Predictors of attendance for prostate-specific antigen screening tests and prostate biopsy

Barriers and facilitators of shared decision-making in prostate cancer screening in primary care: A systematic review

Objective

To identify barriers and facilitators of the implementation of shared decision-making (SDM) on PSA testing in primary care.

Design

Systematic review of articles.

Data sources

PubMed, Scopus, Embase and Web of Science.

Eligibility criteria

Original studies published in English or Spanish that assessed the barriers to and facilitators of SDM before PSA testing in primary care were included. No time restrictions were applied.

Data extraction and synthesis

Two review authors screened the titles, abstracts and full texts for inclusion, and assessed the quality of the included studies. A thematic synthesis of the results were performed and developed a framework. Quality assessment of the studies was based on three checklists: STROBE for quantitative cross-sectional studies, GUIDED for intervention studies and SRQR for qualitative studies.

Results

The search returned 431 articles, of which we included 13: five cross-sectional studies, two intervention studies, five qualitative studies and one mixed methods study. The identified barriers included lack of time (healthcare professionals), lack of knowledge (healthcare professionals and patients), and preestablished beliefs (patients). The identified facilitators included decision-making training for professionals, education for patients and healthcare professionals, and dissemination of information.

Conclusions

SDM implementation in primary care seems to be a recent field. Many of the barriers identified are modifiable, and the facilitators can be leveraged to strengthen the implementation of SDM.

'Is it painful'? A qualitative study on experiences of patients before prostate needle biopsy

OBJECTIVE

To assess the experiences and emotional reactions of men prior to receiving a prostate needle biopsy (PNB).

DESIGN

This was a qualitative study involving (1) material research and filter, (2) interviewer training, (3) cognitive semistructured interviews with open-ended questions, (4) data analysis, including translation and back translation and (5) group discussions to determine common themes in the data. All interviews were digitally audio-recorded. The thematic analysis was conducted by repeatedly reading the data manuscript and engaging in group discussion.

SETTING AND PARTICIPANTS

A total of 30 participants with suspected prostate cancer (PC) who were scheduled to receive a PNB were interviewed. Eligible participants were Chinese native men aged 51-77 years, and the study was conducted in China between September and December 2020. All participants were informed about the purpose of the study and provided written informed consent.

RESULTS

Four main themes were identified based on the interview content: (1) fear (of pain, adverse effects and bad results), (2) impact of lower urinary tract symptoms (on emotional impact, work and sleeping), (3) inner struggles (relating to hesitation, regret and embarrassment) and (4) lifestyle change (including diet, exercise and receipt of traditional Chinese medicine).

CONCLUSIONS

This patient cohort had a low level of knowledge about PC and PNB. Providing additional education about these topics would help to reduce patient fear and anxiety and improve experiences of the procedure.

Early Detection of Prostate Cancer: Self-Reported Knowledge and Attitude of Physicians in Jordan

Prostate cancer (PC) screening aims to detect PC in early stages, amenable to curative treatment and reduction in disease morbidity and mortality. However, PC screening may be associated with overdiagnosis and complications of unnecessary treatment for indolent disease. Therefore, careful patient selection for PC screening is critical to avoid overestimation and missed diagnosis. The aim of this study was to assess physicians’ knowledge and attitude towards early detection of PC in Jordan and whether their knowledge is an important predictor of their attitude. An electronic, self-reported questionnaire was used to collect data on demographics, knowledge, and attitude of physicians regarding early detection of PC. The participants’ responses were analyzed using descriptive statistics and multiple linear regression. Around 296 physicians agreed to participate in this study. Most respondents were males (75.7%), residents (34%), practiced medicine more than 15 years (29%) and graduated (81.4%) from local universities. Surprisingly, only 28.4% recognized PC as a non-self-detected disease and less than one-half (48.6%) were aware that PC screening tests are not enough to exclude a diagnosis of PC. The median knowledge Percent of Maximum Possible (POMP) score was 59%. Around two-thirds of participants showed a positive attitude towards early detection of PC (median attitude POMP score was 66%). Higher attitude scores were significantly associated with younger age, those working in private hospitals, and those having higher knowledge POMP score (P < .05). This study highlighted that most physicians demonstrated a positive attitude towards PC screening but with moderate level of knowledge that is considered an important predictor of their attitude towards PC early detection. Thus, improving knowledge and awareness of physicians should be considered as a strategy to improve their attitude towards prostate screening practices and informing men of the importance of regular screening.

