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Hamdy FC, Donovan JL, Lane JA, Mason M, Metcalfe C, Holding P, Wade J, Noble S, Garfield K, Young G, Davis M, Peters TJ, Turner EL, Martin RM, Oxley J, Robinson M, Staffurth J, Walsh E, Blazeby J, Bryant R, Bollina P, Catto J, Doble A, Doherty A, Gillatt D, Gnanapragasam V, Hughes O, Kockelbergh R, Kynaston H, Paul A, Paez E, Powell P, Prescott S, Rosario D, Rowe E, Neal D. Active monitoring, radical prostatectomy and radical radiotherapy in PSA-detected clinically localised prostate cancer: the ProtecT three-arm RCT. Health Technol Assess 2020; 24:1-176. [PMID: 32773013 PMCID: PMC7443739 DOI: 10.3310/hta24370] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Prostate cancer is the most common cancer among men in the UK. Prostate-specific antigen testing followed by biopsy leads to overdetection, overtreatment as well as undertreatment of the disease. Evidence of treatment effectiveness has lacked because of the paucity of randomised controlled trials comparing conventional treatments. OBJECTIVES To evaluate the effectiveness of conventional treatments for localised prostate cancer (active monitoring, radical prostatectomy and radical radiotherapy) in men aged 50-69 years. DESIGN A prospective, multicentre prostate-specific antigen testing programme followed by a randomised trial of treatment, with a comprehensive cohort follow-up. SETTING Prostate-specific antigen testing in primary care and treatment in nine urology departments in the UK. PARTICIPANTS Between 2001 and 2009, 228,966 men aged 50-69 years received an invitation to attend an appointment for information about the Prostate testing for cancer and Treatment (ProtecT) study and a prostate-specific antigen test; 82,429 men were tested, 2664 were diagnosed with localised prostate cancer, 1643 agreed to randomisation to active monitoring (n = 545), radical prostatectomy (n = 553) or radical radiotherapy (n = 545) and 997 chose a treatment. INTERVENTIONS The interventions were active monitoring, radical prostatectomy and radical radiotherapy. TRIAL PRIMARY OUTCOME MEASURE Definite or probable disease-specific mortality at the 10-year median follow-up in randomised participants. SECONDARY OUTCOME MEASURES Overall mortality, metastases, disease progression, treatment complications, resource utilisation and patient-reported outcomes. RESULTS There were no statistically significant differences between the groups for 17 prostate cancer-specific (p = 0.48) and 169 all-cause (p = 0.87) deaths. Eight men died of prostate cancer in the active monitoring group (1.5 per 1000 person-years, 95% confidence interval 0.7 to 3.0); five died of prostate cancer in the radical prostatectomy group (0.9 per 1000 person-years, 95% confidence interval 0.4 to 2.2 per 1000 person years) and four died of prostate cancer in the radical radiotherapy group (0.7 per 1000 person-years, 95% confidence interval 0.3 to 2.0 per 1000 person years). More men developed metastases in the active monitoring group than in the radical prostatectomy and radical radiotherapy groups: active monitoring, n = 33 (6.3 per 1000 person-years, 95% confidence interval 4.5 to 8.8); radical prostatectomy, n = 13 (2.4 per 1000 person-years, 95% confidence interval 1.4 to 4.2 per 1000 person years); and radical radiotherapy, n = 16 (3.0 per 1000 person-years, 95% confidence interval 1.9 to 4.9 per 1000 person-years; p = 0.004). There were higher rates of disease progression in the active monitoring group than in the radical prostatectomy and radical radiotherapy groups: active monitoring (n = 112; 22.9 per 1000 person-years, 95% confidence interval 19.0 to 27.5 per 1000 person years); radical prostatectomy (n = 46; 8.9 per 1000 person-years, 95% confidence interval 6.7 to 11.9 per 1000 person-years); and radical radiotherapy (n = 46; 9.0 per 1000 person-years, 95% confidence interval 6.7 to 12.0 per 1000 person years; p < 0.001). Radical prostatectomy had the greatest impact on sexual function/urinary continence and remained worse than radical radiotherapy and active monitoring. Radical radiotherapy's impact on sexual function was greatest at 6 months, but recovered somewhat in the majority of participants. Sexual and urinary function gradually declined in the active monitoring group. Bowel function was worse with radical radiotherapy at 6 months, but it recovered with the exception of bloody stools. Urinary voiding and nocturia worsened in the radical radiotherapy group at 6 months but recovered. Condition-specific quality-of-life effects mirrored functional changes. No differences in anxiety/depression or generic or cancer-related quality of life were found. At the National Institute for Health and Care Excellence threshold of £20,000 per quality-adjusted life-year, the probabilities that each arm was the most cost-effective option were 58% (radical radiotherapy), 32% (active monitoring) and 10% (radical prostatectomy). LIMITATIONS A single prostate-specific antigen test and transrectal ultrasound biopsies were used. There were very few non-white men in the trial. The majority of men had low- and intermediate-risk disease. Longer follow-up is needed. CONCLUSIONS At a median follow-up point of 10 years, prostate cancer-specific mortality was low, irrespective of the assigned treatment. Radical prostatectomy and radical radiotherapy reduced disease progression and metastases, but with side effects. Further work is needed to follow up participants at a median of 15 years. TRIAL REGISTRATION Current Controlled Trials ISRCTN20141297. