Overall and Disease-Specific Survival of Patients with Screen-Detected Prostate Cancer in the European Randomized Study of Screening for Prostate Cancer, Section Rotterdam

Eliciting men's preferences for decision-making relative to treatments of localized prostate cancer with a good or moderate prognosis

PURPOSE

In diseases where there is no real consensus regarding treatment modalities, promoting shared decision-making can contribute to improving safety and quality of care. This is the case in low- or intermediate-risk localized prostate cancer (PC) treatment. The aim of this study was to investigate the preferences guiding men's decisions regarding the characteristics of the treatment strategies for PC to help physicians adopt a more patient-centered approach.

METHODS

This prospective multicenter study used a discrete choice experiment (DCE). The attributes and the modalities were identified from a qualitative study and a literature review. Relative preferences were estimated using a logistic regression model. Interaction terms (demographic, clinical and socio-economic characteristics) were added to the model to assess heterogeneity in preferences.

RESULTS

652 men were enrolled in the study and completed a questionnaire with 12 pairs of hypothetical therapeutic alternatives between which they had to choose. Men's choices were significantly negatively influenced by the risk of impotence and urinary incontinence, death, and the length and frequency of care. They preferred treatments with a rescue possibility in case of deterioration or recurrence and the use of innovative technology. Surprisingly, the possibility of undergoing prostate ablation negatively influenced their choice. The results also highlighted differences in trade-offs according to socio-economic level.

CONCLUSION

This study confirmed the importance of considering patients' preferences in the decision-making process. It appears essential to better understand these preferences to allow physicians to improve communication and promote case-by-case decision-making.

The prognostic value of transrectal ultrasound guided biopsy in patients over 70 years old with a prostate specific Antigen (PSA) level ≤ 15 ng/ml and normal digital rectal examination: a 10-year prospective follow-up study of 427 consecutive patients

INTRODUCTION

As a urologist, it is common to review a patient above the age of 70 being referred to a prostate assessments clinic with an elevated PSA. We evaluate the prognosis of these patients clinically as there is no international consensus on the exact PSA cutoff level or a single international guideline as to when these patients should be offered a prostate biopsy.

PATIENTS AND METHODS

On receiving ethic committee approval, we recruited 427 consecutive patients aged 70 years and above referred with a PSA of ≥ 4 ng/ml, from January 1996 to December 2000, into our study. All patients were assessed, examined with a digital rectal examination (DRE) of the prostate, and a subsequent prostate biopsy. We followed up on their histologic diagnosis for up to 10 years and analyzed their outcome. The main outcome measures were disease-free survival and overall survival, stratified according to the PSA level (≤ 15 vs. >15 ng/ml) and DRE findings (normal vs. sbnormal).

RESULTS

There was a statistically significant difference in the overall survival (P value < 0.011) and disease specific survival (P value < 0.0001) of cancer patients with a PSA was >15 ng/ml and an abnormal DRE. However, in patients with a PSA ≤ 15 ng/ml and normal DRE, the incidence of cancer was low and they had no disease-specific or overall survival benefit.

CONCLUSIONS

A policy of deferring prostate biopsy in patients with a PSA ≤ 15 ng/ml and normal DRE (Group A) would significantly decrease the need of unnecessary prostate biopsies. Within this group, patients did not have any survival advantage compared with those without cancer. We conclude that up to 20% of the prostate biopsies performed in this age group could have been avoided.

Cysteine-rich secretory protein 3 and β-microseminoprotein on prostate cancer needle biopsies do not have predictive value for subsequent prostatectomy outcome

OBJECTIVES

• To investigate whether cysteine-rich secretory protein 3 (CRISP-3) and/or β-microseminoprotein (β-MSP) expression in diagnostic prostate needle biopsies have predictive value for prostate cancer (PC) on radical prostatecomy (RP). • To evaluate their potential clinical implementation in a preoperative setting.

PATIENTS AND METHODS

• In total, 174 participants from the European Randomized Study of Screening for Prostate Cancer, Rotterdam section, treated by RP for PC were included in the present study. • CRISP-3 and β-MSP immunohistochemistry was performed on corresponding diagnostic needle biopsies. • Outcome was correlated with clinicopathological parameters (prostate-specific-antigen, PSA; number of positive biopsies; Gleason score, GS; pT-stage; surgical margins at RP) and significant PC at RP (pT3/4, or GS > 6, or tumour volume ≥ 0.5 mL) in the total cohort (n= 174) and in a subgroup with low-risk features at biopsy (PSA ≤ 10 ng/ml, cT ≤ 2, PSA density <0.20 ng/mL/g, GS < 7 and ≤ 2 positive biopsy cores; n= 87).

