Long-term distress after radical prostatectomy versus watchful waiting in prostate cancer: a longitudinal study from the Scandinavian Prostate Cancer Group-4 randomized clinical trial

Functional Outcomes and Quality of Life in High-risk Prostate Cancer Patients Treated by Robot-assisted Radical Prostatectomy with or Without Adjuvant Treatments

BACKGROUND

Robot-assisted laparoscopic prostatectomy (RALP) is used frequently to treat prostate cancer; yet, prospective data on the quality of life and functional outcomes are lacking.

OBJECTIVE

To assess the quality of life and functional outcomes after radical prostatectomy in different risk groups with or without adjuvant treatments.

DESIGN, SETTING, AND PARTICIPANTS

The Be-RALP database is a prospective multicentre database that covers 9235 RALP cases from 2009 until 2016. Of these 9235 patients, 2336 high-risk prostate cancer patients were matched with low/intermediate-risk prostate cancer patients.

INTERVENTION

Patients were treated with RALP only or followed by radiotherapy and/or hormone treatment.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We used a mixed-model analysis to longitudinally analyse quality of life, urinary function, and erectile function between risk groups with or without additional treatments.

RESULTS AND LIMITATIONS

Risk group was not significant in predicting quality of life, erectile function, or urinary function after RALP. Postoperative treatment (hormone and/or radiotherapy treatment) was significant in predicting International Index of Erectile Function (IIEF-5), sexual activity, and sexual functioning.

CONCLUSIONS

Risk group was not linked with clinically relevant declines in functional outcomes after RALP. The observed functional outcomes and quality of life are in favour of considering RALP for high-risk prostate cancer. Postoperative treatment resulted in lower erectile function measures without clinically relevant changes in quality of life and urinary functions. Hormone therapy seems to have the most prominent negative effects on these outcomes.

PATIENT SUMMARY

This study investigated the quality of life, and urinary and erectile function in patients with aggressive and less aggressive prostate cancer after surgery only or in combination with hormones or radiation. We found that quality of life recovers completely, while erectile and urinary function recovers only partially after surgery. Aggressiveness of the disease had a minimal effect on the outcomes; yet, postoperative treatments lowered erectile function further.

Ultrasound-mediated drug-free theranostics for treatment of prostate cancer

Lipid-shelled nanobubbles (NBs) can be visualized and activated using noninvasive ultrasound (US) stimulation, leading to significant bioeffects. Prior work demonstrates that active targeting of NBs to prostate-specific membrane antigen (PSMA) overexpressed in prostate cancer (PCa) results in enhanced cellular internalization and prolongs NB retention with persistent, cancer-cell specific acoustic activity. In this work, we hypothesized that tumor-accumulated PSMA-NBs combined with low frequency unfocused therapeutic US (TUS) will lead to selective damage and induce a specific therapeutic effect in PSMA-expressing tumors compared to PSMA-negative tumors. We observed that the internalized NBs and cellular compartments were disrupted after the PSMA-NB + TUS (targeted NB therapy or TNT) application, yet treated cells remained intact and viable. In vivo, PSMA-expressing tumors in mice receiving TNT treatment demonstrated a significantly greater extent of apoptosis (78.4 ± 9.3 %, p < 0.01) compared to controls. TNT treatment significantly inhibited the PSMA expressing tumor growth and increased median survival time by 103 %, p < 0.001). A significant reduction in tumor progression compared to untreated control was also seen in an orthotopic rabbit PCa model. Results demonstrate that cavitation of PSMA-NBs internalized via receptor-mediated endocytosis into target PCa cells using unfocused ultrasound results in significant, tumor-specific bioeffects. The effects, while not lethal to PSMA-expressing cancer cells in vitro, result in significant in vivo reduction in tumor progression in two models of PCa. While the mechanism of action of these effects is yet unclear, it is likely related to a locally-induced immune response, opening the door to future investigations in this area.

Ultrasound-mediated drug-free theranostics for treatment of prostate cancer

Rationale

Lipid-shelled nanobubbles (NBs) can be visualized and activated using noninvasive ultrasound (US) stimulation, leading to significant bioeffects. We have previously shown that active targeting of NBs to prostate-specific membrane antigen (PSMA) overexpressed in prostate cancer (PCa) enhances the cellular internalization and prolongs retention of NBs with persistent acoustic activity (~hrs.). In this work, we hypothesized that tumor-accumulated PSMA-NBs combined with low frequency therapeutic US (TUS) will lead to selective damage and induce a therapeutic effect in PSMA-expressing tumors compared to PSMA-negative tumors.

Methods

PSMA-targeted NBs were formulated by following our previously established protocol. Cellular internalization of fluorescent PSMA-NBs was evaluated by confocal imaging using late endosome/lysosome staining pre- and post-TUS application. Two animal models were used to assess the technique. Mice with dual tumors (PSMA expressing and PSMA negative) received PSMA-NB injection via the tail vein followed by TUS 1 hr. post injection (termed, targeted NB therapy or TNT). Twenty-four hours after treatment mice were euthanized and tumor cell apoptosis evaluated via TUNEL staining. Mice with single tumors (either PSMA + or -) were used for survival studies. Tumor size was measured for 80 days after four consecutive TNT treatments (every 3 days). To test the approach in a larger model, immunosuppressed rabbits with orthotopic human PSMA expressing tumors received PSMA-NB injection via the tail vein followed by TUS 30 min after injection. Tumor progression was assessed via US imaging and at the end point apoptosis was measured via TUNEL staining.

Results

In vitro TNT studies using confocal microscopy showed that the internalized NBs and cellular compartments were disrupted after the TUS application, yet treated cells remained intact and viable. In vivo, PSMA-expressing tumors in mice receiving TNT treatment demonstrated a significantly greater extent of apoptosis (78.45 ± 9.3%, p < 0.01) compared to the other groups. TNT treatment significantly inhibited the PSMA (+) tumor growth and overall survival significantly improved (median survival time increase by 103%, p < 0.001). A significant reduction in tumor progression compared to untreated control was also seen in the rabbit model in intraprostatic (90%) and in extraprostatic lesions (94%) (p = 0.069 and 0.003, respectively).

Conclusion

We demonstrate for the first time the effect of PSMA-targeted nanobubble intracellular cavitation on cancer cell viability and tumor progression in two animal models. Data demonstrate that the targeted nanobubble therapy (TNT) approach relies primarily on mechanical disruption of intracellular vesicles and the resulting bioeffects appear to be more specific to target cancer cells expressing the PSMA receptor. The effect, while not lethal in vitro, resulted in significant tumor apoptosis in vivo in both a mouse and a rabbit model of PCa. While the mechanism of action of these effects is yet unclear, it is likely related to a locally-induced immune response, opening the door to future investigations in this area.

Long-term Health-related Quality of Life in Patients on Active Surveillance for Prostate Cancer: A Systematic Review

CONTEXT

Active surveillance (AS) represents the preferred treatment option in patients with low-risk prostate cancer. Optimised patient selection has enabled more patients to be managed with AS for a longer time. Thus, there is growing interest in its effect on long-term quality of life compared with interventional management.

OBJECTIVE

To perform a systematic review evaluating the long-term patient-reported outcomes regarding mental health, and sexual and urinary function in patients on AS.

EVIDENCE ACQUISITION

We performed a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. We included series assessing validated patient-reported outcomes of health-related quality of life, and sexual and urinary function in AS patients followed up for at least 5 yr.

EVIDENCE SYNTHESIS

Our search yielded 1854 citations, including 19 papers involving 3643 patients on AS, 14 651 patients receiving surgery or radiotherapy, and 2478 controls without prostate cancer. In ten studies, major differences were observed in sexual and urinary symptoms between groups, such as better sexual function and fewer irritative urinary symptoms in patients on AS, though overall functional outcomes were comparable. In all studies, health-related quality of life for patients on AS was better than, or similar to, that for patients who had undergone surgery or radiotherapy and comparable with that for individuals without cancer.

CONCLUSIONS

We observed differences in specific functional outcomes between patients on AS and surgery or radiotherapy, ≥5 yr after treatment. Patients on AS reported good quality of life, similar to that in individuals without prostate cancer. AS should continue to be a recommended management strategy for appropriately selected patients.

