Urologists' and general practitioners' knowledge, beliefs and practice relevant for opportunistic prostate cancer screening: a PRISMA-compliant systematic review

Background

Recent guidelines on opportunistic prostate cancer screening conclude that the decision to screen with prostate-specific antigen should be made by each patient individually together with the clinician. However, there is evidence of a lack of clinicians' awareness of prostate cancer screening. This study sought to assess the recent evidence of clinicians' knowledge, beliefs, and practice regarding opportunistic prostate cancer screening comparing urologists and generals practitioners.

Methods

A systematic search was conducted in 3 online databases: MEDLINE, Web of Science and EMBASE (from January 1, 2015, to January 9th, 2023). Studies that explored clinicians' knowledge, beliefs, and practices regarding opportunistic prostate cancer screening were included. Studies were assessed for quality reporting according to the Strengthening the Reporting of Observational studies in Epidemiology guidelines.

Results

A total of 14 studies met the inclusion criteria: ten studies included primary care health professionals, three studies included urologists, and one study included both. Studies involving general practitioners showed a generally low level of awareness of the recommended uses of the test, and urologists showed a greater knowledge of clinical practice guidelines. General practitioners' opinion of prostate-specific antigen was generally unfavourable in contrast to urologists' who were more likely to be proactive in ordering the test. Less than half of the included studies evaluated shared-decision making in practice and 50% of clinicians surveyed implemented it.

Conclusion

General practitioners had less knowledge of prostate cancer risk factors and clinical practice guidelines in the use of PSA than urologists, which makes them less likely to follow available recommendations. A need to carry out education interventions with trusted resources based on the available evidence and the current guidelines was identified.

Navigating through the Controversies and Emerging Paradigms in Early Detection of Prostate Cancer: Bridging the Gap from Classic RCTs to Modern Population-Based Pilot Programs

Over the last three decades, the European Randomized Study of Screening for Prostate Cancer (ERSPC) and the US-based Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening have steered the conversation around the early detection of prostate cancer. These two randomized trials assessed the effect of screening on prostate cancer disease-specific mortality. Elevated PSA levels were followed by a systematic sextant prostate biopsy. Standard repeat testing intervals were applied. After controversies from 2009 to 2016 due to contradicting results of the two trials, the results aligned in 2016 and showed that early PSA detection reduces prostate cancer-specific mortality. However, overdiagnosis rates of up to 50% were reported, and this sparked an intense debate on harms and benefits for almost 20 years. The balance between harms and benefits is highly debated and has initiated further research to investigate new ways of early detection. In the meantime, the knowledge and tools for the diagnostic algorithm improved. This is a continuously ongoing effort which focuses on individual risk-based screening algorithms that preserve the benefits of the purely PSA-based screening algorithms, while reducing the side effects. An important push towards investigating new techniques for early detection came from the European Commission on the 20th of September 2022. The European Commission published its updated recommendation to investigate prostate, lung, and gastric cancer early detection programs. This opened a new window of opportunity to move away from the trial setting to population-based early detection settings. With this review, we aim to review 30 years of historical evidence of prostate cancer screening, which led to the initiation of the 'The Prostate Cancer Awareness and Initiative for Screening in the European Union' (PRAISE-U) project, which aims to encourage the early detection and diagnosis of PCa through customized and risk-based screening programs.

Modified Citrus Pectin Treatment in Non-Metastatic Biochemically Relapsed Prostate Cancer: Long-Term Results of a Prospective Phase II Study

The optimal therapy for patients with non-metastatic biochemically relapsed prostate cancer (BRPC-M0) after local therapy is elusive. Thus, the evaluation of new non-toxic compounds in BRPC-M0 patients is warranted. PectaSol®-Modified citrus pectin (P-MCP) is a food supplement categorized as GRAS (Generally Recognized As Safe) by the FDA. It is a competitive inhibitor of the galectin-3 protein, which is involved in cancer pathogenesis. In an early report of the present phase 2 study, P-MCP treatment for 6 months led to prostate-specific antigen doubling time (PSADT) improvement in 75% of patients with BRPC-M0. Herein, we report the second long-term treatment phase of an additional 12 months of P-MCP therapy (4.8 g × 3/day orally) in patients without disease progression after the initial 6 months of therapy. Of the 46 patients that entered the second treatment phase, 7 patients withdrew consent and decided to continue therapy out of pocket, and 39 initiated the second treatment phase. After a total of 18 months of P-MCP treatment, 85% (n = 33) had a durable long-term response, with 62% (n = 24) showing decreased/stable PSA, 90% (n = 35) PSADT improvement, and all with negative scans. No patient had grade 3/4 toxicity. In conclusion, P-MCP may have long-term durable efficacy and is safe in BRPC-M0.