Characteristics Associated with the Use of Diagnostic Prostate Biopsy and Biopsy Outcomes in Australian Men

BACKGROUND

Population characteristics associated with the use of prostate biopsy are poorly understood. We described the use of diagnostic prostate biopsy and subsequent biopsy outcomes in a population-based Australian cohort.

METHODS

A total of 91,764 men from the Sax Institute's 45 and Up Study (New South Wales, Australia) recruited during 2006 to 2009 were included. Self-completed baseline questionnaires and linked administrative health data were used. Study period was from the date of recruitment to December 2013. Cox regression and logistic regression identified factors associated with receipt of biopsy and subsequent prostate cancer diagnosis.

RESULTS

During the study period, 5,089 participants had a diagnostic prostate biopsy, and 2,805 men (55.1% of those biopsied) received a cancer diagnosis. Men with a family history of prostate cancer (HR 1.55; 95% confidence interval (CI), 1.43-1.68), severe lower urinary tract symptoms (HR 1.62; 95% CI, 1.41-1.86), or a record of medication for benign prostatic hyperplasia (HR 1.34; 95% CI, 1.23-1.47) had increased risks of receiving a biopsy. Men with a family history of prostate cancer had increased odds of a positive biopsy (OR 1.21; 95% CI, 1.01-1.43). High alcohol consumption (≥21 drinks per week compared with 1-6 drinks per week) was associated with decreased risk of biopsy (HR 0.88; 95% CI, 0.80-0.96) but increased odds of a positive biopsy (OR 1.63; 95% CI, 1.32-2.02).

CONCLUSIONS

Certain characteristics are associated with both undertaking diagnostic prostate biopsy and positive biopsy outcomes.

IMPACT

This highlights the need to improve management of specific groups of men, especially those with clinical symptoms that overlap with prostate cancer, in their investigation for prostate cancer.

The STHLM3-model, Risk-based Prostate Cancer Testing Identifies Men at High Risk Without Inducing Negative Psychosocial Effects

Background

The new STHLM3 test, combining protein markers, genetic markers, and clinical data to assess a man's prostate cancer (PCa) risk, has been investigated in Sweden within the frame of the STHLM3 trial.

Objective

To assess whether the STHLM3 test influences men's worry level, PCa knowledge, attitude, and health-related quality of life (HRQoL).

Design setting and participants

Invitations with login to the web survey were mailed to 10 000 men, 50-69 yr of age, who were eligible for the STHLM3 trial. The survey was sent 3 mo before invitation to the STHLM3 trial (baseline) and 5 mo after STHLM3 (follow-up). At baseline, the men were unaware of the upcoming invitation to STHLM3. The survey covered the following: PCa-specific worry and perceived vulnerability, knowledge about PCa, attitude toward PCa testing and health behavior, and HRQoL.

Outcome measurements and statistical analysis

Survey scores were compared between baseline and follow-up by using the nonparametric Wilcoxon-signed rank tests for paired samples. Analysis of covariance was performed for PCa risk group comparisons.

Results and limitations

A total of 994 men (10%) responded to our survey at baseline and follow-up, and were assessed as follows: low risk: 421 men; intermediate risk: 421 men; and high risk:152, of whom 59 were diagnosed with PCa after further investigation. In men assessed as having low and intermediate risk, level of worrying decreased at follow-up (p <  0.001), whereas no changes were observed in men at high risk. Moreover, no HRQoL changes were observed over time. The low response rate is the main limitation.

Conclusions

We found that the STHLM3 model, a risk-based PCa test, showed no negative impact on the well-being of men.

