vulnerable to this phenomenon. Based on the authors' data, all such specimens should undergo rereview.

Trends in the utilization of androgen-deprivation therapy for patients with prostate carcinoma suggest an effect on mortality

BACKGROUND

After a surge in the incidence of prostate carcinoma in the early 1990s, diminishing rates of mortality became apparent in 1993. This decrease in mortality is unlikely to be explained entirely by treatment with curative intent alone following screen-detected cases, because the time frame between detection and mortality remains relatively brief.

METHODS

This study used incidence and initial treatment data from the Detroit area SEER registry between 1973 and 1998 in addition to mortality data covering the Metropolitan Detroit area obtained from the Michigan Department of Community Health. Data for Caucasian and African-American men were analyzed. The use of androgen-deprivation therapy, which evolved during the study period, was evaluated in conjunction with mortality and incidence trend data for consideration of etiologic contributions.

RESULTS

The incidence of prostate carcinoma, as noted previously in national data, increased sharply in 1988, peaking in 1992 in Southeast Michigan, whereas mortality rates began to decrease in approximately 1993, with a sustained decrease to the latest recorded data in 1998. These trends were identical in Caucasians and African Americans. A sharp increase in the use of androgen-deprivation therapy began in 1990. This use of androgen-deprivation therapy is high and sustained for patients with early-stage disease, increases for several years, and then diminishes for patients with regional disease. The use also diminished through the 1990s for patients with late-stage disease, paralleling the decrease in the incidence rate for late-stage disease.

CONCLUSIONS

The pattern of androgen-deprivation therapy usage was consistent with that for hormonal monotherapy and adjuvant and neoadjuvant therapy. These findings suggest that androgen-deprivation therapy may contribute, along with advances in diagnostic techniques and curative therapy with radiation or surgery, toward decreasing prostate carcinoma mortality rates in Southeast Michigan.

International trends in prostate-cancer mortality in the "PSA ERA"

Incidence and mortality from prostate cancer were rising in most countries until the late 1980s. Following a number of advances in the management of prostate cancer, including introduction of the prostate-specific antigen (PSA) test, there have been reports of declines in mortality in Canada, the United States and the United Kingdom. To investigate the extent to which this pattern was seen in other industrialised countries, we used routinely collected data to explore recent changes in prostate-cancer mortality. Trends in age-standardised death rates between 1979 and 1997 for men aged 50 to 79 years in 24 industrialised countries were compared using join point regression. Join point regression allows estimation of the annual percentage change in death rates and tests for significant changes in trend. During the period studied, age-standardised mortality increased at 1% to 2% per year in most countries. In 7 countries (Canada, United States, Austria, France, Germany, Italy and United Kingdom), a significant down-turn in age-standardised mortality was observed over the period 1988-1991. Trends in age-specific rates within these countries support a period effect on prostate-cancer mortality. Declines in mortality could result from any combination of either artefact, reduction in prostate-cancer incidence, a rise in competing causes of death or changes in the risk of death from prostate cancer. There are inconsistencies in the relationship between national mortality trends and uptake of PSA screening; further research is required to determine whether changes in death rates can be explained by international and secular variations in the treatment of prostate cancer.

The debate about prostate cancer screening: what nurses need to know

OBJECTIVES

Special challenges and unique opportunities for nurses in the 21st century related to prostate cancer screening are reviewed.

DATA SOURCES

Current health care literature pertaining to prostate cancer screening issues.

CONCLUSIONS

Decisions that weigh the immediate risks of incontinence and erectile dysfunction against the long-term potential risk of death from advanced cancer must be made with conflicting values and incomplete data.

IMPLICATIONS FOR NURSING PRACTICE

With their expertise in patient education nurses are in a unique position to communicate the risks and benefits of prostate cancer screening in a manner in which patients can understand. A sample nursing care plan is presented for shared decision making.

Expectant management of prostate cancer

OBJECTIVES

To discuss the role of expectant management in the treatment of clinically localized prostate cancer.

DATA SOURCES

Published research and review articles, textbooks, and pending research publications.

CONCLUSIONS

Expectant management is a viable option for the treatment of clinically localized prostate cancer in carefully selected men.

IMPLICATIONS FOR NURSING PRACTICE

Nursing personnel along with physicians must work together to develop coping strategies for these men to deal with the continual uncertainty of this treatment program.

Disappearance of well-differentiated carcinoma of the prostate: effect of transurethral resection of the prostate, prostate-specific antigen, and prostate biopsy

OBJECTIVES

To characterize the effect of prostate-specific antigen (PSA) and transurethral resection of the prostate (TURP) on the rate of diagnosis of well-differentiated (WD) prostate cancer (PCa) and PCa mortality.