Impact of PSA testing on secondary care costs in England and Wales: estimates from the Cluster randomised triAl of PSA testing for Prostate cancer (CAP)

BACKGROUND

Screening men for prostate cancer using prostate-specific antigen (PSA) testing remains controversial. We aimed to estimate the likely budgetary impact on secondary care in England and Wales to inform screening decision makers.

METHODS

The Cluster randomised triAl of PSA testing for Prostate cancer study (CAP) compared a single invitation to men aged 50-69 for a PSA test with usual care (no screening). Routinely collected hospital care data were obtained for all men in CAP, and NHS reference costs were mapped to each event via Healthcare Resource Group (HRG) codes. Secondary-care costs per man per year were calculated, and cost differences (and population-level estimates) between arms were derived annually for the first five years following randomisation.

RESULTS

In the first year post-randomisation, secondary-care costs averaged across all men (irrespective of a prostate cancer diagnosis) in the intervention arm (n = 189279) were £44.80 (95% confidence interval: £18.30-£71.30) higher than for men in the control arm (n = 219357). Extrapolated to a population level, the introduction of a single PSA screening invitation could lead to additional secondary care costs of £314 million.

CONCLUSIONS

Introducing a single PSA screening test for men aged 50-69 across England and Wales could lead to very high initial secondary-care costs.

Total Prostate Specific Antigen in Prostate Cancer Screening in Hyperglycemic Individuals

AIM

In this study, it was aimed to investigate the reliability of total prostate-specific antigen (t-PSA) in prostate cancer screening in hyperglycemic (≥126 mg/dL) individuals.

METHODS

This research was planned as a cross-sectional retrospective study. Three hundred eleven cases which underwent biopsy with the suspicion of prostate cancer in the hospital were included in the study. Prostate cancer risk groups were categorized as low, intermediate and high. Those with fasting blood glucose (FBG) levels lower than 126 mg/dL were considered as the normoglycemia group.

RESULTS

It was determined that the t-PSA measurement was higher in the patient group with cancer (P < .001). It was determined that the median t-PSA levels of the intermediate and high cancer groups were higher than the low cancer group (P < .001 and P = .001, respectively). t-PSA was found to be associated with increased cancer risk in cases with FBG <126. However, an increase in t-PSA values in cases with FBG ≥126 was not associated with increased prostate cancer. There is no relationship between FBG measurement and t-PSA measurement (rs=0.05, P = .446). In addition, it was determined that the t-PSA measurements of patients with FBG ≥126 and FBG<126 did not differ (P = .962).

CONCLUSIONS

As a contribution to literature, we found that the t-PSA test lost its sensitivity in cases with plasma glucose levels above normal. Loss of sensitivity may result in underdiagnosis in prostate cancer and this, in turn, results in diagnosis of the cancer at a later stage. In the future, it may be necessary to adopt a different approach in prostate cancer screening in hyperglycemic cases.

Predicting biochemical recurrence of prostate cancer with artificial intelligence

Background

The first sign of metastatic prostate cancer after radical prostatectomy is rising PSA levels in the blood, termed biochemical recurrence. The prediction of recurrence relies mainly on the morphological assessment of prostate cancer using the Gleason grading system. However, in this system, within-grade morphological patterns and subtle histopathological features are currently omitted, leaving a significant amount of prognostic potential unexplored.

Methods

To discover additional prognostic information using artificial intelligence, we trained a deep learning system to predict biochemical recurrence from tissue in H&E-stained microarray cores directly. We developed a morphological biomarker using convolutional neural networks leveraging a nested case-control study of 685 patients and validated on an independent cohort of 204 patients. We use concept-based explainability methods to interpret the learned tissue patterns.

Results

The biomarker provides a strong correlation with biochemical recurrence in two sets (n = 182 and n = 204) from separate institutions. Concept-based explanations provided tissue patterns interpretable by pathologists.

Conclusions

These results show that the model finds predictive power in the tissue beyond the morphological ISUP grading.