Patient summary

Since our results suggest that the risk-based screening as used in STHLM3 did not induce negative psychological effects on the participants, we can recommend this risk-based approach for population-based prostate cancer screening.

Peripheral zone PSA density: a predominant variable to improve prostate cancer detection efficiency in men with PSA higher than 4 ng ml-1

To improve the diagnostic efficiency of prostate cancer (PCa) and reduce unnecessary biopsies, we defined and analyzed the diagnostic efficiency of peripheral zone prostate-specific antigen (PSA) density (PZ-PSAD). Patients who underwent systematic 12-core prostate biopsies in Shanghai General Hospital (Shanghai, China) between January 2012 and January 2018 were retrospectively identified (n = 529). Another group of patients with benign prostatic hyperplasia (n = 100) were randomly preselected to obtain the PSA density of the non-PCa cohort (N-PSAD). Prostate volumes and transition zone volumes were measured using multiparameter magnetic resonance imaging (mpMRI) and were combined with PSA and N-PSAD to obtain the PZ-PSAD from a specific algorithm. Receiver operating characteristic (ROC) curve analysis was used to assess the PCa detection efficiency in patients stratified by PSA level, and the area under the ROC curve (AUC) of PZ-PSAD was higher than that of PSA, PSA density (PSAD), and transition zone PSA density (TZ-PSAD). PZ-PSAD could amend the diagnosis for more than half of the patients with inaccurate transrectal ultrasonography (TRUS) and mpMRI results. When TRUS and mpMRI findings were ambiguous to predict PCa (PIRADS score ≤3), PZ-PSAD could increase the positive rate of biopsy from 21.7% to 54.7%, and help 63.8% (150/235) of patients avoid unnecessary prostate biopsy. In patients whose PSA was 4.0–10.0 ng ml⁻¹, 10.1–20.0 ng ml⁻¹, and >20.0 ng ml⁻¹, the ideal PZ-PSAD cut-off value for predicting clinically significant PCa was 0.019 ng ml⁻², 0.297 ng ml⁻², and 1.180 ng ml⁻², respectively (sensitivity >90%). Compared with PSA, PSAD, and TZ-PSAD, the efficiency of PZ-PSAD for predicting PCa is the highest, leading to fewer missed diagnoses and unnecessary biopsies.

The association between the knowledge on prostate cancer screening with the beliefs and behaviors of Saudi men attending King Khalid University Hospital

Background:

The evidence showed that prostate cancer (PC) is the second most common malignancy in men globally. Unfortunately, it rarely produces symptoms, and the diagnosis is delayed until the tumor is advanced.

Objectives:

To determine the participants’ uptake of prostate cancer screening (PCS). Also, to assess their perceptions regarding PCS. Furthermore, to evaluate the association between patients’ knowledge of PC and their beliefs and behaviors towards PCS.

Methods:

This cross-sectional study recruited men aged older than 40attending the King Khalid University Hospital (KKUH) between October 2020 and March 2021. SMS messages were sent to a random sample of 228 participants, inviting them to participate in an online self-administered questionnaire. The questionnaire consisted of 1- demography and history of PCS; 2- the knowledge questionnaire about PC; 3-the Champion's Health Belief Model (HBM).

Results:

Out of the 228 participants, 45.2% were men aged 60 years and above, 54.4% with college degrees and postgraduate studies, and 92.5% were married. The median knowledge score was 5, and the range was 12. Most men (72.4%) had a low knowledge score, and 79.4% of them did not have a previous PCS. Men aged 60 + were more likely to undergo the screening than their counterparts, with P values of 0.005. Higher knowledge scores were associated with the perceived benefits of prostate-specific antigen (PSA), digital rectal examination (DRE), and health motivation, P values of 0.0001, 0.0001, and 0.02, respectively. PSA and DRE›s perceived barriers were associated with low knowledge scores, P values of 0.0001 and 0.003, respectively. A higher probability of PCS participation was associated with the older age group, a P value of 0.001. Low participation was associated with perceived barriers of DRE, a P value of 0.031.

Conclusion:

The majority of the participants had poor knowledge regarding PC and PCS. Only a fifth of the men did PCS. High knowledge was associated with PSA and DRE perceived benefits and health motivation.