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 37. See the National Institute for Health Research Journals Library website for further project information.
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Affiliation(s)
- Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - J Athene Lane
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Malcolm Mason
- School of Medicine, University of Cardiff, Cardiff, UK
| | - Chris Metcalfe
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Holding
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Julia Wade
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Grace Young
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Davis
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Tim J Peters
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Emma L Turner
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Jon Oxley
- Department of Cellular Pathology, North Bristol NHS Trust, Bristol, UK
| | - Mary Robinson
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - John Staffurth
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff, UK
| | - Eleanor Walsh
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane Blazeby
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Richard Bryant
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Prasad Bollina
- Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - James Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Andrew Doble
- Department of Urology, Addenbrooke's Hospital, Cambridge, UK
| | - Alan Doherty
- Department of Urology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Gillatt
- Department of Urology, Southmead Hospital and Bristol Urological Institute, Bristol, UK
| | | | - Owen Hughes
- Department of Urology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Roger Kockelbergh
- Department of Urology, University Hospitals of Leicester, Leicester, UK
| | - Howard Kynaston
- Department of Urology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Alan Paul
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Edgar Paez
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Philip Powell
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Stephen Prescott
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Derek Rosario
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Edward Rowe
- Department of Urology, Southmead Hospital and Bristol Urological Institute, Bristol, UK
| | - David Neal
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
- Academic Urology Group, University of Cambridge, Cambridge, UK
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Tilling K, Lawton M, Robertson N, Tremlett H, Zhu F, Harding K, Oger J, Ben-Shlomo Y. Modelling disease progression in relapsing-remitting onset multiple sclerosis using multilevel models applied to longitudinal data from two natural history cohorts and one treated cohort. Health Technol Assess 2018; 20:1-48. [PMID: 27817792 DOI: 10.3310/hta20810] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The ability to better predict disease progression represents a major unmet need in multiple sclerosis (MS), and would help to inform therapeutic and management choices. OBJECTIVES To develop multilevel models using longitudinal data on disease progression in patients with relapsing-remitting MS (RRMS) or secondary-progressive MS (SPMS); and to use these models to estimate the association of disease-modifying therapy (DMT) with progression. DESIGN Secondary analysis of three MS cohorts. SETTING Two natural history cohorts: University of Wales Multiple Sclerosis (UoWMS) cohort, UK, and British Columbia Multiple Sclerosis (BCMS) cohort, Canada. One observational DMT-treated cohort: UK MS risk-sharing scheme (RSS). PARTICIPANTS The UoWMS database has > 2000 MS patients and the BCMS database (as of 2009) has > 5900 MS patients. All participants who had definite MS (RRMS/SPMS), who reached the criteria set out by the Association of British Neurologists (ABN) for eligibility for DMT [i.e. age ≥ 18 years, Expanded Disability Status Scale (EDSS) score of ≤ 6.5, occurrence of two or more relapses in the previous 2 years] and who had at least two repeated