Effective examination methods for identifying the primary origins of metastatic bone tumors of unknown primary origin during the initial visit: A retrospective chart review study

Objective:

To provide appropriate treatment for patients, early diagnosis of the primary origin of skeletal metastases of unknown primary origin is important. This study aimed to assess the examination strategy effective for identifying the primary origin of skeletal metastases of unknown primary origin.

Methods:

Sixty-one patients with skeletal metastases of unknown primary origin were reviewed. The primary origin was examined via physical examination, blood test including tumor markers, chest radiography, thoracoabdominal computed tomography scan, positron emission tomography–computed tomography scan, metastatic lesion biopsy, and other assessments. Examination methods considered effective for the diagnosis of the primary origin in a specific type of cancer were investigated.

Results:

The lung was the most common primary origin site, followed by the lymph nodes, prostate, and breast. Meanwhile, biopsy was the most effective examination, followed by positron emission tomography–computed tomography scan and thoracoabdominal computed tomography scan. Blood tests are useful for detecting hematological malignancies and prostate cancer. Computed tomography scans can be used to identify cancers in the lung, breast, and kidney, which are the common primary origins. Forty-one (67.2%) of the 61 patients with skeletal metastases of unknown primary origin were diagnosed via the first four steps, that is, physical examination, blood test, chest radiography, and thoracoabdominal computed tomography scan. Finally, two patients were diagnosed with skeletal metastases of unknown primary origin.

Conclusion:

The examination steps used in this study, including physical examination, blood test including tumor markers, chest radiography, thoracoabdominal computed tomography scan, positron emission tomography–computed tomography scan, biopsy, and other assessments were effective in determining the primary origin of skeletal metastases of unknown primary origin during the initial visit.

A scoping review of social relationships and prostate cancer screening

According to current US recommendations, the choice to undergo screening for prostate cancer should be an individual one, after considering with a clinician the balance of harms and benefits, and the values and preferences in the decision. Social relationships may influence such a decision. The purpose of this scoping review was to map the evidence on the association between social relationships and prostate cancer screening in the epidemiological literature and to highlight gaps in knowledge. We performed a systematic search of all relevant articles published up to February 1st 2021. We used variations in search terms related to prostate cancer screening, as well as indicators of social relationships. From the 908 records identified, 19 studies, published in 2007-2020, were included. The most common indicator of social relationships was marital status. Overall, married men or men with a partner had a higher screening uptake. Church attendance, based on studies conducted in the United states, was also associated with screening. We found little evidence linking screening with parenthood status or perceived social support. The overall evidence points to a potentially causal association between social relationships and men's decision to undergo prostate cancer screening. More research is needed on the underlying mechanisms and on the potential barriers and facilitators for screening.

Decision aid and cost compensation influence uptake of PSA-based early detection without affecting decisional conflict: a cluster randomised trial

International guidelines recommend to inform men about the benefits and harms of prostate specific antigen (PSA) based early detection of prostate cancer. This study investigates the influence of a transactional decision aid (DA) or cost compensation (CC) for a PSA test on the decisional behaviour of men. Prospective, cluster-randomised trial to compare two interventions in a 2 × 2 factorial design: DA versus counselling as usual, and CC versus noCC for PSA-testing. 90 cluster-randomised physicians in the administrative district of Muenster, Germany recruited 962 participants aged 55-69 yrs. in 2018. Primary endpoint: the influence of the DA and CC on the decisional conflict. Secondary endpoints: factors which altered the involvement of the men regarding their decision to take a PSA-test. The primary endpoint was analysed by a multivariate regression model. The choice to take the PSA test was increased by CC and reduced by the DA, the latter also reduced PSA uptake in men who were offered CC. The DA led to an increase of the median knowledge about early detection, changed willingness to perform a PSA test without increasing the level of shared decision, giving participants a stronger feeling of having made the decision by themselves. The DA did not alter the decisional conflict, as it was very low in all study groups. DA reduced and CC increased the PSA uptake. The DA seemed to have a greater impact on the participants than CC, as it led to fewer PSA tests even if CC was granted.Trial registration: German Clinical Trial Register (Deutsches Register Klinischer Studien DRKS00007687). Registered: 06/05/2015. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00007687 .

Do the Prostate-Specific Antigen (PSA) Tests That Are Ordered in Clinical Practice Adhere to the Pertinent Guidelines?