PATIENT SUMMARY

Active surveillance is an accepted pathway for patients with low-risk localised prostate cancer. Previous literature has shown that it did not negatively affect short-term quality of life. This review finds that long-term quality of life for these patients is similar to that for people without prostate cancer.

microRNA-205 in prostate cancer: Overview to clinical translation

Prostate cancer (PrCa) is the most common type of cancer among men in the United States. The metastatic and advanced PrCa develops drug resistance to current regimens which accounts for the poor management. microRNAs (miRNAs) have been well-documented for their diagnostic, prognostic, and therapeutic roles in various human cancers. Recent literature confirmed that microRNA-205 (miR-205) has been established as one of the tumor suppressors in PrCa. miR-205 regulates number of cellular functions, such as proliferation, invasion, migration/metastasis, and apoptosis. It is also evident that miR-205 can serve as a key biomarker in diagnostic, prognostic, and therapy of PrCa. Therefore, in this review, we will provide an overview of tumor suppressive role of miR-205 in PrCa. This work also outlines miR-205's specific role in targeted mechanisms for chemosensitization and radiosensitization in PrCa. A facile approach of delivery paths for successful clinical translation is documented. Together, all these studies provide a novel insight of miR-205 as an adjuvant agent for reducing the widening gaps in clinical outcome of PrCa patients.

Clinical Outcomes from Dose-Reduced Radiotherapy to the Prostate in Elderly Patients with Localized Prostate Cancer

Radical treatment of localized prostate cancer in elderly patients may lead to unacceptable treatment-associated toxicities that adversely impact quality of life without improving survival outcomes. This study reports on a cohort of 54 elderly (>70 years) patients that received 4000–5000 cGy of palliative external beam radiotherapy (EBRT) as an alternative to androgen deprivation therapy (ADT). The primary outcome of interest was the period of ADT-free survival, and secondary outcomes included overall survival (OS) and metastases-free survival (MFS). Kaplan–Meier regression was used to estimate survival outcomes. Thirty-six (67%) patients achieved a break in ADT post-radiotherapy, with a median time to ADT reinitiation of 20 months. Common Terminology Criteria for Adverse Events (CTCAE) were limited to low-grade gastrointestinal (GI) or genitourinary (GU) toxicities, with no skin toxicities observed. Grade 1 GI toxicity was observed in 9 (17%) patients, and grades 1 and 2 GU toxicities were observed in 13 (24%) and 3 (6%) patients, respectively, with no higher-grade toxicities reported. Five-year MFS and OS were 56% and 78%, respectively. In summary, the treatment regimen was well-tolerated and achieved durable ADT-free survival in most patients. Dose-reduced EBRT appears to be a viable alternative to ADT in elderly patients with localized prostate cancer.

Health-related quality of life in men with localized prostate cancer treated with radiotherapy: validation of an abbreviated version of the Expanded Prostate Cancer Index Composite for Clinical Practice in Spain

Background

Health-related quality of life (HRQoL) is greatly affected by prostate cancer (PCa) and associated treatments. This study aimed to measure the impact of radiotherapy on HRQoL and to further validate the Spanish version of the 16-item Expanded Prostate Cancer Index Composite (EPIC-16) in routine clinical practice.

Methods

An observational, non-interventional, multicenter study was conducted in Spain with localized PCa patients initiating treatment with external beam radiotherapy (EBRT) or brachytherapy (BQT). Changes from baseline in EPIC-16, University of California-Los Angeles Prostate Cancer Index (UCLA-PCI), and patient-perceived health status were longitudinally assessed at end of radiotherapy (V2) and 90 days thereafter (V3). Psychometric evaluations of the Spanish EPIC-16 were conducted.

Results

Of 516 patients enrolled, 495 were included in the analysis (EBRT, n = 361; BQT, n = 134). At baseline, mean (standard deviation [SD]) EPIC-16 global scores were 11.9 (7.5) and 10.3 (7.7) for EBRT and BQT patients, respectively; scores increased, i.e., HRQoL worsened, from baseline, by mean (SD) of 6.8 (7.6) at V2 and 2.4 (7.4) at V3 for EBRT and 4.2 (7.6) and 3.9 (8.2) for BQT patients. Changes in Spanish EPIC-16 domains correlated well with urinary, bowel, and sexual UCLA-PCI domains. EPIC-16 showed good internal consistency (Cronbach’s alpha = .84), reliability, and construct validity.

Conclusion

The Spanish EPIC-16 questionnaire demonstrated sensitivity, strong discriminative properties and reliability, and validity for use in clinical practice. EPIC-16 scores worsened after radiotherapy in different HRQoL domains; however, a strong tendency towards recovery was seen at the 3-month follow-up visit.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-021-01856-z.

The unique information and communication needs of men affected by prostate cancer: A qualitative study of men's experience

OBJECTIVE

The objective of this study is to explore the specific information and communication needs of men affected by prostate cancer to inform the development of educational materials for clinicians.

METHODS

This is a qualitative descriptive study. A purposive sampling strategy was used to identify men at different cancer stages and with experience of different treatment regimens. Semistructured interviews (25) were conducted with 19 men and six carers over the phone. Interview data were analysed using a framework approach.

RESULTS

Four themes emerged: gaps in the information provided by secondary care doctors and nurses, communication skills needed in effective clinical information provision, a need for individualised information and alternative information sources used to meet unmet needs. Regardless of cancer stage and treatment, men with prostate cancer and their carers found information regarding common and burdensome adverse effects of prostate cancer treatment particularly lacking, and their ongoing and changing information needs often overlooked. They needed information delivered in a compassionate and individually tailored manner, considering content, timing and emotional support within the context of their unique life circumstances.

CONCLUSION

Clinicians often fail to recognise the need for or deliver patient-centred conversations about treatment, managing side effects and prognosis. The findings will be used to develop clinician-facing educational materials.

Current Mental Distress Among Men With a History of Radical Prostatectomy and Related Adverse Correlates

Recent reviews and observational studies have reported that patients with prostate cancer (PCa) are at increased risk of mental health issues, which in turn negatively affects oncological outcomes. Here, we examine possible explanatory variables of mental distress in a population-based cohort of men who have undergone radical prostatectomy (RP). Data were derived from a Maritimes-Canada online survey assessing patient-reported quality of life outcomes between 2017 and 2019 administered to 136 men (47–88 years old, currently in a relationship) who have undergone RP for their PCa diagnosis. The primary outcome was a validated assessment of mental distress, the Kessler Psychological Distress Scale (K10). Urinary function was assessed using the International Prostate Symptom Score, and relationship satisfaction was assessed using the Dyadic Assessment Scale. A multivariate logistic regression assessed the contribution of urinary function, relationship satisfaction, age, multimorbidity, additional treatments, medication for depression and/or anxiety, and survivorship time. A total of 16.2% men in this sample screened positive for mental distress. The severity of urinary problems was positively associated with increased mental distress (OR = 4.79, 95% CI [1.04, 22.03]), while increased age (OR = 0.87, 95% CI [0.78, 0.97]), relationship satisfaction (OR = 0.14, 95% CI [0.3, .077]), and current medication for anxiety, depression, or both (OR = 0.09, 95% CI [0.02, 0.62]) were protective factors. Survivorship time, the presence of additional comorbidities, or PCa treatments were not identified to be statistically significant contributions to the fitted model. Here, we report that RP survivors are prone to presenting with increased mental distress long after treatment. Screening for mental distress during RP survivorship is recommended.

Prostate cancer

Prostate cancer is a complex disease that affects millions of men globally, predominantly in high human development index regions. Patients with localized disease at a low to intermediate risk of recurrence generally have a favourable outcome of 99% overall survival for 10 years if the disease is detected and treated at an early stage. Key genetic alterations include fusions of TMPRSS2 with ETS family genes, amplification of the MYC oncogene, deletion and/or mutation of PTEN and TP53 and, in advanced disease, amplification and/or mutation of the androgen receptor (AR). Prostate cancer is usually diagnosed by prostate biopsy prompted by a blood test to measure prostate-specific antigen levels and/or digital rectal examination. Treatment for localized disease includes active surveillance, radical prostatectomy or ablative radiotherapy as curative approaches. Men whose disease relapses after prostatectomy are treated with salvage radiotherapy and/or androgen deprivation therapy (ADT) for local relapse, or with ADT combined with chemotherapy or novel androgen signalling-targeted agents for systemic relapse. Advanced prostate cancer often progresses despite androgen ablation and is then considered castration-resistant and incurable. Current treatment options include AR-targeted agents, chemotherapy, radionuclides and the poly(ADP-ribose) inhibitor olaparib. Current research aims to improve prostate cancer detection, management and outcomes, including understanding the fundamental biology at all stages of the disease.