Exploring the experiences of patients, general practitioners and oncologists of prostate cancer follow-up: A qualitative interview study

Purpose

To examine the experiences of patients and healthcare professionals of prostate cancer follow-up in primary care and to identify areas where current policy and practice could be improved.

Methods

Semi-structured interviews with patients, GPs and oncologists explored experiences of prostate cancer follow-up. Interviews were audio recorded and transcribed verbatim. Data were analysed using thematic analysis. The three participant groups were analysed as individual datasets but the same key themes were evident across the groups.

Results

14 patients, 6 GPs and 5 oncologists were interviewed. Four main themes were identified: Experience of current practice; Knowledge and understanding of prostate cancer follow up; Disparity of processes and pathways; Unclear roles and responsibilities.

Conclusions

Findings from this study highlight the variation in the approach to prostate specific antigen monitoring and emphasise the lack of clear policies and practices. The lack of clarity around existing follow up and monitoring processes could cause delays in the diagnosis of recurrence. There is a need for a new and improved pathway for prostate cancer follow up. The pathway should include clear and concise guidance for patients, primary care and secondary care and all relevant parties need to understand what their role is within the pathway.

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There is huge variation in PSA monitoring processes and after care.

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Patients and professionals are unsure of their role.

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Lack of clarity means there is a risk that patients may not be monitored routinely.

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There is a need for a new and improved pathway for prostate cancer follow up.

Awareness of prostate cancer diagnosis and management among Turkish males: a cross sectional study from Çorum

Introduction: Prostate cancer is the most common malignancy among men in the United States and the second most common cancer in Turkey. The incidence of prostate cancer is increasing in industrialized countries.Aim: The aim of the study was to assess the knowledge about prostate cancer, its diagnosis, and treatment among patients with lower urinary tract symptoms.Methods: This study was performed from January to April 2015 with the patients applied to our clinic. A questionnaire that includes 10 questions was administered to the participants.Results: One hundred fifty-nine participants were included in this study. The participants' ages were between 40 and 82 with a mean age of 61.5 ± 7.9 years. Patient awareness of prostate biopsy and prostate cancer were 21.37 and 71.06%. The main origin awareness of PSA testing is family and friends. On the other hand, if the doctor advises acout prostate biopsy, 47.16% of the patients would accept and 11.31% of them would refuse this invasive procedure.Conclusion: Prostate cancer is one of the important health-related problem among men in the world. Additional researches are needed to investigate the knowledge of prostate cancer among men and the Ministry of Health may take preventive methods to increase the cancer knowledge level of people.

Prostate specific antigen test uptake: a cross sectional study on elderly men in Western Iran

BACKGROUND

Prostate cancer (PCa) is the second most common malignancy in men worldwide and the incidence rate of PCa has been increasing in recent years. The aim of the current study was to determine beliefs elderly men towards prostate-specific antigen (PSA) test uptake.

METHODS

This cross-sectional study conducted among 352 elderly men (60-74 years old age) in the west of Iran. The Health Belief Model (HBM) was applied as a study framework to evaluation of beliefs towards PSA test uptake. Data were analyzed by SPSS version 16 using appropriate statistical tests including t-test, chi-square, bivariate correlations, and logistic regression at 95% significant level.

RESULT

The mean age of participants was 65.55 years [SD: 3.90]. Almost 16.9% of the elderly men had uptake PSA during last year. There was significant association between PSA test uptake with older age (P = 0.013), better economic status (P = 0.023), higher education level (P = 0.004), positive family history of prostate cancer (P = 0.018), and number of family members more than four (P = 0.032). The best determinants predictors for PSA test uptake were cues to action [OR: 1.967 and 95% CI: 1.546, 2.504], perceived severity [OR: 1.140 and 95% CI: 1.008, 1.290], and perceived benefits towards PSA test uptake [OR: 1.133 and 95% CI: 1.024, 1.253].