Scientific societies have provided guidelines to reduce PSA-specific harms. We studied the potential non-compliance of PSA testing with current guidelines in general practice. A cross-sectional study of a random sample of 1291 patients with a PSA test was performed between January and April 2018 in primary health care. Patients with a previous prostate cancer diagnosis or those who were being followed-up for previous high PSA values were excluded. Two independent researchers classified whether each test was potentially non-compliant with recommendations. We estimated frequencies of potentially non-compliant PSA determinations and calculated prevalence ratios (PR) to assess their relationship with possible explanatory variables. A total of 66% (95% CI: 62-69%) of PSA requests in asymptomatic patients were potentially non-compliant with the current guideline. This was associated with having a previous diagnosis of neoplasm (PR adjusted by age and life expectancy: 1.18; 95% CI: 1.02-1.37) as well as being a current consumer of tobacco, alcohol, or other drugs (PR: 0.80; 95% CI: 0.67-0.97). Real world data shows that patients are still frequently exposed to overdiagnosis risk with a PSA potentially non-compliant with recommendations. Patients diagnosed with another neoplasm or non-consumers of toxic substances were more exposed, probably due to increased contact with doctors or health-seeking behaviour.

Blood-Derived Biomarkers of Diagnosis, Prognosis and Therapy Response in Prostate Cancer Patients

Prostate cancer is among the most frequent cancers in men worldwide. Despite the fact that multiple therapeutic alternatives are available for its treatment, it is often discovered in an advanced stage as a metastatic disease. Prostate cancer screening is based on physical examination of prostate size and prostate-specific antigen (PSA) level in the blood as well as biopsy in suspect cases. However, these markers often fail to correctly identify the presence of cancer, or their positivity might lead to overdiagnosis and consequent overtreatment of an otherwise silent non-progressing disease. Moreover, these markers have very limited if any predictive value regarding therapy response or individual risk for therapy-related toxicities. Therefore, novel, optimally liquid biopsy-based (blood-derived) markers or marker panels are needed, which have better prognostic and predictive value than the ones currently used in the everyday routine. In this review the role of circulating tumour cells, extracellular vesicles and their microRNA content, as well as cellular and soluble immunological and inflammation- related blood markers for prostate cancer diagnosis, prognosis and prediction of therapy response is discussed. A special emphasis is placed on markers predicting response to radiotherapy and radiotherapy-related late side effects.

Prostate-specific antigen testing and opportunistic prostate cancer screening: a cohort study in England, 1998-2017

Background

Prostate cancer is a leading cause of cancer- related death. Interpreting the results from trials of screening with prostate-specific antigen (PSA) is complex in terms of defining optimal prostate cancer screening policy.

Aim

To assess the rates of, and factors associated with, the uptake of PSA testing and opportunistic screening (that is, a PSA test in the absence of any symptoms) in England between 1998 and 2017, and to estimate the likely rates of pre-randomisation screening and contamination (that is, unscheduled screening in the ‘control’ arm) of the UK-based Cluster Randomised Trial of PSA Testing for Prostate Cancer (CAP).

Design and setting

Open cohort study of men in England aged 40–75 years at cohort entry (1998–2017), undertaken using the QResearch database.

Method

Eligible men were followed for up to 19 years. Rates of PSA testing and opportunistic PSA screening were calculated; Cox regression was used to estimate associations.

Results

The cohort comprised 2 808 477 men, of whom 631 426 had a total of 1 720 855 PSA tests. The authors identified that 410 724 men had opportunistic PSA screening. Cumulative proportions of uptake of opportunistic screening in the cohort were 9.96% at 5 years’, 22.71% at 10 years’, and 44.13% at 19 years’ follow-up. The potential rate of contamination in the CAP control arm was estimated at 24.50%.

Conclusion

A substantial number of men in England opt in to opportunistic prostate cancer screening, despite uncertainty regarding its efficacy and harms. The rate of opportunistic prostate cancer screening in the population is likely to have contaminated the CAP trial, making it difficult to interpret the results.

Harms and Benefits of Cancer Screening

In recommending and offering screening, health services make a health claim ('it's good for you'). This article considers ethical aspects of establishing the case for cancer screening, building a service programme, monitoring its operation, improving its quality and integrating it with medical progress. The value of (first) screening is derived as a function of key parameters: prevalence of the target lesion in the detectable pre-clinical phase, the validity of the test and the respective net utilities or values attributed to four health states-true positives, false positives, false negatives and true negatives. Decision makers as diverse as public regulatory agencies, medical associations, health insurance funds or individual screenees can legitimately come up with different values even when presented with the same evidence base. The main intended benefit of screening is the reduction of cause-specific mortality. All-cause mortality is not measurably affected. Overdiagnosis and false-positive tests with their sequelae are the main harms. Harms and benefits accrue to distinct individuals. Hence the health claim is an invitation to a lottery with benefits for few and harms to many, a violation of the non-maleficence principle. While a public decision maker may still propose a justified screening programme, respect for individual rights and values requires preference-sensitive, autonomy-enhancing educational materials-even at the expense of programme effectiveness. Opt-in recommendations and more 'consumer-oriented' qualitative research are needed.