Prostate cancer

Prostate cancer is a complex disease that affects millions of men globally, predominantly in high human development index regions. Patients with localized disease at a low to intermediate risk of recurrence generally have a favourable outcome of 99% overall survival for 10 years if the disease is detected and treated at an early stage. Key genetic alterations include fusions of TMPRSS2 with ETS family genes, amplification of the MYC oncogene, deletion and/or mutation of PTEN and TP53 and, in advanced disease, amplification and/or mutation of the androgen receptor (AR). Prostate cancer is usually diagnosed by prostate biopsy prompted by a blood test to measure prostate-specific antigen levels and/or digital rectal examination. Treatment for localized disease includes active surveillance, radical prostatectomy or ablative radiotherapy as curative approaches. Men whose disease relapses after prostatectomy are treated with salvage radiotherapy and/or androgen deprivation therapy (ADT) for local relapse, or with ADT combined with chemotherapy or novel androgen signalling-targeted agents for systemic relapse. Advanced prostate cancer often progresses despite androgen ablation and is then considered castration-resistant and incurable. Current treatment options include AR-targeted agents, chemotherapy, radionuclides and the poly(ADP-ribose) inhibitor olaparib. Current research aims to improve prostate cancer detection, management and outcomes, including understanding the fundamental biology at all stages of the disease.

Cognitive and Psychological Impacts of Different Treatment Options for Prostate Cancer: A Critical Analysis

Objectives

Psychological morbidity as well as cognitive impairment are increasingly reported in prostate cancer (PCa) patients. However, despite growing numbers of PCa survivors and the well estimated negative impact of cognitive decline and emotional distress on survivors' quality of life, no study has assessed the whole range of cognitive and psychological sequelae as a response to treatment options for PCa. The objective of the present review was to systematically characterize the types and estimate the prevalence of the cognitive impairment and emotional burdens that were found in PCa survivors secondary to different treatment options.

Methods

Systematic, general reviews, meta-analysis, and overviews of review studies in English, that were published in PubMed during the last 10 years until l August 2019 and that reported psychological distress, anxiety, depression, cognitive decline, or dementia among individuals with PCa exposed to a particular treatment option were analyzed.

Results

A total of 21 articles were reviewed. Some of the studies described one or more cognitive or psychological consequences of only one therapeutic strategy while others compared the psychological impacts among different strategies. Most of these studies suggested that either radical prostatectomy or active surveillance and radiotherapy were well-tolerated treatments in terms of psychological modifications. However, many of these patients may require additional emotional support. There is also increasing evidence that androgen deprivation therapy may be associated with depression, while controversy surrounding the association between cognitive dysfunction, dementia, and androgen deprivation therapy remains ambivalent.

Conclusion

Emotional distress and cognitive decline may accompany every PCa treatment option to different degrees. Accurate information on the short- and long-term effect of treatments on cognitive and psychological aspects should be provided to patients during treatment decision-making. There is also a need to develop well-targeted psychological and neurological interventions that could help those experiencing ongoing post-treatment difficulties.

Active monitoring, radical prostatectomy and radical radiotherapy in PSA-detected clinically localised prostate cancer: the ProtecT three-arm RCT

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.

Radical prostatectomy versus deferred treatment for localised prostate cancer

BACKGROUND

Prostate cancer is a common cancer but is oftentimes slow growing. When confined to the prostate, radical prostatectomy (RP), which involves removal of the prostate, offers potential cure that may come at the price of adverse events. Deferred treatment, involving observation and palliative treatment only (watchful waiting (WW)) or close monitoring and delayed local treatment with curative intent as needed in the setting of disease progression (active monitoring (AM)/surveillance (AS)) might be an alternative. This is an update of a Cochrane Review previously published in 2010.

OBJECTIVES

To assess effects of RP compared with deferred treatment for clinically localised prostate cancer.

SEARCH METHODS

We searched the Cochrane Library (including CDSR, CENTRAL, DARE, and HTA), MEDLINE, Embase, AMED, Web of Science, LILACS, Scopus, and OpenGrey. Additionally, we searched two trial registries and conference abstracts of three conferences (EAU, AUA, and ASCO) until 3 March 2020.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared RP versus deferred treatment in patients with localised prostate cancer, defined as T1-2, N0, M0 prostate cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of references and extracted data from included studies. The primary outcome was time to death from any cause; secondary outcomes were: time to death from prostate cancer; time to disease progression; time to metastatic disease; quality of life, including urinary and sexual function; and adverse events. We assessed the certainty of evidence per outcome using the GRADE approach.  MAIN RESULTS: We included four studies with 2635 participants (average age between 60 to 70 years). Three multicentre RCTs, from Europe and USA, compared RP with WW (n = 1537), and one compared RP with AM (n = 1098). Radical prostatectomy versus watchful waiting RP probably reduces the risk of death from any cause (hazard ratio (HR) 0.79, 95% confidence interval (CI) 0.70-0.90; 3 studies with 1537 participants; moderate-certainty evidence). Based on overall mortality at 29 years, this corresponds to 764 deaths per 1000 men in the RP group compared to 839 deaths per 1000 men in the WW group. RP probably also lowers the risk of death from prostate cancer (HR 0.57, 95% CI 0.44-0.73; 2 studies with 1426 participants; moderate-certainty evidence). Based on prostate cancer-specific mortality at 29 years, this corresponds to 195 deaths from prostate cancer per 1000 men in the RP group compared with 316 deaths from prostate cancer per 1000 men in the WW group. RP may reduce the risk of progression (HR 0.43, 95% CI 0.35-0.54; 2 studies with 1426 participants; I² = 54%; low-certainty evidence); at 19.5 years, this corresponds to 391 progressions per 1000 men for the RP group compared with 684 progressions per 1000 men for the WW group) and probably reduces the risk of developing metastatic disease (HR 0.56, 95% CI 0.46-0.70; 2 studies with 1426 participants; I² = 0%; moderate-certainty evidence); at 29 years, this corresponds to 271 metastatic diseases per 1000 men for RP compared with 431 metastatic diseases per 1000 men for WW. General quality of life at 12 years' follow-up is probably similar for both groups (risk ratio (RR) 1.0, 95% CI 0.85-1.16; low-certainty evidence), corresponding to 344  patients with high quality of life per 1000 men for the RP group compared with 344 patients with high quality of life per 1000 men for the WW group. Rates of urinary incontinence may be considerably higher (RR 3.97, 95% CI 2.34-6.74; low-certainty evidence), corresponding to 173 incontinent men per 1000 in the RP group compared with 44 incontinent men per 1000 in the WW group, as are rates of erectile dysfunction (RR 2.67, 95% CI 1.63-4.38; low-certainty evidence), corresponding to 389 erectile dysfunction events per 1000 for the RP group compared with 146 erectile dysfunction events per 1000 for the WW group, both at 10 years' follow-up. Radical prostatectomy versus active monitoring Based on one study including 1098 participants with 10 years' follow-up, there are probably no differences between RP and AM in time to death from any cause (HR 0.93, 95% CI 0.65-1.33; moderate-certainty evidence). Based on overall mortality at 10 years, this corresponds to 101 deaths per 1000 men in the RP group compared with 108 deaths per 1000 men in the AM group. Similarly, risk of death from prostate cancer probably is not different between the two groups (HR 0.63, 95% CI 0.21-1.89; moderate-certainty evidence). Based on prostate cancer-specific mortality at 10 years, this corresponds to nine prostate cancer deaths per 1000 men in the RP group compared with 15 prostate cancer deaths per 1000 men in the AM group. RP probably reduces the risk of progression (HR 0.39, 95% CI 0.27-0.56; moderate-certainty evidence; at 10 years, this corresponds to 86 progressions per 1000 men for RP compared with 206 progressions per 1000 men for AM) and the risk of developing metastatic disease (RR 0.39, 95% CI 0.21-0.73; moderate-certainty evidence; at 10 years, this corresponds to 24 metastatic diseases per 1000 men for the RP group compared with 61 metastatic diseases per 1000 men for the AM group).The general quality of life during follow-up was not different between the treatment groups. However, urinary function (mean difference (MD) 8.60 points lower, 95% CI 11.2-6.0 lower) and sexual function (MD 14.9 points lower, 95% CI 18.5-11.3 lower) on the Expanded Prostate Cancer Index Composite-26 (EPIC-26) instrument, were worse in the RP group.