RESULTS

• β-MSP and CRISP-3 expression in PC tissue was heterogeneous, with variable staining intensities occurring in the same tissue specimen. • High expression of β-MSP significantly correlated with GS < 7 at RP; it was not a predictor for significant PC at RP neither in the total group (n= 174; odds ratio, OR, 0.319; 95% confidence interval, CI, 0.060-1.695; P= 0.180), nor in the low-risk group (n= 87; OR, 0.227; 95% CI, 0.040-1.274; P= 0.092). • CRISP-3 expression was not related to clinicopathological parameters, and did not predict significant PC at RP in the total group (n= 174; OR, 1.056; 95% CI, 0.438-2.545; P= 0.904) or the low-risk group (n= 87; OR, 1.856; 95% CI, 0.626-5.506; P= 0.265).

CONCLUSIONS

• High β-MSP expression correlated with low GS in subsequent RP specimens, supporting the view that β-MSP exerts a tumour-suppressive effect. • No significant prognostic value of β-MSP or CRISP-3 in prostate needle biopsies for significant PC at RP was found. • β-MSP or CRISP-3 do not have additional value in the therapeutic stratification of patients with PC.

MRI of the prostate: interobserver agreement compared with histopathologic outcome after radical prostatectomy

BACKGROUND

The purpose of this study was to evaluate interobserver agreement of prostatic MRI in assessing the performance of staging prostate carcinoma in comparison with histopathologic step section prostate specimens.

METHODS

We retrospectively evaluated 46 patients who underwent prostatic MRI examination at 1.5 T MRI and "subsequently" radical prostatectomy. All MR-images were reevaluated by two different experienced radiologists (15 and 1.5 years of experience) with special focus on T2/T3 differentiation. Both radiologists were not aware of the patient's clinical data, except that the patient had prostate cancer. These findings were compared with histopathologic whole mount step section prostate specimens, which served as the "gold standard". Fourfold tables were created to calculate sensitivity, specificity, positive and negative predictive values and efficiency for T2/T3 differentiation. Cohen's kappa was calculated to measure inter-rater agreement.

RESULTS

Twenty-eight patients were diagnosed with organ defined cancer (T2), 18 patients were staged with extracapsular extension (T3), and thereof 7 patients were staged with seminal vesicle invasion (T3b) by the pathologists. The experienced reader reached a sensitivity of 77.78% (95%-CI 52.36%; 93.59%) and specificity of 92.86% (95%-CI 76.50%; 99.12%) for T2/T3 differentiation, the less experienced reader however achieved a sensitivity of 33.33% (95%-CI 13.34%; 59.01%) and specificity of 71.43% (95%-CI 51.33%; 86.78%). The Cohen's kappa for inter-rater reliability for differentiation between T2 and T3 stage was κ=0.0129.

CONCLUSIONS

Evaluation of prostatic MR imaging requires lengthy experience for accurate interpretation and staging. While a highly experienced reader can achieve good correlation with histopathology even without utilization of functional MR imaging, a less experienced reader with theoretical knowledge falls short of expectation.

EORTC elderly task force position paper: approach to the older cancer patient

As a result of an increasing life expectancy, the incidence of cancer cases diagnosed in the older population is rising. Indeed, cancer incidence is 11-fold higher in persons over the age of 65 than in younger ones. Despite this high incidence of cancer in older patients, solid data regarding the most appropriate approach and best treatment for older cancer patients are still lacking, mostly due to under-representation of these patients in prospective clinical trials. The clinical behaviour of common malignant diseases, e.g. breast, ovarian and lung cancers, lymphomas and acute leukaemias, may be different in older patients because of intrinsic variation of the neoplastic cells and the ability of the tumour host to support neoplastic growth. The decision to treat or not these patients should be based on patients' functional age rather than the chronological age. Assessment of patients' functional age includes the evaluation of health, functional status, nutrition, cognition and the psychosocial and economic context. The purpose of this paper is to focus on the influence of age on cancer presentation and cancer management in older cancer patients and to provide suggestions on clinical trial development and methodology in this population.