Impact of PI-RADS Category 3 lesions on the diagnostic accuracy of MRI for detecting prostate cancer and the prevalence of prostate cancer within each PI-RADS category: A systematic review and meta-analysis

OBJECTIVE

To evaluate Prostate Imaging Reporting and Data System (PI-RADS) category 3 lesions' impact on the diagnostic test accuracy (DTA) of MRI for prostate cancer (PC) and to derive the prevalence of PC within each PI-RADS category.

METHODS

MEDLINE and Embase were searched until April 10, 2020 for studies reporting on the DTA of MRI by PI-RADS category. Accuracy metrics were calculated using a bivariate random-effects meta-analysis with PI-RADS three lesions treated as a positive test, negative test, and excluded from the analysis. Differences in DTA were assessed utilizing meta-regression. PC prevalence within each PI-RADS category was estimated with a proportional meta-analysis.

RESULTS

In total, 26 studies reporting on 12,913 patients (4,853 with PC) were included. Sensitivities for PC in the positive, negative, and excluded test groups were 96% (95% confidence interval [CI] 92-98), 82% (CI 75-87), and 95% (CI 91-97), respectively. Specificities for the positive, negative, and excluded test groups were 33% (CI 23-44), 71% (CI 62-79), and 52% (CI 37-66), respectively. Meta-regression demonstrated higher sensitivity (p < 0.001) and lower specificity (p < 0.001) in the positive test group compared to the negative group. Clinically significant PC prevalences were 5.9% (CI 0-17.1), 11.4% (CI 6.5-17.3), 24.9% (CI 18.4-32.0), 55.7% (CI 47.8-63.5), and 81.4% (CI 75.9-86.4) for PI-RADS categories 1, 2, 3, 4 and 5, respectively.

CONCLUSION

PI-RADS category 3 lesions can significantly impact the DTA of MRI for PC detection. A low prevalence of clinically significant PC is noted in PI-RADS category 1 and 2 cases.

ADVANCES IN KNOWLEDGE

Inclusion or exclusion of PI-RADS category 3 lesions impacts the DTA of MRI for PC detection.

Assessment of harms, benefits, and cost-effectiveness of prostate cancer screening: A micro-simulation study of 230 scenarios

Background

Prostate cancer screening incurs a high risk of overdiagnosis and overtreatment. An organized and age‐targeted screening strategy may reduce the associated harms while retaining or enhancing the benefits.

Methods

Using a micro‐simulation analysis (MISCAN) model, we assessed the harms, benefits, and cost‐effectiveness of 230 prostate‐specific antigen (PSA) screening strategies in a Dutch population. Screening strategies were varied by screening start age (50, 51, 52, 53, 54, and 55), stop age (51‐69), and intervals (1, 2, 3, 4, 8, and single test). Costs and effects of each screening strategy were compared with a no‐screening scenario.

Results

The most optimum strategy would be screening with 3‐year intervals at ages 55–64 resulting in an incremental cost‐effectiveness ratio (ICER) of €19 733 per QALY. This strategy predicted a 27% prostate cancer mortality reduction and 28 life years gained (LYG) per 1000 men; 36% of screen‐detected men were overdiagnosed. Sensitivity analyses did not substantially alter the optimal screening strategy.

Conclusions

PSA screening beyond age 64 is not cost‐effective and associated with a higher risk of overdiagnosis. Similarly, starting screening before age 55 is not a favored strategy based on our cost‐effectiveness analysis.