AUTHORS' CONCLUSIONS

Based on long-term follow-up, RP compared with WW probably results in substantially improved oncological outcomes in men with localised prostate cancer but also markedly increases rates of urinary incontinence and erectile dysfunction. These findings are largely based on men diagnosed before widespread PSA screening, thereby limiting generalisability. Compared to AM, based on follow-up to 10 years, RP probably has similar outcomes with regard to overall and disease-specific survival yet probably reduces the risks of disease progression and metastatic disease. Urinary function and sexual function are probably decreased for the patients treated with RP.

All change in the prostate cancer diagnostic pathway

Following detection of high levels of serum prostate-specific antigen, many men are advised to have transrectal ultrasound-guided biopsy in an attempt to locate a cancer. This nontargeted approach lacks accuracy and carries a small risk of potentially life-threatening sepsis. Worse still, it can detect clinically insignificant cancer cells, which are unlikely to be the origin of advanced-stage disease. The detection of these indolent cancer cells has led to overdiagnosis, one of the major problems of contemporary medicine, whereby many men with clinically insignificant disease are advised to undergo unnecessary radical surgery or radiotherapy. Advances in imaging and biomarker discovery have led to a revolution in prostate cancer diagnosis, and nontargeted prostate biopsies should become obsolete. In this Perspective article, we describe the current diagnostic pathway for prostate cancer, which relies on nontargeted biopsies, and the problems linked to this pathway. We then discuss the utility of prebiopsy multiparametric MRI and novel tumour markers. Finally, we comment on how the incorporation of these advances into a new diagnostic pathway will affect the current risk-stratification system and explore future challenges.

Prostatectomy Versus Observation for Localized Prostate Cancer: A Meta-Analysis

BACKGROUND AND AIMS

Controversy exists regarding whether prostatectomy benefits localized prostate cancer patients; the aim of our study was to evaluate the role of prostatectomy in localized prostate cancer patients.

MATERIALS AND METHODS

A systematic search was conducted using PubMed and Web of Science through March 22, 2019, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify randomized studies reporting on prostatectomy for localized prostate cancer patients.

RESULTS

Of a total of 1827 studies, six were considered for evidence synthesis. A total of 2524 patients in 3 studies were included for survival analysis, where 1256 patients received prostatectomy and 1268 patients received no treatment but were regularly followed up. Three other studies were included for adverse effects analysis. Prostatectomy displayed a significantly decreased risk of death of 9% compared with that of observation for patients with localized prostate cancer (risk ratio = 0.91; 95% confidence interval, 0.85-0.97; p = 0.007). Pooled data indicated that prostatectomy reduced the risk of disease progression by 43% (risk ratio = 0.57; 95% confidence interval, 0.47-0.70; p < 0.00001). Anxiety, depressed mood, well-being, and sense of meaningfulness for patients were not different between the prostatectomy and observation groups. However, prostatectomy increased the risk of erectile dysfunction by 2.10-fold (risk ratio = 2.10; 95% confidence interval, 1.36-3.26; p = 0.0009) and the risk of urinary function problems by 2.02-fold (risk ratio = 2.02; 95% confidence interval, 1.15-3.54; p = 0.01).

CONCLUSION

Prostatectomy prolonged survival and deferred disease progression compared to observation for patients with localized prostate cancer. Symptoms between the two groups were not significantly different except for erectile and urinary function. Patients should decide on prostatectomy after balancing the survival benefit and risk of erectile dysfunction.

Diet and lifestyle considerations for patients with prostate cancer

PURPOSE

To review the literature and provide recommendations on diet and lifestyle considerations in patients with prostate cancer using evidence from randomized controlled trials (RCTs) with additional considerations based on observational evidence.

MATERIALS AND METHODS

We initiated our search on ClinicalTrials.gov combining the term "prostate cancer" with a variety of diet and lifestyle factors. We then supplemented our summary of publications from registered trials by including other publications available on Pubmed.

RESULTS

There is a well-established benefit of exercise for improving functional outcomes and pelvic floor muscle training for improving treatment-related adverse effects. Multimodality interventions that integrate several factors (e.g., low-saturated fat, plant-based, whole-food diets with exercise, and stress reduction) appear to have the most clinically significant benefit for patients with prostate cancer. Ongoing multimodality interventions are including the efficacy of implementation strategies as observed outcomes. Limited RCT evidence suggests a clinically significant benefit for guided imagery/progressive muscle relaxation, Pilates, and lycopene-rich diets and a modest benefit for green tea, qigong, massage, and avoidance of nonprescribed vitamin and mineral supplements. Observational and single arm trial evidence indicates a need for further exploration of acupuncture, coffee, cruciferous vegetables, fish, Larrea tridentata, mushrooms, and vegetable-derived fats and avoidance of eggs, dairy, poultry with skin, processed red meat, and saturated fat. Published trials suggest no benefit from hypnosis, milk thistle, pomegranate, soy, or omega-3 fatty acid supplementation.

CONCLUSIONS

Our search demonstrated that most diet and lifestyle factors identified from observational studies have limited data from RCTs. Few items have shown early evidence of benefit. The best recommendation for patients with prostate cancer is to form a habit of wellness through healthy eating, aerobic and resistance exercise, and psychological well-being. Future trial development should consider how interventions can be implemented into real world practice.

Development of an ICF-based questionnaire for urinary and/or fecal incontinence (ICF-IAF): The male patients' perspective using focus groups

AIMS

This study seeks to explore barriers faced by and resources available to male patients with urinary (UI) and/or fecal incontinence (FI) based on the ICF framework. As a result, this study contributes to the development of the ICF-Incontinence Assessment Form (ICF-IAF), which is designed to be a standardized planning and evaluation tool for interventions in a multidisciplinary setting.

METHODS

A mixed-method sequential design that places emphasis on the quantitative approach was considered appropriate for this study. Focus group interviews (FG) were chosen to collect data. Data were analysed with deductive content analysis and themes identified during FG were linked to the most corresponding ICF categories by two raters. Cohen's κ was calculated to determine interrater reliability.

RESULTS

Four FG were conducted with a total of 13 male participants. The mean age of the participants was 74.7 years. A total of 73 barriers and resources on the second ICF level (body functions 26, body structures five, activities and participation 26 and environmental factors 16), whereby four categories were not sufficiently covered by the ICF, could be identified. The κ score for the two raters was 0.82.

CONCLUSIONS

While barriers are fundamental factors affecting patients, this study found that resources are as important and should not be overlooked in the conventional treatment in both UI and FI-specific assessments.

Optimizing prostate cancer accumulating model: combined PI-RADS v2 with prostate specific antigen and its derivative data

BACKGROUND

To establish a new accumulating model to enhance the accuracy of prostate cancer (PCa) diagnosis by incorporating prostate-specific antigen (PSA) and its derivative data into the Prostate Imaging-Reporting and Data System version 2 (PI-RADS v2).

METHODS

A total of 357 patients who underwent prostate biopsy between January 2014 and December 2017 were included in this study. All patients had 3.0 T multiparametric magnetic resonance imaging (MRI) and complete laboratory examinations. PI-RADS v2 was used to assess the imaging. PSA, PSA density (PSAD), the free/total PSA ratio (f/t PSA) and the Gleason score (GS) were classified into four-tiered levels, and optimal weights were pursued on these managed levels to build a PCa accumulating model. A receiver operating characteristic curve was generated.

RESULTS

In all, 174 patients (48.7%) had benign prostatic hyperplasia, and 183 (51.3%) had PCa, among whom 149 (81.4%, 149/183) had clinically significant PCa. The established model 6 (PI-RADS v2 + level of PSAD + level of f/t PSA+ level of PSA) had a sensitivity and specificity of 81.4 and 84.5%, respectively, at the cut-off point of 11 in PCa diagnosis. Correspondingly, at the 12 cut-off point, the sensitivity and specificity were 87.7 and 83.0%, respectively, in diagnosing clinically significant PCa. The score of the new accumulating system was significantly different among the defined GS groups (p < 0.001). The mean values and 95% confidence intervals for GS 1-4 groups were 10.20 (9.63-10.40), 12.03 (11.19-12.87), 14.12 (13.60-14.64) and 15.44 (15.09-15.79).

CONCLUSIONS

A new PCa accumulating model may be useful in improving the accuracy of the primary diagnosis of PCa and helpful in the clinical decision to perform a biopsy when MRI results are negative.