outcome measures were included: 404 patients for the UoWMS cohort and 978 patients for the BCMS cohort. Through the UK MS RSS scheme, 5583 DMT-treated patients were recruited, with the analysis sample being the 4137 who had RRMS and were eligible and treated at baseline, with at least one valid EDSS score post baseline. MAIN OUTCOME MEASURES EDSS score observations post ABN eligibility. METHODS We used multilevel models in the development cohort (UoWMS) to develop a model for EDSS score with time since ABN eligibility, allowing for covariates and appropriate transformation of outcome and/or time. These methods were then applied to the BCMS cohort to obtain a 'natural history' model for changes in the EDSS score with time. We then used this natural history model to predict the trajectories of EDSS score in treated patients in the UK MS RSS database. Differences between the progression predicted by the natural history model and the progression observed at 6 years' follow-up for the UK MS RSS cohort were used as indicators of the effectiveness of the DMTs. Previously developed utility scores were assigned to each EDSS score, and differences in utility also examined. RESULTS The model best fitting the UoWMS data showed a non-linear increase in EDSS score over time since ABN eligibility. This model fitted the BCMS cohort data well, with similar coefficients, and the BCMS model predicted EDSS score in UoWMS data with little evidence of bias. Using the natural history model predicts EDSS score in a treated cohort (UK MS RSS) higher than that observed [by 0.59 points (95% confidence interval 0.54 to 0.64 points)] at 6 years post treatment. LIMITATIONS Only two natural history cohorts were compared, limiting generalisability. The comparison of a treated cohort with untreated cohorts is observational, thus limiting conclusions about causality. CONCLUSIONS EDSS score progression in two natural history cohorts of MS patients showed a similar pattern. Progression in the natural history cohorts was slightly faster than EDSS score progression in the DMT-treated cohort, up to 6 years post treatment. FUTURE WORK Long-term follow-up of randomised controlled trials is needed to replicate these findings and examine duration of any treatment effect. FUNDING DETAILS The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Kate Tilling
- School of Social and Community Medicine, Bristol University, Bristol, UK
| | - Michael Lawton
- School of Social and Community Medicine, Bristol University, Bristol, UK
| | - Neil Robertson
- Department of Neurology, Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Helen Tremlett
- Faculty of Medicine, Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Feng Zhu
- Faculty of Medicine, Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Katharine Harding
- Department of Neurology, Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, Cardiff, UK
| | - Joel Oger
- Faculty of Medicine, Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Yoav Ben-Shlomo
- School of Social and Community Medicine, Bristol University, Bristol, UK
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Simpkin AJ, Donovan JL, Tilling K, Athene Lane J, Martin RM, Albertsen PC, Bill-Axelson A, Ballentine Carter H, Bosch JLHR, Ferrucci L, Hamdy FC, Holmberg L, Jeffrey Metter E, Neal DE, Parker CC, Metcalfe C. Prostate-specific antigen patterns in US and European populations: comparison of six diverse cohorts. BJU Int 2016; 118:911-918. [PMID: 26799945 DOI: 10.1111/bju.13422] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine whether there are differences in prostate-specific antigen (PSA) levels at diagnosis or changes in PSA levels between US and European populations of men with and without prostate cancer (PCa). SUBJECTS AND METHODS We analysed repeated measures of PSA from six clinically and geographically diverse cohorts of men: two cohorts with PSA-detected PCa, two cohorts with clinically detected PCa and two cohorts without PCa. Using multilevel models, average PSA at diagnosis and PSA change over time were compared among study populations. RESULTS The annual percentage PSA change of 4-5% was similar between men without cancer and men with PSA-detected cancer. PSA at diagnosis was 1.7 ng/mL lower in a US cohort of men with PSA-detected PCa (95% confidence interval 1.3-2.0 ng/mL), compared with a UK cohort of men with PSA-detected PCa, but there was no evidence of a different rate of PSA change between these populations. CONCLUSION We found that PSA changes over time are similar in UK and US men diagnosed through PSA testing and even in men without PCa. Further development of PSA models to monitor men on active surveillance should be undertaken in order to take advantage of these similarities. We found no evidence that guidelines for using PSA to monitor men cannot be passed between US and European studies.