Spatial Autocorrelation of Breast and Prostate Cancer in Slovakia

Cancer is one of the dominant causes of death in the Slovak population. Monitoring the course of the cancer death rate in Slovakia can be considered as a relevant subject for geographical research. Relatively little is known about the geographic distribution of breast and prostate cancer incidence in Slovakia. In the submitted paper, it is hypothesized that breast and prostate cancer in the examined territory are characterized by different intensities, incidences, and spatial differences. The spatial patterns of breast and prostate cancer in Slovakia were examined by means of spatial autocorrelation analyses with the Local Moran's I and Anselin Local Moran's statistics. Data on standardized death rates of breast and prostate cancer in Slovakia between 2001 and 2018 were used. Prostate cancer in men and breast cancer in women show a positive statistically significant Global Moran's I, whose values indicate a tendency to cluster. The Anselin Local Moran's I analysis indicates significant clusters of breast cancer in the western part of Slovakia, and prostate cancer clusters mostly in the central part of Slovakia. The findings we have obtained in this study may help us investigate further hypotheses regarding the causes and identification of spatial differences in breast and prostate cancer incidence. Our findings might stimulate further research into the possible causes which underlie the clusters.

Cancer stem cell and mesenchymal cell cooperative actions in metastasis progression and hormone resistance in prostate cancer: Potential role of androgen and gonadotropin‑releasing hormone receptors (Review)

Prostate cancer (PCa) is the leading cause of male cancer‑associated mortality worldwide. Mortality is associated with metastasis and hormone resistance. Cellular, genetic and molecular mechanisms underlying metastatic progression and hormone resistance are poorly understood. Studies have investigated the local effects of gonadotropin‑releasing hormone (GnRH) analogs (used for androgen deprivation treatments) and the presence of the GnRH receptor (GnRH‑R) on PCa cells. Furthermore, cell subpopulations with stem‑like properties, or cancer stem cells, have been isolated and characterized using a cell culture system derived from explants of human prostate tumors. In addition, the development of preclinical orthotopic models of human PCa in a nonobese diabetic/severe combined immunodeficiency mouse model of compromised immunity has enabled the establishment of a reproducible system of metastatic progression in vivo. There is increasing evidence that metastasis is a complex process involving the cooperative actions of different cancer cell subpopulations, in which cancer stem‑like cells would be responsible for the final step of colonizing premetastatic niches. It has been hypothesized that PCa cells with stemness and mesenchymal signatures act cooperatively in metastatic progression and the inhibition of stemness genes, and that overexpression of androgen receptor (AR) and GnRH‑R decreases the rate the metastasis and sensitizes tumors to hormone therapy. The aim of the present review is to analyze the evidence regarding this cooperative process and the possible influence of stem‑like cell phenotypes, AR and GnRH‑R in metastatic progression and hormone resistance. These aspects may represent an important contribution in the understanding of the mechanisms underlying metastasis and hormone resistance in PCa, and potential routes to blocking these processes, enabling the development of novel therapies that would be particularly relevant for patients with metastatic and castration‑resistant PCa.

Incidence and disease burden of prostate cancer from 1990 to 2017: Results from the Global Burden of Disease Study 2017

BACKGROUND

The patterns of the incidence and mortality of prostate cancer (PC) have been changing over the years. In addition, the unclear etiology of PC necessitates further studies into the geographic distribution and age composition of patients with PC. This study was aimed at examining the patterns of the epidemiology of PC to help policymakers to allocate the limited resources of the health care system accordingly.

METHODS

Annual case data and age-standardized rates (ASRs) were obtained for the incidence, mortality, and disability-adjusted life-years (DALYs) of PC according to age from 1990 to 2017 and for 21 regions, including 195 countries and territories. The estimated annual percentage changes (EAPCs) of ASRs were calculated to evaluate the incidence and mortality trends of PC.

RESULTS

Worldwide, the age-standardized incidence rate (ASIR) of PC increased from 30.5 cases per 100,000 population in 1990 to 37.9 cases per 100,000 population in 2017 with an EAPC of 0.59 (95% confidence interval [CI], 0.49-0.7), whereas the mortality decreased with an EAPC of -0.73 (95% CI, -0.80 to -0.67). The ASIR was positively associated with the sociodemographic index (SDI) in most regions, and the increase in the ASIR was steeper with a higher SDI. The proportion of patients younger than 65 years increased from 23.6% in 1990 to 27.3% in 2017.

CONCLUSIONS

The incidence of PC has been increasing globally, whereas its mortality and DALYs have been decreasing. These trends are particularly significant in developed regions and vary across geographic regions. Adjustments to the medical strategy by governments and medical institutions are required.