Prostate cancer in the elderly

Prostate cancer is the most frequent malignancy in men and predominantly in elderly men. The issue of prostate cancer is likely to assume greater importance with progressive aging of the population. With frequent use of PSA testing most patients were diagnosed with localized cancer even in senior adults. Cancer-specific mortality is low in elderly men with prostate cancer and is dependent on the aggressiveness of the tumor. Currently, no established guidelines for the management of prostate cancer in the elderly exist, and treatment of senior adults with localized cancer is not optimal. While elderly men with indolent disease will not benefit from curative treatment, some patients with aggressive cancers will progress if not adequately treated. Comorbidity is the main predictor of life expectancy in the elderly. In everyday clinical practice, treatment decisions are much more influenced by age than by comorbidity. Curative treatment is an effective treatment option for selected elderly with localized prostate cancer. Conversely, most elderly men with prostate cancer received hormonal therapy, although the benefit of hormonal therapy in localized cancer is not clear and is associated with severe toxicities in some patients. In conclusion, there is a need for more risk stratified approaches for the management of prostate cancer in the elderly to avoid unnecessary intervention in men who unlikely benefit from such intervention, and allow treatment in those who might benefit from it.

The diagnostic value of abdominal ultrasound, urine cytology and prostate-specific antigen testing in the lower urinary tract symptoms clinic

INTRODUCTION

Lower urinary tract symptoms (LUTS) affect 18-26% of men aged 40-79 years, many of whom present with a fear of having cancer. Current guidelines for the assessment of LUTS focus mainly upon benign prostatic hypertrophy. It has been our practice to perform an abdominal ultrasound scan (USS), a prostate-specific antigen (PSA) blood test and urine cytology during the assessment of males presenting with LUTS to investigate the alternative potentially life-threatening causes for LUTS. We report on the added value of these tests during the assessment of men with LUTS.

RESULTS

A total of 263/3976 (6.6%) patients investigated for LUTS were found to have incidental urological malignancies, urinary tract calculi or abdominal aortic aneurysms (AAA). Abdominal USSs resulted in the incidental diagnosis of four renal carcinomas (0.1%), 45 AAAs (incidence = 1.1%) and 44 urinary tract calculi (1.1%). Urine cytology testing and bladder USSs helped diagnose 17 new bladder cancers (0.4%), five of which did not present with haematuria. Patients found to have an elevated age-specific PSA had a 23.6% chance of being diagnosed with prostate cancer (3.8%).

CONCLUSION

The addition of abdominal ultrasound scanning, urine cytology and PSA testing as part of an LUTS assessment protocol can help to diagnose significant, potentially life-threatening conditions in up to 6.6% of patients. While the pick up rate of each individual condition is not higher in the LUTS patient than in the general population, the combined pick up rate may justify these additional investigations.

[Public health approach and urology]

Public health approach, in its different fields: observational epidemiology, interventional epidemiology, health economics or health education carries major problems that can influence everyday practice. We review some practical examples of what public health can afford to urology practice.

[PSA--Quo vadis?]

Prostate cancer is the most frequent cancer in males. Because of the high cure rates, early detection of prostate cancer should identify organ-confined prostate cancers. An early detection examination should be performed annually starting at the age of 50 years and ending when life expectancy is less than 10 years. Digital rectal examination is supplemented by determination of prostate-specific antigen (PSA). Before the first PSA test, the patient must be informed of possible consequences such as biopsy recommendation and treatment options. A threshold of 4 ng/ml is defined as the indication for prostate biopsy. Imaging methods do not play a major role in early detection of prostate cancer today. Early detection identifies many latent prostate cancers, and patients may receive overtreatment. A possible solution is to change the early detection paradigm from detection of all prostate cancers to identification of aggressive ones. In this article, early detection is discussed based on the recent literature.

[Trends in prostate biopsy interpretation]

Driven by the pressure of increasing use of PSA screening, cancer diagnosis based on histopathology has been constantly improved. When appropriate quality standards for obtaining a biopsy specimen and for tissue preparation are upheld, even the smallest tumour foci can be identified with certainty. Efforts to standardize the Gleason grading should also help to render assessments of tumour biology more precise. In addition, subtle diagnosis of precancerous or cancer-associated lesions will permit more exact prognoses of existing cancer risk to be made. There are still weak points: reliable recognition of clinically insignificant carcinomas and the danger of overtreatment. Further research activity on this topic is needed.