Conservative management and radical treatment in localised prostate cancer: A systematic review with meta-analysis and trial sequential analysis

Background:

Several randomised control trials comparing conservative management (watchful waiting/observation/active monitoring) and radical treatments (radical prostatectomy/radiotherapy) for localised prostate cancer with at least more than 10 years of follow-up (median) have been published with conflicting findings. The primary aim of this study was to determine all-cause mortality and prostate cancer-related mortality between conservative management and radical treatment for localised prostate cancer.

Methods:

All randomised clinical trials were searched in MEDLINE, EMBASE, PubMed and CENTRAL from their inception until September 2018.

Results:

Four trials were eligible ( n = 3211) for inclusion in the data synthesis. In patients who had radical treatment, the incidence of all-cause mortality and prostate cancer-related mortality (three trials, 3069 patients) were reduced (with odds ratio, i.e. 95% confidence interval (CI)), of 1.37 (1.14–1.64), ρ < 0.001, low quality of evidence and odd ratio (95% CI) of 1.74 (1.31–2.30), ρ < 0.001, low quality of evidence, respectively). The radical treatment group was associated with reduced incidence of distant metastases, the odds ratio (95% CI) being 1.87 (1.48–2.36), ρ < 0.001, low quality of evidence. However, patients who were randomised to radical treatment had a significantly higher incidence of erectile dysfunction (the odds ratio (95% CI) being 0.62 (0.39–0.98), ρ = 0.04, very low quality of evidence) and urinary incontinence (odds ratio (95% CI) of 0.42 (0.21–0.86), ρ = 0.02, very low quality of evidence).

Conclusions:

In summary, radical treatments reduce all-cause mortality, and prostate cancer-related and distant metastases, at the expense of higher incidence of erectile dysfunction and urinary incontinence. The general quality of evidence ranged from very low to low.

Level of evidence: 1a

PROSPERO Registration Number: CRD42017072687

Multiparametric MRI to improve detection of prostate cancer compared with transrectal ultrasound-guided prostate biopsy alone: the PROMIS study

BACKGROUND

Men with suspected prostate cancer usually undergo transrectal ultrasound (TRUS)-guided prostate biopsy. TRUS-guided biopsy can cause side effects and has relatively poor diagnostic accuracy. Multiparametric magnetic resonance imaging (mpMRI) used as a triage test might allow men to avoid unnecessary TRUS-guided biopsy and improve diagnostic accuracy.

OBJECTIVES

To (1) assess the ability of mpMRI to identify men who can safely avoid unnecessary biopsy, (2) assess the ability of the mpMRI-based pathway to improve the rate of detection of clinically significant (CS) cancer compared with TRUS-guided biopsy and (3) estimate the cost-effectiveness of a mpMRI-based diagnostic pathway.

DESIGN

A validating paired-cohort study and an economic evaluation using a decision-analytic model.

SETTING

Eleven NHS hospitals in England.

PARTICIPANTS

Men at risk of prostate cancer undergoing a first prostate biopsy.

INTERVENTIONS

Participants underwent three tests: (1) mpMRI (the index test), (2) TRUS-guided biopsy (the current standard) and (3) template prostate mapping (TPM) biopsy (the reference test).

MAIN OUTCOME MEASURES

Diagnostic accuracy of mpMRI, TRUS-guided biopsy and TPM-biopsy measured by sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) using primary and secondary definitions of CS cancer. The percentage of negative magnetic resonance imaging (MRI) scans was used to identify men who might be able to avoid biopsy.

RESULTS

Diagnostic study - a total of 740 men were registered and 576 underwent all three tests. According to TPM-biopsy, the prevalence of any cancer was 71% [95% confidence interval (CI) 67% to 75%]. The prevalence of CS cancer according to the primary definition (a Gleason score of ≥ 4 + 3 and/or cancer core length of ≥ 6 mm) was 40% (95% CI 36% to 44%). For CS cancer, TRUS-guided biopsy showed a sensitivity of 48% (95% CI 42% to 55%), specificity of 96% (95% CI 94% to 98%), PPV of 90% (95% CI 83% to 94%) and NPV of 74% (95% CI 69% to 78%). The sensitivity of mpMRI was 93% (95% CI 88% to 96%), specificity was 41% (95% CI 36% to 46%), PPV was 51% (95% CI 46% to 56%) and NPV was 89% (95% CI 83% to 94%). A negative mpMRI scan was recorded for 158 men (27%). Of these, 17 were found to have CS cancer on TPM-biopsy. Economic evaluation - the most cost-effective strategy involved testing all men with mpMRI, followed by MRI-guided TRUS-guided biopsy in those patients with suspected CS cancer, followed by rebiopsy if CS cancer was not detected. This strategy is cost-effective at the TRUS-guided biopsy definition 2 (any Gleason pattern of ≥ 4 and/or cancer core length of ≥ 4 mm), mpMRI definition 2 (lesion volume of ≥ 0.2 ml and/or Gleason score of ≥ 3 + 4) and cut-off point 2 (likely to be benign) and detects 95% (95% CI 92% to 98%) of CS cancers. The main drivers of cost-effectiveness were the unit costs of tests, the improvement in sensitivity of MRI-guided TRUS-guided biopsy compared with blind TRUS-guided biopsy and the longer-term costs and outcomes of men with cancer.

LIMITATIONS

The PROstate Magnetic resonance Imaging Study (PROMIS) was carried out in a selected group and excluded men with a prostate volume of > 100 ml, who are less likely to have cancer. The limitations in the economic modelling arise from the limited evidence on the long-term outcomes of men with prostate cancer and on the sensitivity of MRI-targeted repeat biopsy.

CONCLUSIONS

Incorporating mpMRI into the diagnostic pathway as an initial test prior to prostate biopsy may (1) reduce the proportion of men having unnecessary biopsies, (2) improve the detection of CS prostate cancer and (3) increase the cost-effectiveness of the prostate cancer diagnostic and therapeutic pathway. The PROMIS data set will be used for future research; this is likely to include modelling prognostic factors for CS cancer, optimising MRI scan sequencing and biomarker or translational research analyses using the blood and urine samples collected. Better-quality evidence on long-term outcomes in prostate cancer under the various management strategies is required to better assess cost-effectiveness. The value-of-information analysis should be developed further to assess new research to commission.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN16082556 and NCT01292291.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 39. See the NIHR Journals Library website for further project information. This project was also supported and partially funded by the NIHR Biomedical Research Centre at University College London (UCL) Hospitals NHS Foundation Trust and UCL and by The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research Biomedical Research Centre and was co-ordinated by the Medical Research Council's Clinical Trials Unit at UCL (grant code MC_UU_12023/28). It was sponsored by UCL. Funding for the additional collection of blood and urine samples for translational research was provided by Prostate Cancer UK.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU – Actualisation 2018–2020 : cancer de la prostate French ccAFU guidelines – Update 2018–2020: Prostate cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: DOI:10.1016/j.purol.2019.01.007. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the DOI:10.1016/j.purol.2019.01.007. That newer version of the text should be used when citing the article.

Management of Overactive Bladder Symptoms After Radical Prostatectomy

PURPOSE OF REVIEW

Post-prostatectomy overactive bladder (OAB) is a common and challenging condition to manage. The aim of the present report was to review the recent evidences regarding OAB symptoms that develop in men after prostatectomy and how to manage them.

RECENT FINDINGS

The prevalence of OAB after radical prostatectomy may range from 15.2 to 37.8%. Recent studies have highlighted the role of the urethrogenic mechanism (facilitation of the urethrovesical reflex due to stress urinary incontinence (SUI)) in the genesis of post-prostatectomy OAB in a significant proportion of patients. Several other pathophysiological factors such as iatrogenic decentralization of the bladder, defunctionalized bladder due to severe SUI, detrusor underactivity, or bladder outlet obstruction might be involved. The evaluation should aim to identify the underlying mechanism to tailor the treatment, which could range from SUI surgery, to fixing a urethral stricture, improving bladder emptying or using the conventional spectrum of OAB therapies. There is a paucity of data for OAB therapies specific to post-prostatectomy patients, with the exception of solifenacin, tolterodine, and botulinum toxin. There is currently no data on how preoperative management or surgical technique may prevent post-prostatectomy OAB.