CONCLUSIONS

It seems that development of health promotion programs to increase cues to action and positive beliefs toward PSA test uptake and also perceived treat about side effect of PCa could be beneficial to increase PSA test uptake.

Comparison of prostate cancer detection rates of various prostate biopsy methods for patients with prostate-specific antigen levels of <10.0 ng/mL in real-world practice

Purpose

Several strategies of prostate biopsy (PBx) have been introduced to improve prostate cancer (PCa) detection rates. However, studies comparing cancer detection rates (CDRs) according to biopsy methods in real-world practice are scarce. This study aimed to investigate CDRs according to the biopsy methods for patients with prostate-specific antigen (PSA) <10.0 ng/mL.

Materials and Methods

From 2006 to 2015, patients who underwent PBx were initially selected. All patients were categorized according to the biopsy methods performed (magnetic resonance imaging targeted biopsy [MR-TBx], 12+2 hypoechoic lesion target biopsy, saturation biopsy [sPBx], extended biopsy, and 12-core PBx). The CDR of MR-TBx was compared to that of sPBx and other protocols. Volume per core (VPC) was defined as prostate volume divided by the number of biopsy cores. Patients previously diagnosed with PCa were excluded.

Results

Of the 1,598 patients (median PSA, 5.41 ng/mL), 401 (25.1%) were diagnosed with PCa. Among the biopsy methods, MR-TBx has the highest CDR and proportion of Gleason score ≥7 (3+4). Biopsy methods, VPC, age, prostate volume, and PSA were associated with PCa detection. In the sub-analysis for initial biopsy, MR-TBx had no significant difference with sPBx, but had higher CDR than the other biopsy protocols. For repeat biopsy, VPC, rather than the biopsy method, was associated with CDR.

Conclusions

This study reaffirmed the efficacy of MR-TBx on CDR in real-world practice. In cases with barriers to performing magnetic resonance imaging, VPC might be useful for adjusting the optimal number of biopsy cores in repeat biopsy.

Predictors of participation in risk-based prostate cancer screening

BACKGROUND

Implementation of risk-based prostate cancer screening has been proposed as a means to reduce the harms of PSA screening. Little is known, however, about the factors influencing men's decision to attend a prostate cancer screening based on a risk assessment.

METHOD

We sent postal invitations with a login to a survey to 10.000 men, three months before invitation to a risk-based prostate cancer screening. Prostate cancer specific worry, prostate cancer-related knowledge, health behaviour, and health related quality of life were used as predictors of subsequent participation. Participation to risk-based prostate cancer screening was defined as providing a blood sample for the STHLM3 trial, a study evaluating a risk-based model that predicts the risk for aggressive prostate cancer.

RESULTS

With a response rate of 20%, 1.347 men (70%) participated in ensuing risk-based prostate cancer screening three months later whereas 568 men (30%) declined participation in the STHLM3-study. These decliners reported less worry and feeling less vulnerable to prostate cancer and responded "Do not know" more often than participants when asked questions about prostate cancer knowledge. Participants reported greater benefits of prostate testing (p = 0.0005), less barriers to prostate testing (p<0.0001), and higher intention to attend prostate cancer testing (p<0.0001) than decliners. Finally, participants reported better overall health than decliners (p<0.0001).

CONCLUSION

Prostate cancer worry, PC knowledge, health behaviour and quality of life were identified as predictors of participation in risk-based prostate cancer screening. Targeting these predictors may improve the participation rates. These results can inform policymaking for future population-based prostate cancer screening programs that should address potential worry in men and lack of knowledge about prostate cancer.

Physician-Patient Communication is Associated With Hepatocellular Carcinoma Screening in Chronic Liver Disease Patients

BACKGROUND

Patients with chronic liver disease are at high risk for developing liver cancer. Factors associated with screening awareness and doctor-patient communication regarding liver cancer were examined.

STUDY

Four hundred sixty-seven patients with chronic liver disease at a tertiary-care clinic participated in a phone survey regarding awareness of cancer screening, doctor-patient communication, and health behaviors. Medical records were retrospectively reviewed for data on liver disease etiology and dates of liver imaging tests.