Diffusion and perfusion MR imaging of the prostate

Conventional anatomic MR imaging has evolved to a superior modality in the evaluation of prostate carcinoma and is now a widely established technique in the detection and staging of this disease, aiding in clinical decision making on treatment and therapy evaluation. Recent improvements in functional MR techniques, such as diffusion-weighted MR imaging and dynamic contrast-enhanced MR imaging, have greatly increased the impact of MR imaging in prostate cancer. The combination of T2-weighted imaging, diffusion-weighted MR imaging, and dynamic contrast-enhanced MR imaging may overcome the limitations of conventional T2-weighted MR imaging of the prostate and may be able accurately to detect, localize, stage, and grade prostate carcinoma and guide biopsies.

Patterns of primary and secondary therapy for prostate cancer in elderly men: analysis of data from CaPSURE

PURPOSE

We examined patterns of primary treatment for prostate cancer in men 75 years or older.

MATERIALS AND METHODS

Data were obtained from the multi-institutional CaPSURE database on the type of primary therapy performed in men younger than 75, or 75 years old or older. Primary therapy was defined as watchful waiting, radical prostatectomy, brachytherapy, brachytherapy plus external beam radiotherapy, external beam radiotherapy or primary androgen deprivation therapy. The chi-square test and multinomial logistic regression analysis were performed to identify predictors of the type of primary therapy and outcomes.

RESULTS

A greater proportion of patients 75 years or older were white, single, had multiple comorbidities, low income and low education, and were classified as being at high risk compared to those younger than 75 years (43% vs 25%). On multivariate analysis adjusted for sociodemographic factors, diagnostic risk category and the number of comorbidities at diagnosis patients 75 years or older were less likely to be treated with primary therapy than with watchful waiting regardless of the risk category or comorbidity level.

CONCLUSIONS

Older patients with high risk cancer are far more likely to be observed regardless of the burden of comorbidity. A more tailored approach to prostate cancer therapy that considers comorbidity and functional level to determine primary therapy may be more appropriate. Well selected older patients with high risk disease, particularly those with low comorbidity levels, may derive survival benefit from a primary therapy other than watchful waiting. Alternatively elderly patients with low risk disease may be better treated with watchful waiting.

[Cryosurgical ablation as primary treatment in prostate cancer patients]

OBJECTIVE

Cryosurgical ablation (CSA) is one treatment option that has been developed and it is now recognised as a true therapeutic alternative in the treatment of localised disease. The aim of this paper is to present the preliminary experience with CSA in prostate cancer from the centre in Norway.

MATERIALS AND METHODS

A total of 132 patients with prostate cancer have been treated with CSA since September 2003. In 90 patients, CSA was the primary therapy used and these patients included those with low (LR; n=27), intermediate (IR; n=37) and high risk (HR: n=26) disease. Low risk patients were defined as those with T1a-T2a, NO, MO, Gleason score < or = 6 and prostate-specific antigen (PSA) <10 ng/ml. Intermediate risk were patients with T2b tumours or a PSA level of 10-20 ng/ml or Gleason score 7. High risk were defined as those with T2c tumours or Gleason score >7 or PSA >20 ng/ml. The remaining 42 patients either had locally advanced disease or had received salvage treatment after previous external beam radiation (EBRT), cryotherapy or hormone treatment. Patients were evaluated at 3 and 6 months and thereafter at 6 month intervals. A voiding history was taken and the following tests conducted: uroflowmetry, residual urine.

RESULTS

Results are presented for those patients receiving CSA as a primary therapy. Currently, the longest follow-up period is 42 months. The median observation period is 21 months and 39% of patients have been seen at the 24-month follow-up visit. No evidence of clinical progression has been observed in patients in the LR or HR group. Two patients in the IR group had clinical evidence of progression. The most common side effects seen during the first year post CSA were urinary tract obstruction and the need for removal of dead prostatic tissue or calcifications. Histological examination of the removed tissue did not shown evidence of prostate cancer. All patients in the LR and IR group that were sexually active before treatment were also sexually active on last follow-up, 37% using some kind of aid. 86% of patients in the LR and IR groups reported no bother as to sexual function.

CONCLUSIONS

CSA is now recognised by the EAU as a true therapeutic alternative for the treatment of prostate cancer. Many institutions offer CSA only to older patients due to the lack of long-term data. If longer follow-up data confirm the short-term effect seen in my series, and if comparable side effects are reported in other studies, CSA might also be offered as primary treatment to younger patients.