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Affiliation(s)
- Andrew J Simpkin
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Kate Tilling
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - J Athene Lane
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Richard M Martin
- School of Social and Community Medicine, University of Bristol, Bristol, UK
- NIHR Bristol Nutrition Biomedical Research Unit, University of Bristol, Bristol, UK
| | - Peter C Albertsen
- Division of Urology, University of Connecticut Health Center, Farmington, CT, USA
| | - Anna Bill-Axelson
- Institution of Surgical Sciences, Department of Urology, Uppsala University, Uppsala, Sweden
| | | | - J L H Ruud Bosch
- Department of Urology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Luigi Ferrucci
- National Institute on Aging, National Institutes of Health, Baltimore, MA, USA
| | - Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Lars Holmberg
- Faculty of Life Sciences and Medicine, King's College London, London, UK
- Regional Cancer Centre, Uppsala/Örebro Region, Uppsala, Sweden
| | - E Jeffrey Metter
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - David E Neal
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Christopher C Parker
- Academic Urology Unit, Royal Marsden Hospital, Institute of Cancer Research, London, UK
| | - Chris Metcalfe
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Simpkin AJ, Rooshenas L, Wade J, Donovan JL, Lane JA, Martin RM, Metcalfe C, Albertsen PC, Hamdy FC, Holmberg L, Neal DE, Tilling K. Development, validation and evaluation of an instrument for active monitoring of men with clinically localised prostate cancer: systematic review, cohort studies and qualitative study. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03300] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundActive surveillance [(AS), sometimes called active monitoring (AM)],is a National Institute for Health and Care Excellence-recommended management option for men with clinically localised prostate cancer (PCa). It aims to target radical treatment only to those who would benefit most. Little consensus exists nationally or internationally about safe and effective protocols for AM/AS or triggers that indicate if or when men should move to radical treatment.ObjectiveThe aims of this project were to review how prostate-specific antigen (PSA) has been used in AM/AS programmes; to develop and test the validity of a new model for predicting future PSA levels; to develop an instrument, based on PSA, that would be acceptable and effective for men and clinicians to use in clinical practice; and to design a robust study to evaluate the cost-effectiveness of the instrument.MethodsA systematic review was conducted to investigate how PSA is currently used to monitor men in worldwide AM/AS studies. A model for PSA change with age was developed using Prostate testing for cancer and Treatment (ProtecT) data and validated using data from two PSA-era cohorts and two pre-PSA-era cohorts. The model was used to derive 95% PSA reference ranges (PSARRs) across ages. These reference ranges were used to predict the onset of metastases or death from PCa in one of the pre-PSA-era cohorts. PSARRs were incorporated into an active monitoring system (AMS) and demonstrated to 18 clinicians and 20 men with PCa from four NHS trusts. Qualitative interviews investigated patients’ and clinicians’ views about current AM/AS protocols and the acceptability of the AMS within current practice.ResultsThe systematic review found that the most commonly used triggers for clinical review of PCa were PSA doubling time (PSADT) < 3 years or PSA velocity (PSAv) > 1 ng/ml/year. The model for PSA change (developed using ProtecT study data) predicted PSA values in AM/AS cohorts within 2 ng/ml of observed PSA in up to 79% of men. Comparing the three PSA markers, there was no clear optimal approach to alerting men to worsening cancer. The PSARR and PSADT markers improved the modelc-statistic for predicting death from PCa by 0.11 (21%) and 0.13 (25%), respectively, compared with using diagnostic information alone [PSA, age, tumour stage (T-stage)]. Interviews