RESULTS

Seventy-nine percent of patients reported awareness of liver cancer screening, and 50% reported talking to their doctor about liver cancer. Patients with higher education, abstinence from alcohol, and liver cirrhosis were more likely to be aware of liver cancer screening (P=0.06, 0.005, <0.0001). Whites, patients with higher education, and those with cirrhosis were more likely to talk to their doctor about liver cancer (P=0.006; P=0.09, <0.0001). Awareness of liver cancer screening (79%) was similar to that of colorectal cancer screening (85%), lower than breast cancer screening (91%), and higher than prostate cancer screening (66%). Patients who were aware of liver cancer screening and reported talking to their doctor about liver cancer were significantly more likely to receive consistent liver surveillance (odds ratio, 4.81; 95% confidence interval, 2.62-8.84 and odds ratio, 1.97; 95% confidence interval, 1.19-3.28, respectively).

CONCLUSIONS

Our study demonstrates the importance of effective physician communication with chronic liver disease patients on the risks of developing liver cancer and the importance of regular screening, especially among nonwhites and patients with lower education.

Determinants of Behavioral Intentions to Screen for Prostate Cancer in Omani Men

Objective:

This study aimed at exploring the perceived barriers and intention to screen for prostate cancer (PCa).

Methods:

A survey questionnaire and a descriptive design were used to collect data from 129 Omani men above the age of 40 years. The questionnaire comprised the International Prostate Symptom Score (IPSS), barriers, and intention to screen scales. The participants were recruited from barbershops located in two cities of Oman.

Results:

The mean IPSS score was 8.31 ± 3.34 and the majority of participants had mild prostate cancer symptoms (60.4%). The others had moderate (28.7%) or severe symptoms (10.9%). Most men had low-to-moderate intention to screen using the method of digital rectal examination (DRE) (76%) and prostate-specific antigen test (PSA) (69.8%). The most common barriers to screening were fear of finding out something wrong (48.1%), not knowing what will be done during screening (54.3%), belief that PCa is not a serious disease (55.8%), and belief that DRE is embarrassing (56.6%). The significant determinants of intention to screen using DRE were perceived threat of the disease (P = 0.006) and past information from doctors that one has any prostate disease (P = 0.017). The determinants of intention to screen using PSA were perceived threat of the disease (P = 0.025), perceived general health (P = 0.047), and past information from doctors that one has any prostate disease (P = 0.017).

Conclusions:

The participants had diminutive intention to undergo PCa screening. Interventions aimed at enhancing PCa disease and risk awareness may help to reduce the barriers and increase PCa screening uptake.

Predictors of Participation in Prostate Cancer Screening among Older Men in Jordan

BACKGROUND

Participation is one of the major factors affecting the long-term success of population-based prostate cancer screening programs. The aim of this study was to explore strong factors linked to participation in prostate cancer screening among older Jordanian adults using the Health Belief Model (HBM).

MATERIALS AND METHODS

Data were obtained from Jordanian older adults, aged 40 years and over, who visited a comprehensive health care center within the Ministry of Health. A pilot test was conducted to investigate the internal consistency of the the Champion Health Belief Model Scale for prostate cancer screening and the clarity of survey questions. Sample characteristics and rates of participation in prostate cancer screening were examined using means and frequencies. Important factors associated with participation in prostate cancer screening were examined using bivariate correlation and multivariate logistic regression analysis.

RESULTS

About 13% of the respondents had adhered to prostate cancer screening guidelines over the previous decade. Four out of the seven HBM-driven factors (perceived susceptibility, benefits and barriers to PSA test, and health motivation) were statistically significant. Those with greater levels of susceptibility, benefits of PSA test and health motivation and lower levels of barriers to PSA testing were more likely to participate in prostate cancer screening. Family history, presence of urinary symptoms, age, and knowledge about prostate cancer significantly predicted the participation in prostate cancer screening.

CONCLUSIONS

Health professionals should focus more on the four modifiable HBM-related factors to encourage older adults to participate in prostate cancer screening. Intervention programs, which lower perceived barriers to PSA testing and increase susceptibility, benefits of PSA testing and health motivation, should be developed and implemented.