Extracellular vesicles in urological malignancies: an update

Extracellular vesicles (EVs) have an essential functional role in local tumour progression, metastatic spread and the emergence of drug resistance in bladder, kidney and prostate cancer. Thus, EVs could be diagnostic, prognostic and predictive biomarkers for these malignancies. Virtually all biomolecules (including DNA, mRNA, microRNA, long non-coding RNA, proteins and lipids) packaged into EVs have been tested as biomarkers in blood and urine samples. The results are very heterogeneous, but promising biomarker candidates have been identified. Differing methods of EV isolation, characterization and analysis of their content have been used owing to a lack of international consensus; hence, comparing study results is challenging. Furthermore, validation of potential biomarkers in independent cohorts or prospective trials has rarely been performed. Future efforts to establish EV-derived biomarkers need to adequately address these points. In addition, emerging technologies such as mass spectroscopy and chip-based approaches can identify surface markers specific for cancer-associated EVs and will enable specific separation from blood and urine EVs, which probably will improve their performance as biomarkers. Moreover, EVs could be harnessed as therapeutic drug delivery vehicles for precise and effective anticancer therapy.

Carcinogenicity assessment: Addressing the challenges of cancer and chemicals in the environment

Cancer is a key public health concern, being the second leading cause of worldwide morbidity and mortality after cardiovascular diseases. At the global level, cancer prevalence, incidence and mortality rates are increasing. These trends are not fully explained by a growing and ageing population: with marked regional and socioeconomic disparities, lifestyle factors, the resources dedicated to preventive medicine, and the occupational and environmental control of hazardous chemicals all playing a role. While it is difficult to establish the contribution of chemical exposure to the societal burden of cancer, a number of measures can be taken to better assess the carcinogenic properties of chemicals and manage their risks. This paper discusses how these measures can be informed not only by the traditional data streams of regulatory toxicology, but also by using new toxicological assessment methods, along with indicators of public health status based on biomonitoring. These diverse evidence streams have the potential to form the basis of an integrated and more effective approach to cancer prevention.

Development and Prospective Randomized Evaluation of a Decision Aid for Prostate-specific Antigen-based Early Detection of Prostate Cancer in Men Aged Between 55 and 69Yr: The PSAInForm Trial

For men interested in early detection of prostate cancer, the potential impact on decisional conflict of a decision aid with or without cost compensation for the prostate-specific antigen test will be investigated.

Predicting trajectories of recovery in prostate cancer patients undergone Robot-Assisted Radical Prostatectomy (RARP)

OBJECTIVE

To identify trends of patients' urinary and sexual dysfunctions from a clinical and psychological perspective and understand whether sociodemographic and medical predictors could differentiate among patients following different one-year longitudinal trajectories.

METHODS

An Italian sample of 478 prostate cancer patients undergone Robot-Assisted Radical Prostatectomy completed the EPIC-26 survey between July 2015 and July 2016 at the pre-hospitalization (T0), 45 days (T1) and 3 (T2), 6 (T3), 9 (T4), and 12 months (T5) after surgery. Sociodemographic and clinical characteristics (age, BMI, diabetes, nerve-sparing procedure) were also collected. Latent Class Growth Analysis was conducted separately for sexual dysfunction and urinary incontinence EPIC-26 subscales. The association between membership in the two longitudinal trajectories of urinary and sexual dysfunctions was assessed by considering Chi-square test and its related contingency table.

RESULTS

People who have a high level of urinary incontinence at T1 are likely to have a worse recovery. Age, BMI and pre-surgical continence may affect the level of incontinence at T1 and the recovery trajectories. Patients with low and moderate sexual problems at T1 can face a moderate linear recovery, while people with high level of impotence immediately after surgery may take a longer period to solve sexual dysfunctions. Age and the pre-surgical sexual condition may impact the recovery. Finally, a great proportion of patients reported both steady problems in sexual function and constant high levels of urinary incontinence over time.

CONCLUSIONS

This study highlights different categories of patients at risk who may be important to know in order to develop personalized medical pathways and predictive models in a value-based healthcare.