revealed variation in clinical practice regarding eligibility and follow-up protocols. Patients and clinicians perceive current AM/AS practice to be framed by uncertainty, ranging from uncertainty about selection of eligible AM/AS candidates to uncertainty about optimum follow-up protocols and thresholds for clinical review/radical treatment. Patients and clinicians generally responded positively to the AMS. The impact of the AMS on clinicians’ decision-making was limited by a lack of data linking AMS values to long-term outcomes and by current clinical practice, which viewed PSA measures as one of several tools guiding clinical decisions in AM/AS. Patients reported that they would look to clinicians, rather than to a tool, to direct decision-making.LimitationsThe quantitative findings were severely hampered by a lack of clinical outcomes or events (such as metastases). The qualitative findings were limited through reliance on participants’ reports of practices and recollections of events rather than observations of actual interactions.ConclusionsPatients and clinicians found that the instrument provided additional, potentially helpful, information but were uncertain about the current usefulness of the risk model we developed for routine management. Comparison of the model with other monitoring strategies will require clinical outcomes from ongoing AM/AS studies.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Andrew J Simpkin
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Leila Rooshenas
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Julia Wade
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - J Athene Lane
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Richard M Martin
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Chris Metcalfe
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Peter C Albertsen
- Division of Urology, University of Connecticut Health Center, Farmington, CT, USA
| | - Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Lars Holmberg
- Faculty of Life Sciences & Medicine, King’s College London, London, UK
- Regional Cancer Centre, Uppsala/Örebro Region, Uppsala, Sweden
| | - David E Neal
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Kate Tilling
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Lawton M, Tilling K, Robertson N, Tremlett H, Zhu F, Harding K, Oger J, Ben-Shlomo Y. A longitudinal model for disease progression was developed and applied to multiple sclerosis. J Clin Epidemiol 2015; 68:1355-65. [PMID: 26071892 PMCID: PMC4643305 DOI: 10.1016/j.jclinepi.2015.05.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 03/30/2015] [Accepted: 05/05/2015] [Indexed: 11/26/2022]
Abstract
Objectives To develop a model of disease progression using multiple sclerosis (MS) as an exemplar. Study Design and Settings Two observational cohorts, the University of Wales MS (UoWMS), UK (1976), and British Columbia MS (BCMS) database, Canada (1980), with longitudinal disability data [the Expanded Disability Status Scale (EDSS)] were used; individuals potentially eligible for MS disease-modifying drugs treatments, but who were unexposed, were selected. Multilevel modeling was used to estimate the EDSS trajectory over time in one data set and validated in the other; challenges addressed included the choice and function of time axis, complex observation-level variation, adjustments for MS relapses, and autocorrelation. Results The best-fitting model for the UoWMS cohort (404 individuals, and 2,290 EDSS observations) included a nonlinear function of time since onset. Measurement error decreased over time and ad hoc methods reduced autocorrelation and the effect of relapse. Replication within the BCMS cohort (978 individuals and 7,335 EDSS observations) led to a model with similar time (years) coefficients, time [0.22 (95% confidence interval {CI}: 0.19, 0.26), 0.16 (95% CI: 0.10, 0.22)] and log time [−0.13 (95% CI: −0.39, 0.14), −0.15 (95% CI: −0.70, 0.40)] for BCMS and UoWMS, respectively. Conclusion It is possible to develop robust models of disability progression for chronic disease. However, explicit validation is important given the complex methodological challenges faced.