Psychological impact of different primary treatments for prostate cancer: A critical analysis

Limited attention has been given to the psychological impact of primary treatments in patients with prostate cancer. Aim of our analysis was to critically analyse the current evidence on the psychological impact of different primary treatments (surgery, radiotherapy and active surveillance), in patients with prostate cancer, using validated questionnaires. We searched in the MEDLINE and Cochrane library database from the literature of the past 15 years (primary fields: prostate neoplasm, AND radical prostatectomy or radiotherapy or active surveillance AND psychological distress or anxiety or depression; secondary fields: urinary, sexual, bowel modifications, non-randomised and randomised trials). Overall eighteen original and review articles were included and critically evaluated. Either radical prostatectomy or active surveillance and radiotherapy are well-tolerated in terms of definite anxiety and depression during the post-treatment follow-up. A mutual influence between functional and psychological modifications induced by treatments has been demonstrated. Urinary symptoms related to incontinence more than sexual and bowel dysfunction are able to induce psychological distress worsening. In conclusion, patients and their clinicians might wish to know how functional and psychological aspects may differently be influenced by treatment choice.

Quality of Life Among Black Prostate Cancer Survivors: An Integrative Review

The purpose of this integrative review was to explore the impact of prostate cancer (PCa) on the quality of life (QoL) and factors that contribute to the QoL for Black men with PCa. Prostate is recognized as the prevalent cancer among men in the United States. Compared to other men, Black men are diagnosed more frequently and with more advanced stages of PCa. Black men also experience disproportionately higher morbidity and mortality rates of PCa, among all racial and ethnic groups. The initial diagnosis of PCa is often associated with a barrage of concerns for one's well-being including one's QoL. As a result, men must contend with various psychosocial and physiological symptoms of PCa survivorship. Whittemore and Knafl's integrative review method was utilized to examine empirical articles from the electronic databases of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, PubMed, Project Muse, and Google Scholar. The time frame for the literature was January 2005 to December 2016. A synthesis of the literature yielded 18 studies that met the inclusion criteria for the integrative review. A conceptual framework that examined QoL among cancer survivors identified four domains that measured the QoL among Black PCa survivors: (a) physical; (b) psychological; (c) social; and (d) spiritual well-being. Social well-being was the dominant factor among the studies in the review, followed by physical, psychological, and spiritual. Results indicate the need for additional studies that examine the factors impacting the QoL among Black PCa survivors, using a theoretical framework so as to develop culturally appropriate interventions for Black PCa survivors.

Focal therapy for localized prostate cancer: is there a "middle ground" between active surveillance and definitive treatment?

In recent years, it has come a long way in the diagnosis, treatment, and follow-up of prostate cancer. Beside this, it was argued that definitive treatments could cause overtreatment, particularly in the very low, low, and favorable risk group. When alternative treatment and follow-up methods are being considered for this group of patients, active surveillance is seen as a good alternative for patients with very low and low-risk groups in this era. However, it has become necessary to find other alternatives for patients in the favorable risk group or patients who cannot adopt active follow-up. In the light of technological developments, the concept of focal therapy was introduced with the intensification of research to treat only the lesioned area instead of treating the entire organ for prostate lesions though there are not many publications about many of them yet. According to the initial results, it was understood that the results could be good if the appropriate focal therapy technique was applied to the appropriate patient. Thus, focal therapies have begun to find their "middle ground" place between definitive therapies and active follow-up.

Worse Urinary, Sexual and Bowel Function Cause Emotional Distress and Vice Versa in Men Treated for Prostate Cancer

PURPOSE

Definitive therapy for prostate cancer (eg surgery or radiotherapy) often has side effects, including urinary, sexual and bowel dysfunction. The purpose of this study was to test whether urinary, sexual and bowel functions contribute to emotional distress during the first 2 years after treatment and whether distress may in turn decrease function.

MATERIALS AND METHODS

The study participants were 1,148 men diagnosed with clinically localized disease who were treated with surgery (63%) or radiotherapy (37%). Urinary, sexual and bowel functions were assessed with EPIC (Expanded Prostate Cancer Index Composite). Emotional distress was assessed with the NCCN® (National Comprehensive Cancer Network®) Distress Thermometer. Assessment time points were before treatment, and 6 weeks, and 6, 12, 18 and 24 months after treatment. We used time lagged multilevel models to test whether physical function predicted emotional distress and vice versa.

RESULTS

Men with worse urinary, bowel and sexual functions reported more emotional distress than others at subsequent time points. The relationships were bidirectional. Men who reported worse distress also reported worse urinary, bowel and sexual functions at subsequent time points.

CONCLUSIONS

Clinicians supported by practice and payer policies should screen for and facilitate the treatment of side effects and heightened emotional distress to improve well-being in survivors of prostate cancer. These interventions may be cost-effective, given that emotional distress can negatively impact functioning across life domains.

Functional outcomes of robot-assisted radical prostatectomy in patients eligible for active surveillance

OBJECTIVE

To assess the outcome of low risk prostate cancer (PCa) patients who were candidates for active surveillance (AS) but had undergone robot-assisted radical prostatectomy (RARP).

METHOD

We reviewed our prospectively collected database of patients operated by RARP between 2006 and 2014. Low D'Amico risk patients were selected. Oncological outcomes were reported based on pathology results and biochemical failure. Functional outcomes on continence and potency were reported at 12 and 24 months. Continence was assessed by the number of pads per day. With respect to potency, it was assessed using the Sexual Health Inventory for Men (SHIM) and Erectile Hardness Scale (EHS).

RESULTS

Out of 812 patients, 237 (29.2%) patients were D'Amico low risk and were eligible for analysis. 44 men fit Epstein's criteria. 134 (56.5%) men had pathological upgrading. Age and clinical stage were predictors of upgrading on multivariate analysis. 220 (92.8%) patients had available follow-up for biochemical recurrence, potency, and continence for 2 years. The mean and median follow-up was 34.8 and 31.4 months, respectively. Only 5 (2.3%) men developed BCR, all of whom had pathological upgrading. Extra capsular extension and positive surgical margins were observed in 14.8 and 19.1%, respectively. 0 pad was achieved in 86.7 and 88.9% at 1 and 2 years, respectively. Proportion of patients with SHIM > 21 at 1 and 2 years was 24.8 and 30.6%, respectively. Moreover, patients having erections adequate for intercourse (EHS ≥ 3) were seen in 69.6 and 83.1% at 1 and 2 years, respectively. Functional outcomes of patients fitting Epstein's criteria (n = 44) and patients with no upgrading on final pathology (n = 103) were not significantly different compared to the overall low risk study group.

CONCLUSION

This retrospective study showed that RARP is not without harm even in patients with low risk disease. On the other hand, considerable rate of upgrading was noted.

The German version of the Expanded Prostate Cancer Index Composite (EPIC): translation, validation and minimal important difference estimation

BACKGROUND

No official German translation exists for the 50-item Expanded Prostate Cancer Index Composite (EPIC), and no minimal important difference (MID) has been established yet. The aim of the study was to translate and validate a German version of the EPIC with cultural adaptation to the different German speaking countries and to establish the MID.

METHODS

We translated and culturally adapted the EPIC into German. For validation, we included a consecutive subsample of 92 patients with localized prostate cancer undergoing radical prostatectomy who participated the Prostate Cancer Outcomes Cohort. Baseline and follow-up assessments took place before and six weeks after prostatectomy in 2010 and 2011. We assessed the EPIC, EORTC QLQ-PR25, Feeling Thermometer, SF-36 and a global rating of health state change variable. We calculated the internal consistency, test-retest reliability, construct validity, responsiveness and MID.

RESULTS

For most EPIC domains and subscales, our a priori defined criteria for reliability were fulfilled (construct reliability: Cronbach's alpha 0.7-0.9; test-retest reliability: intraclass-correlation coefficient ≥ 0.7). Cross-sectional and longitudinal correlations between EPIC and EORTC QLQ-PR25 domains ranged from 0.14-0.79, and 0.06-0.5 and 0.08-0.72 for Feeling Thermometer and SF-36, respectively. We established MID values of 10, 4, 12, and 6 for the urinary, bowel, sexual and hormonal domain.

CONCLUSION

The German version of the EPIC is reliable, responsive and valid to measure HRQL in prostate cancer patients and is now available in German language. With the suggested MID we provide interpretation to what extent changes in HRQL are clinically relevant for patients. Hence, study results are of interest beyond German speaking countries.