Prostate Cancer in Primary Care

Prostate cancer is a common malignancy seen worldwide. The incidence has risen in recent decades, mainly fuelled by more widespread use of prostate-specific antigen (PSA) testing, although prostate cancer mortality rates have remained relatively static over that time period. A man's risk of prostate cancer is affected by his age and family history of the disease. Men with prostate cancer generally present symptomatically in primary care settings, although some diagnoses are made in asymptomatic men undergoing opportunistic PSA screening. Symptoms traditionally thought to correlate with prostate cancer include lower urinary tract symptoms (LUTS), such as nocturia and poor urinary stream, erectile dysfunction and visible haematuria. However, there is significant crossover in symptoms between prostate cancer and benign conditions affecting the prostate such as benign prostatic hypertrophy (BPH) and prostatitis, making it very challenging to distinguish between them on the basis of symptoms. The evidence for the performance of PSA in asymptomatic and symptomatic men for the diagnosis of prostate cancer is equivocal. PSA is subject to false positive and false negative results, affecting its clinical utility as a standalone test. Clinicians need to counsel men about the risks and benefits of PSA testing to inform their decision-making. Digital rectal examination (DRE) by primary care clinicians has some evidence to show discrimination between benign and malignant conditions affecting the prostate. Patients referred to secondary care for diagnostic testing for prostate cancer will typically undergo a transrectal or transperineal biopsy, where a number of samples are taken and sent for histological examination. These biopsies are invasive procedures with side effects and a risk of infection and sepsis, and alternative tests such as multiparametric magnetic resonance imaging (mpMRI) are currently being trialled for their accuracy and safety in diagnosing clinically significant prostate cancer.

Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline

OBJECTIVE

To update the "Testosterone Therapy in Men With Androgen Deficiency Syndromes" guideline published in 2010.

PARTICIPANTS

The participants include an Endocrine Society-appointed task force of 10 medical content experts and a clinical practice guideline methodologist.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies.

CONSENSUS PROCESS

One group meeting, several conference calls, and e-mail communications facilitated consensus development. Endocrine Society committees and members and the cosponsoring organization were invited to review and comment on preliminary drafts of the guideline.

CONCLUSIONS

We recommend making a diagnosis of hypogonadism only in men with symptoms and signs consistent with testosterone (T) deficiency and unequivocally and consistently low serum T concentrations. We recommend measuring fasting morning total T concentrations using an accurate and reliable assay as the initial diagnostic test. We recommend confirming the diagnosis by repeating the measurement of morning fasting total T concentrations. In men whose total T is near the lower limit of normal or who have a condition that alters sex hormone-binding globulin, we recommend obtaining a free T concentration using either equilibrium dialysis or estimating it using an accurate formula. In men determined to have androgen deficiency, we recommend additional diagnostic evaluation to ascertain the cause of androgen deficiency. We recommend T therapy for men with symptomatic T deficiency to induce and maintain secondary sex characteristics and correct symptoms of hypogonadism after discussing the potential benefits and risks of therapy and of monitoring therapy and involving the patient in decision making. We recommend against starting T therapy in patients who are planning fertility in the near term or have any of the following conditions: breast or prostate cancer, a palpable prostate nodule or induration, prostate-specific antigen level > 4 ng/mL, prostate-specific antigen > 3 ng/mL in men at increased risk of prostate cancer (e.g., African Americans and men with a first-degree relative with diagnosed prostate cancer) without further urological evaluation, elevated hematocrit, untreated severe obstructive sleep apnea, severe lower urinary tract symptoms, uncontrolled heart failure, myocardial infarction or stroke within the last 6 months, or thrombophilia. We suggest that when clinicians institute T therapy, they aim at achieving T concentrations in the mid-normal range during treatment with any of the approved formulations, taking into consideration patient preference, pharmacokinetics, formulation-specific adverse effects, treatment burden, and cost. Clinicians should monitor men receiving T therapy using a standardized plan that includes: evaluating symptoms, adverse effects, and compliance; measuring serum T and hematocrit concentrations; and evaluating prostate cancer risk during the first year after initiating T therapy.

Screening for prostate cancer: are organized screening programs necessary?

Already in 1991 when the prostate-specific antigen (PSA) test was proposed as a diagnostic test, screening for prostate cancer (PCa) was considered controversial due to the considerable risk of detecting latent PCa. Randomised controlled trials were initiated to assess the potential of PSA-based screening in reducing disease-specific mortality. Harms and benefit were closely monitored and both were confirmed. A reduction in mortality was seen and at the same time the initial fear of unnecessary testing and over diagnosis became reality. This triggered professional organizations to adapt their guidelines and to focus on shared decision making (SDM) and selective screening for those men considered at high risk. Unfortunately implementation of guidelines into daily clinical practice is bothersome. As a result many men are being (re)tested while not being at risk and the potential benefit being unclear. This raises the question on whether PSA screening should be organized in controlled programs. While the PSA test will remain the mainstay of PCa early detection many other additional tests (biomarkers/imaging) are currently being tested in large population-based initiatives as a first step to organized programs in selective groups of men.