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Affiliation(s)
- Michael Lawton
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, BS8 2PS, UK.
| | - Kate Tilling
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, BS8 2PS, UK
| | - Neil Robertson
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales, Cardiff, CF14 4XN, UK
| | - Helen Tremlett
- Faculty of Medicine (Neurology), UBC Hospital, 2211 Wesbrook Mall, University of British Columbia, Vancouver, BC V6T 2B5 Canada
| | - Feng Zhu
- Faculty of Medicine (Neurology), UBC Hospital, 2211 Wesbrook Mall, University of British Columbia, Vancouver, BC V6T 2B5 Canada
| | - Katharine Harding
- Institute of Psychological Medicine and Clinical Neuroscience, Cardiff University, University Hospital of Wales, Cardiff, CF14 4XN, UK
| | - Joel Oger
- Faculty of Medicine (Neurology), UBC Hospital, 2211 Wesbrook Mall, University of British Columbia, Vancouver, BC V6T 2B5 Canada
| | - Yoav Ben-Shlomo
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, BS8 2PS, UK
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Associations of circulating 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, and vitamin D pathway genes with prostate-specific antigen progression in men with localized prostate cancer undergoing active monitoring. Eur J Cancer Prev 2013; 22:121-5. [PMID: 22955340 DOI: 10.1097/cej.0b013e3283584954] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Current diagnostic tests cannot differentiate the majority of prostate cancers with a low likelihood of progression from the minority with more aggressive potential. We examined whether the measures of vitamin D were associated with prostate-specific antigen (PSA) doubling time in men undergoing active monitoring. We examined the associations of circulating 25-hydroxyvitamin D (25(OH)D), 1,25-dihydroxyvitamin D (1,25(OH)2D), and vitamin D pathway polymorphisms with PSA doubling time in 490 men undergoing active monitoring for localized prostate cancer within a UK population-based cohort study [mean follow-up 4.4 years (range: 0.3-7.6)]. Repeat PSA measurements were analyzed using multilevel models. There was no evidence that circulating 25(OH)D levels, 1,25(OH)2D levels, or vitamin D pathway polymorphisms were associated with postdiagnosis PSA doubling time. Stratifying the results by prostate cancer grade at diagnosis (high grade or low grade) did not alter the results. We found no evidence that either circulating 25(OH)D, 1,25(OH)2D, or vitamin D pathway polymorphisms were associated with PSA doubling time in men undergoing active monitoring for localized prostate cancer. Future studies should examine the associations of variation in vitamin D with clinical outcomes (metastases and death).
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Simpkin AJ, Metcalfe C, Martin RM, Lane JA, Donovan JL, Hamdy FC, Neal DE, Tilling K. Longitudinal prostate-specific antigen reference ranges: Choosing the underlying model of age-related changes. Stat Methods Med Res 2013; 25:1875-1891. [PMID: 24108270 DOI: 10.1177/0962280213503928] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Serial measurements of prostate-specific antigen (PSA) are used as a biomarker for men diagnosed with prostate cancer following an active monitoring programme. Distinguishing pathological changes from natural age-related changes is not straightforward. Here, we compare four approaches to modelling age-related change in PSA with the aim of developing reference ranges for repeated measures of PSA. A suitable model for PSA reference ranges must satisfy two criteria. First, it must offer an accurate description of the trend of PSA on average and in individuals. Second, it must be able to make accurate predictions about new PSA observations for an individual and about the entire PSA trajectory for a new individual.
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Affiliation(s)
- Andrew J Simpkin
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Chris Metcalfe
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Richard M Martin
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - J Athene Lane
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - David E Neal
- Cambridge Research Institute Cancer Research, Cambridge, UK
| | - Kate Tilling
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Abstract
Mechanisms postulated to link folate and B12 metabolism with cancer, including genome-wide hypomethylation, gene-specific promoter hypermethylation, and DNA uracil misincorporation, have been observed in prostate tumor cells. However, epidemiological studies of prostate cancer risk, based on dietary intakes and blood levels of folate and vitamin B12 and on folate-pathway gene variants, have generated contradictory findings. In a meta-analysis, circulating concentrations of B12 (seven studies, OR = 1.10; 95% CI 1.01, 1.19; P = 0.002) and (in cohort studies) folate (five studies, OR = 1.18; 95% CI 1.00, 1.40; P = 0.02) were positively associated with an increased risk of prostate cancer. Homocysteine was not associated with risk of prostate cancer (four studies, OR = 0.91; 95% CI 0.69, 1.19; P = 0.5). In a meta-analysis of folate-pathway polymorphisms, MTR 2756A > G (eight studies, OR = 1.06; 95% CI 1.00, 1.12; P = 0.06) and SHMT1 1420C > T (two studies, OR = 1.11; 95% CI 1.00, 1.22; P = 0.05) were positively associated with prostate cancer risk. There were no effects due to any other polymorphisms, including MTHFR 677C > T (12 studies, OR = 1.04; 95% CI 0.97, 1.12; P = 0.3). The positive association of circulating B12 with an increased risk of prostate cancer could be explained by reverse causality. However, given current controversies over mandatory B12 fortification, further research to eliminate a causal role of B12 in prostate cancer initiation and/or progression is required. Meta-analysis does not entirely rule out a positive association of circulating folate with increased prostate cancer risk. As with B12, even a weak positive association would be a significant public health issue, given the high prevalence of prostate cancer and concerns about the potential harms versus benefits of mandatory folic acid fortification.