METHODS

All cases of PCa and rates of TURP at both Wilford Hall and Brooke Army Medical Centers between 1984 and 1995 were reviewed. Tumor grade was compared between prostate needle biopsy and TURP. The pattern of diagnosis was analyzed annually and for two time periods: pre-PSA (1984 to 1988) and post-PSA (1989 to 1995).

RESULTS

The number of WD tumors fell by 50% over the period of study and was caused by a fall in number of TURPs as well as in WD tumors detected by TURP. PSA for early detection of PCa began in 1988, and within 5 years a more than 50% fall in the rate of metastatic disease was witnessed. These two events (PSA screening and fall in TURPs) led to an increase from 57% to 92% of tumors that were both clinically significant and potentially curable.

CONCLUSIONS

These data help explain the fall in the rate of diagnosis of WD PCa. The resultant increase in the diagnosis of moderately and poorly differentiated PCa, coupled with the dramatic fall in the rate of diagnosis of metastatic PCa, may explain the reports of a fall in PCa mortality. If this observation is replicated in other populations, it may provide further impetus for a stronger recommendation for early detection with PSA and digital rectal examination.

Prostate cancer incidence and mortality trends among elderly and adult Europeans

Prostate cancer is a common malignancy primarily of elderly men, with incidence rates rapidly increasing, owing to the population ageing and the introduction of more sensitive diagnostic procedures. Although the effectiveness of a screening test remains controversial, the decreasing mortality rates, which recently emerged in the USA, may be partly attributable to the changes of patterns of care, thus suggesting a potential effect of preventive measure. The object of this study is to examine time trends in incidence and mortality from prostate cancer in European Union (EU) countries, with particular attention to possible differences between the elderly (65 years old or over) and younger or middle age adults (35-64 years old). EUROCIM, the data base created by the European Network of Cancer Registries, provided the incidence and mortality data for the 12 EU Countries analysed (namely: Finland, Denmark, Scotland, England and Wales, Ireland and The Netherlands in Northern Europe; Austria, Germany and France in Central Europe; Italy, Spain and Portugal in Southern Europe), for the 1978-1994 period. Incidence and mortality time trends, expressed as mean difference per cent (MD%) per year, were estimated by a Poisson log-linear regression model. Higher resolution analyses were also carried out to check differences in time trends by age class within the two groups under study. Upward mortality trends occurred in several countries, excepting Ireland, Austria and Southern Europe, but only for younger and middle aged adults. Rates increased more rapidly in older age groups; a clear north-south gradient appeared both in the elderly and in younger adults; for the elderly, MD% higher than +1.5 for most countries of Northern Europe, MD% around +1 for Central Europe, and MD% less than +1 for Southern Europe were registered, with lower values for younger people. Incidence rates rose across the period considered, almost in all countries both for elderly and for younger and middle age adults, increasing more rapidly in younger age. Incidence trends showed a less clear geographic pattern than for mortality. In the younger group, high MD%, ranging in Northern Europe from +3.2 in Finland and England and Wales to +5.7 in The Netherlands, were observed, while in the South values ranged between +4.2 and +5.0. In Central Europe, very high MD%, ranging between +8.4 in France and +16.6 in Austria, were noted. No significant trends were observed for Denmark, Ireland and Portugal. For the elderly the increase was generally lower and no significant trend was observed in Germany and Portugal. Interaction between age and calendar period in the older group was observed for most of the considered countries. With reference to mortality, the MD% showed a tendency to rise, with increasing age, while no consistent pattern emerged for incidence. The observed incidence trends are probably a consequence of the different times in which the more recent detection methods were introduced in each country, and of the different policies adopted by each health care system towards the elderly. A comparison with the USA data suggests that in the next future a favourable downward mortality trend could be expected also in some EU Countries and, particularly, for younger age groups, even though prostatic cancer in old patients will remain a great burden, which National Health Care Systems will have to face in the next decades.

Trends and characteristics in prostate cancer mortality in Japan

BACKGROUND

In North America, the incidence and mortality of prostate cancer has been declining since the early 1990s. We calculated the age-adjusted death rates, age-specific death rates and standardized mortality ratio (SMR) for prostate cancer in Japan and analyzed their features.

METHODS

Yearly age-adjusted death rates for prostate cancer were calculated by dividing the number of events by the population at risk, with direct standardization to the world population. Age-specific death rates were calculated for the 1970s, 1980s and 1990s and which age group showed the highest rate of increase was examined. The SMR in each prefecture was also calculated for each period.

RESULTS

The respective number of deaths and the age-adjusted death rate was 1107 and 2.29 in 1973 and 6251 and 5.15 in 1997. The age-specific death rates showed an exponential increase with age in all three periods and the rate of increase was higher in older age groups. The distribution of SMR showed the same tendency in all three periods. The prefectures with significantly high or low SMR were distributed in clusters.