Baseline subject characteristics predictive of compliance with study-mandated prostate biopsy in men at risk of prostate cancer: results from REDUCE

Introduction

Study compliance is crucial when the study outcome is determined by an invasive procedure, such as prostate biopsy. To investigate predictors of compliance in study-mandated prostate biopsies, we analyzed demographic, clinical and reported lifestyle data from the REDUCE trial.

Methods

We retrospectively identified 8,025 men from REDUCE with at least 2-years of follow-up, and used multivariable logistic regression to test the association between baseline demographic and clinical characteristics and undergoing the study-mandated prostate biopsy at 2 years. We then examined whether missing any of these data was associated with undergoing a biopsy

Results

In REDUCE, 22% of men did not undergo a 2-year biopsy. On multivariable analysis, non-North American region was predictive of 42-44% increased likelihood of undergoing a 2-year biopsy (p≤0.001). Being enrolled at a center that enrolled >10 subjects (2^nd and 3^rd tertile) was associated with a 42-48% increased likelihood of undergoing a 2-year biopsy (p<0.001). Additionally, black race predicted 44% lower rate of on-study 2-year biopsy (OR=0.56; p=0.001). Finally, missing one or more baseline variables was associated with a 32% decreased likelihood of undergoing a 2-year biopsy (OR=0.68; p<0.001).

Conclusions

In REDUCE, men outside North America, those at higher volume centers, and those with complete baseline data were more likely to undergo study mandated 2-year biopsies. Given prostate biopsy is becoming increasingly utilized as an endpoint in trials that are often multi-national, regional differences in compliance should be considered when designing future trials. Likewise, efforts are needed to ensure compliance in low-volume centers or among subjects missing baseline data.

Role of information in preparing men for transrectal ultrasound guided prostate biopsy: a qualitative study embedded in the ProtecT trial

BACKGROUND

The histological diagnosis of prostate cancer requires a prostate needle biopsy. Little is known about the relationship between information provided to prepare men for transrectal ultrasound guided biopsy (TRUS-Bx) and how men experience biopsy. The objectives were a) to understand men's experiences of biopsy as compared to their expectations; and b) to propose current evidence-based information for men undergoing TRUS-Bx.

METHODS

Between February 2006 and May 2008, 1,147 men undergoing a standardised 10-core transrectal ultrasound guided biopsy protocol under antibiotic cover following a PSA 3.0-19.9 ng/ml in the Prostate Testing for Cancer and Treatment (ProtecT) trial, completed questionnaires about biopsy symptoms. In this embedded qualitative study, in-depth interviews were undertaken with 85 men (mean age 63.6 yrs, mean PSA 4.5 ng/ml) to explore men's experiences of prostate biopsy and how the experience might be improved. Interview data were analysed thematically using qualitative research methods. Findings from the qualitative study were used to guide selection of key findings from the questionnaire study in developing a patient information leaflet preparing men for biopsy.

RESULTS

Although most men tolerated TRUS-Bx, a quarter reported problematic side-effects and anxiety. Side effects were perceived as problematic and anxiety arose most commonly when experiences deviated from information provided. Men who were unprepared for elements of TRUS-Bx procedure or its sequelae responded by contacting health professionals for reassurance and voiced frustration that pre-biopsy information had understated the possible severity or duration of pain/discomfort and bleeding. Findings from questionnaire and interview data were combined to propose a comprehensive, evidence-based patient information leaflet for TRUS-Bx.

CONCLUSIONS

Men reported anxiety associated with TRUS-Bx or its side-effects most commonly if they felt inadequately prepared for the procedure. Data from this qualitative study and the previous questionnaire study have been used to propose an updated, comprehensive evidence-based set of information for men undergoing TRUS-Bx.

Preferences for cancer investigation: a vignette-based study of primary-care attendees

BACKGROUND

The UK lags behind many European countries in terms of cancer survival. Initiatives to address this disparity have focused on barriers to presentation, symptom recognition, and referral for specialist investigation. Selection of patients for further investigation has come under particular scrutiny, although preferences for referral thresholds in the UK population have not been studied. We investigated preferences for diagnostic testing for colorectal, lung, and pancreatic cancers in primary-care attendees.