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Xia J, Trock BJ, Cooperberg MR, Gulati R, Zeliadt SB, Gore JL, Lin DW, Carroll PR, Carter HB, Etzioni R. Prostate cancer mortality following active surveillance versus immediate radical prostatectomy. Clin Cancer Res 2012; 18:5471-8. [PMID: 23008476 DOI: 10.1158/1078-0432.ccr-12-1502] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE [corrected] Active surveillance has been endorsed for low-risk prostate cancer, but information about long-term outcomes and comparative effectiveness of active surveillance is lacking. The purpose of this study is to project prostate cancer mortality under active surveillance followed by radical prostatectomy versus under immediate radical prostatectomy. EXPERIMENTAL DESIGN A simulation model was developed to combine information on time from diagnosis to treatment under active surveillance and associated disease progression from a Johns Hopkins active surveillance cohort (n = 769), time from radical prostatectomy to recurrence from cases in the CaPSURE database with T-stage ≤ T2a (n = 3,470), and time from recurrence to prostate cancer death from a T-stage ≤ T2a Johns Hopkins cohort of patients whose disease recurred after radical prostatectomy (n = 963). Results were projected for a hypothetical cohort aged 40 to 90 years with low-risk prostate cancer (T-stage ≤ T2a, Gleason score ≤ 6, and prostate-specific antigen level ≤ 10 ng/mL). RESULTS The model projected that 2.8% of men on active surveillance and 1.6% of men with immediate radical prostatectomy would die of their disease in 20 years. Corresponding lifetime estimates were 3.4% for active surveillance and 2.0% for immediate radical prostatectomy. The average projected increase in life expectancy associated with immediate radical prostatectomy was 1.8 months. On average, the model projected that men on active surveillance would remain free of treatment for an additional 6.4 years relative to men treated immediately. CONCLUSIONS Active surveillance is likely to produce a very modest decline in prostate cancer-specific survival among men diagnosed with low-risk prostate cancer but could lead to significant benefits in terms of quality of life.