Do psychological harms result from being labelled with an unexpected diagnosis of abdominal aortic aneurysm or prostate cancer through screening? A systematic review

OBJECTIVE

A potential psychological harm of screening is unexpected diagnosis-labelling. We need to know the frequency and severity of this harm to make informed decisions about screening. We asked whether current evidence allows an estimate of any psychological harm of labelling. As case studies, we used two conditions for which screening is common: prostate cancer (PCa) and abdominal aortic aneurysm (AAA).

DESIGN

Systematic review with narrative synthesis.

DATA SOURCES AND ELIGIBILITY CRITERIA

We searched the English language literature in PubMed, PsychINFO and Cumulative Index of Nursing and Allied Health Literature (CINAHL) for research of any design published between 1 January 2002 and 23 January 2017 that provided valid data about the psychological state of people recently diagnosed with early stage PCa or AAA. Two authors independently used explicit criteria to review and critically appraise all studies for bias, applicability and the extent to which it provided evidence about the frequency and severity of harm from labelling.

RESULTS

35 quantitative studies (30 of PCa and 5 of AAA) met our criteria, 17 (48.6%) of which showed possible or definite psychological harm from labelling. None of these studies, however, had either appropriate measures or relevant comparisons to estimate the frequency and severity of psychological harm. Four PCa and three AAA qualitative studies all showed clear evidence of at least moderate psychological harm from labelling. Seven population-based studies found increased suicide in patients recently diagnosed with PCa.

CONCLUSIONS

Although qualitative and population-based studies show that at least moderate psychological harm due to screening for PCa and AAA does occur, the current quantitative evidence is insufficient to allow a more precise estimation of frequency and severity. More sensitive measures and improved research designs are needed to fully characterise this harm. In the meantime, clinicians and recommendation panels should be aware of the occurrence of this harm.

High miR-205 expression in normal epithelium is associated with biochemical failure - an argument for epithelial crosstalk in prostate cancer?

Due to insufficient prognostic tools, failure to predict aggressive prostate cancer (PC) has left patient selection for radical treatment an unsolved challenge. This has resulted in overtreatment with radical therapy. Better prognostic tools are urgently warranted. MicroRNAs (miRs) have emerged as important regulators of cellular pathways, resulting in altered gene expressions. miR-205 has previously been observed downregulated in PC, acting as tumor suppressor. Herein, the expression of miR-205 in prostate tissue was examined in a large, well-described cohort of 535 Norwegian prostatectomy patients. Using in situ hybridization, miR-205 expression was semiquantatively measured in normal and tumor tissues from radical prostatectomy specimens. Associations with clinicopathological data and PC relapse were calculated. Expression of miR-205 was lower in tumor epithelium compared to normal epithelium. No association was observed between miR-205 expression in primary tumor epithelium and cancer relapse. In contrast, high expression of miR-205 in normal epithelium was independently associated with biochemical relapse (HR = 1.64, p = 0.003). A prognostic importance of miR-205 expression was only found in the normal epithelium, raising the hypothesis of epithelial crosstalk between normal and tumor epithelium in PC. This finding supports the proposed novel hypothesis of an anti-cancerogenous function of normal epithelium in tumor tissue.

Coping and adjustment in men with prostate cancer: a systematic review of qualitative studies

Purpose

Prostate cancer (PCa) is one of the most common forms of cancer amongst males. Men’s coping responses are an important determinant of functioning and adjustment to this disease. Previous qualitative research exists in this area, but the current review sought to systematically review and summarise these studies.

Methods

A systematic review was conducted to identify studies concerned with men’s coping strategies in their attempts to live with PCa. A search of relevant electronic databases was conducted to identify studies that met inclusion criteria for this review. Methodological quality assessment was also undertaken for each included study.

Results

One hundred twenty-one publications were identified for initial screening, and 18 studies were included in the review. A total of five coping strategy categories or ‘meta-themes’ were identified across included studies. These categories were labelled ‘avoidance, minimisation, and withdrawal’, ‘directing cognition and attention’, ‘reframing masculinity and seeking support’, ‘retain pre-illness identity and lifestyle’, and ‘symptom/side-effect management’.

Conclusions

A range of coping strategies were reported by men with PCa. Some of these strategies appear to be partially influenced by gender roles and masculinities. Coping meta-themes reported in this review have also been found in other research on men’s coping. Strategies relating to flexible interpretation of gender roles/masculinities may be a particularly relevant category of coping responses due to the hypothesised beneficial impact of flexibility on psychological well-being.

Implications for cancer survivors

PCa survivors utilise a range of coping strategies, and the types of strategies used may have implications for men’s well-being. The ability to be flexible in both coping responses used, and in the view of oneself as a man may be particularly important skills in meeting the challenges associated with this disease.

Prevalence and associations of general practitioners' ordering of "non-symptomatic" prostate-specific antigen tests: A cross-sectional analysis

AIMS

Testing for asymptomatic prostate cancer with prostate specific antigen (PSA) is of uncertain benefit. Most relevant authorities recommend against screening, and for informed patient choice. We aimed to establish the prevalence and associations of "non-symptomatic" PSA-testing of men aged 40 or older by early-career general practitioners (GP registrars).

METHODS

A cross-sectional analysis from the ReCEnT cohort study of registrars' consultations, 2010-2014 (analysed in 2016). Registrars record 60 consecutive consultations each 6-month training term. The outcome factor was ordering an "asymptomatic" PSA test (a PSA ordered for an indication that was not prostate-related symptoms or prostatic disease monitoring). Independent variables were patient, registrar, practice, consultation and educational factors.

RESULTS

A total of 856 registrars contributed details of 21,372 individual consultations and 35,696 problems/diagnoses of males 40 or older. Asymptomatic PSAs were ordered for 1.8% (95%CI: 1.7-2.0%) of consultations and for 1.1% (95%CI: 1.0-1.2%) of problems/diagnoses. Multivariable associations of asymptomatic PSA testing (compared with problems/diagnoses for which a PSA was not ordered) included patient age (OR 2.32 [95%CI: 1.53-3.53] for 60-69 years compared with 40-49), patient ethnicity (OR 0.40 [95%CI: 0.19-0.86] for non-English speaking background), the patient being new to both the registrar and practice (ORs 1.46 [95%CI: 1.08-1.99] and 1.79 [95%CI: 1.03-3.10]), the number of problems/diagnoses addressed (OR 1.44 [95%CI: 1.25-1.66] for each extra problem) and more pathology tests being ordered (OR 1.88 [95%CI: 1.79-1.97] for each extra test).

CONCLUSION

GP registrars frequently order "asymptomatic" PSA tests. Our findings suggest that non-compliance with current guidelines for PSA screening may be relatively common and that targeted education is warranted.

Eleven-year management of prostate cancer patients on active surveillance: what have we learned?

PURPOSE

To evaluate the outcomes of active surveillance (AS) on patients with low-risk prostate cancer (PCa) and to identify predictors of disease reclassification.

METHODS

In 2005, we defined an institutional AS protocol (Sorveglianza Attiva Istituto Nazionale Tumori [SAINT]), and we joined the Prostate Cancer Research International: Active Surveillance (PRIAS) study in 2007. Eligibility criteria included clinical stage ≤T2a, initial prostate-specific antigen (PSA) <10 ng/mL, and Gleason Pattern Score (GPS) ≤3 + 3 (both protocols); ≤25% positive cores with a maximum core length containing cancer ≤50% (SAINT); and ≤2 positive cores and PSA density <0.2 ng/mL/cm3 (PRIAS). Switching to active treatment was advised for a worsening of GPS, increased positive cores, or PSA doubling time <3 years. Active treatment-free survival (ATFS) was assessed using the Kaplan-Meier method. Factors associated with ATFS were evaluated with a multivariate Cox proportional hazards model.

RESULTS

A total of 818 patients were included: 200 in SAINT, 530 in PRIAS, and 88 in personalized AS monitoring. Active treatment-free survival was 50% after a median follow-up of 60 months. A total of 404/818 patients (49.4%) discontinued AS: 274 for biopsy-related reclassification, 121/404 (30%) for off-protocol reasons, 9/404 (2.2%) because of anxiety. Biopsy reclassification was associated with PSA density (hazard ratio [HR] 1.8), maximum percentage of core involvement (HR 1.5), positive cores at diagnostic biopsy (HR 1.6), older age (HR 1.5), and prostate volume (HR 0.6) (all p<0.01). Patients from SAINT were significantly more likely to discontinue AS than were the patients from PRIAS (HR 1.65, p<0.0001).