CONCLUSIONS

The prostate cancer death rate is increasing rapidly in Japan. However, the age-adjusted death rate has remained stable from 1996 to 1997. How this figure will change and whether the prostate cancer death rate in Japan will begin to decline, like in North America, is of interest. The prefectures with significantly high or low SMR showed a characteristic clustered distribution pattern.

Comparison of trends in prostate-cancer mortality in England and Wales and the USA

Although trends in prostate-cancer screening and disease incidence differ substantially between the USA and England and Wales, trends in mortality are very similar.

Total PSA, free PSA/total PSA ratio, and molecular PSA detection in prostate cancer: which is clinically effective and when?

OBJECTIVES

To ascertain when the serum determination of the free prostate-specific antigen (PSA)/total PSA (fPSA/tPSA) ratio is clinically useful, and whether the identification of PSA or prostate-specific membrane antigen (PSM) mRNA in circulating cells has diagnostic advantages over the determination of their protein product.

METHODS

fPSA, tPSA, and the fPSA/tPSA ratio were determined in the sera of 50 men with benign nonprostatic urologic diseases (EPD), 112 patients with prostate cancer (PCa), and 218 with benign prostatic hyperplasia (BPH). mRNA was extracted from the circulating mononuclear cells of 13 EPD samples, 25 PCa samples, and 38 BPH samples. PSA and PSM mRNA signals were identified in these samples by means of reverse transcriptase-polymerase chain reaction.

RESULTS

Overall, at a fixed specificity of 95%, the sensitivity of tPSA was 19% and that of the fPSA/tPSA ratio was 40% in distinguishing PCa from BPH. The fPSA/tPSA ratio allowed the discrimination of PCa from BPH with satisfactory sensitivity and specificity when considering patients less than 60 years of age (100% and 95%, respectively). PSA and PSM mRNA were positive in 1 and 7 of 13 EPD samples, 6 and 13 of 25 PCa samples, and 6 and 17 of 38 BPH samples. The Gleason score did not correlate with tPSA, the fPSA/tPSA ratio, PSA mRNA, or PSM mRNA.

CONCLUSIONS

The serum determination of the fPSA/tPSA ratio is an excellent index of PCa for subjects younger than 60 years of age; the clinical utility of PSA mRNA identification in circulating cells needs to be validated by large follow-up studies, and the analysis of PSM mRNA seems to be of no clinical interest.

Implications of stage-specific survival rates in assessing recent declines in prostate cancer mortality rates

It has been noted that the most important evidence for a benefit of early detection of prostate cancer using prostate-specific antigen (PSA) testing would be a decline in prostate cancer mortality rates to levels below those existing before diagnostic use of PSA testing. We document a decrease in U.S. prostate cancer mortality rates in white men less than 85 years of age to levels below those existing in 1986, the year use of PSA testing was approved. In fact, for men 60-79 years of age, prostate cancer mortality rates were lower in 1997 than in any year since 1950. Although it has been argued that the decrease in prostate cancer mortality rates began too soon to be explained by PSA testing, stage-specific survival rates indicate that a rapid decrease in mortality may be explained by the large number of high-grade prostate cancers detected before metastasis. If recent decreases in U.S. prostate cancer mortality rates are due to early detection using PSA testing, randomized clinical trials investigating PSA testing will show early evidence of a mortality benefit.

Prostate-specific antigen

Prostate-specific antigen (PSA) has revolutionized the diagnosis and management of men with prostate cancer. Significant advances have been made since the early development of immunoassays. While PSA is useful for staging and monitoring of established disease, it has shown the greatest utility in the realm of early detection realm. PSA is the most important tumor marker; its importance in evaluating men for the possibility of prostate cancer is irrefutable. Enhancing specificity is a pressing need. In this regard, the recognition of the molecular forms of free PSA and complex PSA have shown the most promise and undoubtedly will result in fewer false-positive PSA test results. The salient literature is reviewed and commentary made on the current status of PSA with particular emphasis on methods to enhance its specificity in early detection and applications.

Screening for prostate cancer

Screening for prostate cancer has shown great promise in its ability to detect prostate cancer at a curable stage; however, significant problems exist with respect to our knowledge of its impact on prostate cancer mortality. For the properly informed patient with at least a 10-year life expectancy, it would seem that early detection efforts utilizing digital rectal examination (DRE) and serum prostate-specific antigen (PSA) determination are beneficial. Considerable controversy abounds about early detection and screening and will continue until definitive proof of decreased prostate cancer mortality as a result of effective early detection and treatment regimens is demonstrated. Until then, all men with at least a 10-year life expectancy should be counseled as to the potential benefits and risks. The salient literature is reviewed and commentary made as to the benefits of screening methods that can be invoked as well as their limitations and potential liabilities.