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Affiliation(s)
- Jing Xia
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, WA, USA
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10
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Hegarty J, Beirne PV, Walsh E, Comber H, Fitzgerald T, Wallace Kazer M. Radical prostatectomy versus watchful waiting for prostate cancer. Cochrane Database Syst Rev 2010:CD006590. [PMID: 21069689 DOI: 10.1002/14651858.cd006590.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The lack of evidence regarding the effectiveness of treatment options for clinically localised prostate cancer continues to impact on clinical decision-making. Two such options are radical prostatectomy (RP) and watchful waiting (WW). WW involves providing no initial treatment and monitoring the patient with the intention of providing palliative treatment if there is evidence of disease progression. OBJECTIVES To compare the beneficial and harmful effects of RP versus WW for the treatment of localised prostate cancer. SEARCH STRATEGY MEDLINE, EMBASE, The Cochrane Library, ISI Science Citation Index, DARE and LILACS were searched through 30 July 2010. SELECTION CRITERIA Randomised or quasi-randomised controlled trials comparing the effects of RP versus WW for clinically localised prostate cancer. DATA COLLECTION AND ANALYSIS Data extraction and quality assessment were carried out independently by two authors. MAIN RESULTS Two trials met the inclusion criteria. Both trials commenced prior to the widespread availability of prostate-specific antigen (PSA) screening; hence the results may not be applicable to men with PSA-detected disease.One trial (N = 142), conducted in the US, was judged to be of poor quality. All cause (overall) mortality was not significantly different between RP and WW groups after fifteen years of follow up (Hazard Ratio (HR) 0.9 (95% Confidence Interval (CI) 0.56 to 1.43).The second trial (N = 695), conducted in Scandinavia, was judged to be of good quality. After 12 years of follow up, the trial results were compatible with a beneficial effect of RP on the risks of overall mortality, prostate cancer mortality and distant metastases compared with WW but the precise magnitude of the effect is uncertain as indicated by the width of the confidence intervals for all estimates (risk difference (RD) -7.1% (95% CI -14.7 to 0.5); RD -5.4% (95% CI -11.1 to 0.2); RD -6.7% (95% CI -13.2 to -0.2), respectively). Compared to WW, RP increased the absolute risks of erectile dysfunction (RD 35% (95% CI 25 to 45)) and urinary leakage (RD 27% (95% CI 17 to 37)). These estimates must be interpreted cautiously as they are derived from data obtained from a self-administered questionnaire survey of a sample of the trial participants (N = 326), no baseline quality of life data were obtained and nerve-sparing surgery was not routinely performed on trial participants undergoing RP. AUTHORS' CONCLUSIONS The existing trials provide insufficient evidence to allow confident statements to be made about the relative beneficial and harmful effects of RP and WW for patients with localised prostate cancer. The results of ongoing trials should help to inform treatment decisions for men with screen-detected localised prostate cancer.
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Affiliation(s)
- Josephine Hegarty
- School of Nursing and Midwifery, University College Cork, Brookfield Health Sciences Complex, College Road, Cork, Ireland
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11
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Moul JW, Tang P, Sun L. Editorial Comment on: Development of a New Method for Monitoring Prostate-Specific Antigen Changes in Men with Localised Prostate Cancer: A Comparison of Observational Cohorts. Eur Urol 2010; 57:452. [DOI: 10.1016/j.eururo.2009.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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12
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Metcalfe C, Tilling K, Davis M, Lane JA, Martin RM, Kynaston H, Powell P, Neal DE, Hamdy F, Donovan JL. Current strategies for monitoring men with localised prostate cancer lack a strong evidence base: observational longitudinal study. Br J Cancer 2009; 101:390-4. [PMID: 19603015 PMCID: PMC2720224 DOI: 10.1038/sj.bjc.6605181] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: The UK National Institute for Health and Clinical Excellence (NICE) guidance recommends conservative management of men with ‘low-risk’ localised prostate cancer, monitoring the disease using prostate-specific antigen (PSA) kinetics and re-biopsy. However, there is little evidence of the changes in PSA level that should alert to the need for clinical re-assessment. Methods: This study compares the alerts resulting from PSA kinetics and a novel longitudinal reference range approach, which incorporates age-related changes, during the monitoring of 408 men with localised prostate cancer. Men were monitored by regular PSA tests over a mean of 2.9 years, recording when a man's PSA doubling time fell below 2 years, PSA velocity exceeded 2 ng ml–1 per year, or when his upper 10% reference range was exceeded. Results: Prostate-specific antigen doubling time and PSA velocity alerted a high proportion of men initially but became unresponsive to changes with successive tests. Calculating doubling time using recent PSA measurements reduced the decline in response. The reference range method maintained responsiveness to changes in PSA level throughout the monitoring. Conclusion: The increasing unresponsiveness of PSA kinetics is a consequence of the underlying regression model. Novel methods are needed for evaluation in cohorts currently being managed by monitoring. Meanwhile, the NICE guidance should be cautious.
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Affiliation(s)
- C Metcalfe
- Department of Social Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
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