METHODS

In a vignette-based study, researchers recruited individuals aged at least 40 years attending 26 general practices in three areas of England between Dec 6, 2011, and Aug 1, 2012. Participants completed up to three of 12 vignettes (four for each of lung, pancreatic, and colorectal cancers), which were randomly assigned. The vignettes outlined a set of symptoms, the risk that these symptoms might indicate cancer (1%, 2%, 5%, or 10%), the relevant testing process, probable treatment, possible alternative diagnoses, and prognosis if cancer were identified. Participants were asked whether they would opt for diagnostic testing on the basis of the information in the vignette.

FINDINGS

3469 participants completed 6930 vignettes. 3052 individuals (88%) opted for investigation in their first vignette. We recorded no strong evidence that participants were more likely to opt for investigation with a 1% increase in risk of cancer (odds ratio [OR] 1·02, 95% CI 0·99-1·06; p=0·189), although the association between risk and opting for investigation was strong when colorectal cancer was analysed alone (1·08, 1·03-1·13; p=0·0001). In multivariable analysis, age had an effect in all three cancer models: participants aged 60-69 years were significantly more likely to opt for investigation than were those aged 40-59 years, and those aged 70 years or older were less likely. Other variables associated with increased likelihood of opting for investigation were shorter travel times to testing centre (colorectal and lung cancers), a family history of cancer (colorectal and lung cancers), and higher household income (colorectal and pancreatic cancers).

INTERPRETATION

Participants in our sample expressed a clear preference for diagnostic testing at all risk levels, and individuals want to be tested at risk levels well below those stipulated by UK guidelines. This willingness should be considered during design of cancer pathways, particularly in primary care. The public engagement with our study should encourage general practitioners to involve patients in referral decision making.

FUNDING

The National Institute for Health Research Programme Grants for Applied Research programme.

Peripheral zone prostate-specific antigen density: an effective parameter for prostate cancer prediction in men receiving 5α-reductase inhibitors

Purpose:

To evaluate the predictive performance of various parameters derived from volume-adjusted prostate-specific antigen (PSA) values in detecting prostate cancer (PCa) and high-grade (Gleason score≥7) PCa according to treatment with a 5α-reductase inhibitor (5ARI).

Methods:

The results of 3,520 prostate biopsies performed between May 2006 and January 2013 were retrospectively assessed. With adjustment for age, 291 patients who had received 5ARI treatment for more than 6 months were identified and matched 1:3 to patients naïve to 5ARIs, resulting in a total of 873 patients. Peripheral zone (PZ) and transition zone (TZ) volumes were determined by transrectal ultrasonography. Receiver-operating characteristic (ROC) curve analysis was used to compare predictive performances of PSA, PSA density (PSAD; PSA/prostate volume), PZPSAD (PSA/PZ volume), and TZPSAD (PSA/TZ volume) for detecting PCa and high-grade PCa for each group.

Results:

The area under the ROC curve (AUC) was higher for PSAD than for PSA in the 5ARI group (0.751 vs. 0.677) and in the 5ARI-naïve group (0.649 vs. 0.582), respectively (P<0.001). In the 5ARI group, the AUC for PZPSAD was even higher than that for PSAD (0.781 vs. 0.751, P=0.038); in the 5ARI-naïve group, however, PZPSAD failed to achieve significant superiority (0.652 vs. 0.649, P=0.321). All volume-adjusted PSA indexes showed higher predictive accuracies for detecting PCa than did PSA in both groups. For detecting high-grade cancer, PZPSAD also revealed the highest predictive value in the 5ARI group, whereas PSA revealed the highest predictive value in the 5ARI-naïve group.

Conclusions:

The diagnostic performance of PSAD in the detection of PCa is superior to that of PSA. For patients receiving 5ARI for more than 6 months, PZPSAD confers additional benefits for detecting both PCa and high-grade PCa.