CONCLUSIONS

Five years after diagnosis, 50% of patients with early PCa were spared from active treatment. Wide inclusion criteria are associated with lower ATFS. However, at preliminary analysis, this does not seem to affect the probability of unfavorable pathology.

[CCAFU french national guidelines 2016-2018 on prostate cancer]

OBJECTIVES

The purpose of the guidelines national committee CCAFU was to propose updated french guidelines for localized and metastatic prostate cancer (PCa).

METHODS

A Medline search was achieved between 2013 and 2016, as regards diagnosis, options of treatment and follow-up of PCa, to evaluate different references with levels of evidence.

RESULTS

Epidemiology, classification, staging systems, diagnostic evaluation are reported. Disease management options are detailed. Recommandations are reported according to the different clinical situations. Active surveillance is a major option in low risk PCa. Radical prostatectomy remains a standard of care of localized PCa. The three-dimensional conformal radiotherapy is the technical standard. A dose of > 74Gy is recommended. Moderate hypofractionation provides short-term biochemical control comparable to conventional fractionation. In case of intermediate risk PCa, radiotherapy can be combined with short-term androgen deprivation therapy (ADT). In case of high risk disease, long-term ADT remains the standard of care. ADT is the backbone therapy of metastatic disease. In men with metastases at first presentation, upfront chemotherapy combined with ADT should be considered as a new standard. In case of metastatic castration-resistant PCa (mCRPC), new hormonal treatments and chemotherapy provide a better control of tumor progression and increase survival.

CONCLUSIONS

These updated french guidelines will contribute to increase the level of urological care for the diagnosis and treatment for prostate cancer. © 2016 Elsevier Masson SAS. All rights reserved.

African American prostate cancer survivorship: Exploring the role of social support in quality of life after radical prostatectomy

Purpose: The aim of this study was to explore the African American prostate cancer survivorship experience following radical prostatectomy and factors contributing to quality of life during survival. Design: African American men who were part of a larger prostate cancer cohort were invited to participate in a focus group. Eighteen open-ended questions were designed by the study team and an experienced moderator to elicit participants' survivorship experiences. Results: Twelve men consented to participate in the study. Emergent themes included views of prostate cancer in the African American community, perceptions of normalcy, emotional side effects following radical prostatectomy, and social support involvement and impact during recovery. Conclusions: Previous findings suggest that African American men may experience more distress than Caucasian men when facing typical prostate cancer side effects. Traditional masculine role norms and negative perceptions of “disease disclosure” in the African American community could be contributing to the distress reported by some in this study. Strengthening social support systems by promoting more prosocial coping and help-seeking behaviors early in the survivorship journey may help bypass the detrimental health effects associated with masculine role identification, resulting in improved quality of life throughout the lengthy survival period anticipated for these men.

High expression of PDGFR-β in prostate cancer stroma is independently associated with clinical and biochemical prostate cancer recurrence

Due to a lack of sufficient diagnostic tools to predict aggressive disease, there is a significant overtreatment of patients with prostate cancer. Platelet derived growth factors (PDGFs) and their receptors (PDGFRs) are key regulators of mesenchymal cells in the tumor microenvironment, and has been associated with unfavorable outcome in several other cancers. Herein, we aimed to investigate the prognostic impact of PDGFR-β and its ligands (PDGF-B and PDGF-D) in a multicenter prostatectomy cohort of 535 Norwegian patients. Using tissue microarrays and immunohistochemistry, the expression of ligands PDGF-B and PDGF-D and their corresponding receptor, PDGFR-β, was assessed in neoplastic tissue and tumor-associated stroma. PDGFR-β was expressed in benign and tumor associated stroma, but not in epithelium. High stromal expression of PDGFR-β was independently associated with clinical relapse (HR = 2.17, p = 0.010) and biochemical failure (HR = 1.58, p = 0.002). This large study highlights the prognostic importance of PDGFR-β expression, implicating its involvement in prostate cancer progression even in early stage disease. Hence, analyses of PDGFR-β may help distinguish which patients will benefit from radical treatment, and since PDGFR-β is associated with relapse and shorter survival, it mandates a focus as a therapeutic target.

Advocacy, support and survivorship in prostate cancer

Across Australia, prostate cancer support groups (PCSG) have emerged to fill a gap in psychosocial care for men and their families. However, an understanding of the triggers and influencers of the PCSG movement is absent. We interviewed 21 SG leaders (19 PC survivors, two partners), of whom six also attended a focus group, about motivations, experiences, past and future challenges in founding and leading PCSGs. Thematic analysis identified four global themes: illness experience; enacting a supportive response; forming a national collective and challenges. Leaders described men's feelings of isolation and neglect by the health system as the impetus for PCSGs to form and give/receive mutual help. Negotiating health care systems was an early challenge. National affiliation enabled leaders to build a united voice in the health system and establish a group identity and collective voice. Affiliation was supported by a symbiotic relationship with tensions between independence, affiliation and governance. Future challenges were group sustainability and inclusiveness. Study findings describe how a grassroots PCSG movement arose consistent with an embodied health movement perspective. Health care organisations who seek to leverage these community resources need to be cognisant of SG values and purpose if they are to negotiate effective partnerships that maximise mutual benefit.

Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer

BACKGROUND

Robust data on patient-reported outcome measures comparing treatments for clinically localized prostate cancer are lacking. We investigated the effects of active monitoring, radical prostatectomy, and radical radiotherapy with hormones on patient-reported outcomes.

METHODS

We compared patient-reported outcomes among 1643 men in the Prostate Testing for Cancer and Treatment (ProtecT) trial who completed questionnaires before diagnosis, at 6 and 12 months after randomization, and annually thereafter. Patients completed validated measures that assessed urinary, bowel, and sexual function and specific effects on quality of life, anxiety and depression, and general health. Cancer-related quality of life was assessed at 5 years. Complete 6-year data were analyzed according to the intention-to-treat principle.

RESULTS

The rate of questionnaire completion during follow-up was higher than 85% for most measures. Of the three treatments, prostatectomy had the greatest negative effect on sexual function and urinary continence, and although there was some recovery, these outcomes remained worse in the prostatectomy group than in the other groups throughout the trial. The negative effect of radiotherapy on sexual function was greatest at 6 months, but sexual function then recovered somewhat and was stable thereafter; radiotherapy had little effect on urinary continence. Sexual and urinary function declined gradually in the active-monitoring group. Bowel function was worse in the radiotherapy group at 6 months than in the other groups but then recovered somewhat, except for the increasing frequency of bloody stools; bowel function was unchanged in the other groups. Urinary voiding and nocturia were worse in the radiotherapy group at 6 months but then mostly recovered and were similar to the other groups after 12 months. Effects on quality of life mirrored the reported changes in function. No significant differences were observed among the groups in measures of anxiety, depression, or general health-related or cancer-related quality of life.

CONCLUSIONS

In this analysis of patient-reported outcomes after treatment for localized prostate cancer, patterns of severity, recovery, and decline in urinary, bowel, and sexual function and associated quality of life differed among the three groups. (Funded by the U.K. National Institute for Health Research Health Technology Assessment Program; ProtecT Current Controlled Trials number, ISRCTN20141297 ; ClinicalTrials.gov number, NCT02044172 .).

Ablative Focused Ultrasound Synergistically Enhances Thermally Triggered Chemotherapy for Prostate Cancer in Vitro

High-intensity focused ultrasound (HIFU) can locally ablate biological tissues such as tumors, i.e., induce their rapid heating and coagulative necrosis without causing damage to surrounding healthy structures. It is widely used in clinical practice for minimally invasive treatment of prostate cancer. Nonablative, low-power HIFU was established as a promising tool for triggering the release of chemotherapeutic drugs from temperature-sensitive liposomes (TSLs). In this study, we combine ablative HIFU and thermally triggered chemotherapy to address the lack of safe and effective treatment options for elderly patients with high-risk localized prostate cancer. DU145 prostate cancer cells were exposed to chemotherapy (free and liposomal Sorafenib) and ablative HIFU, alone or in combination. Prior to cell viability assessment by trypan blue exclusion and flow cytometry, the uptake of TSLs by DU145 cells was verified by confocal microscopy and cryogenic scanning electron microscopy (cryo-SEM). The combination of TSLs encapsulating 10 μM Sorafenib and 8.7W HIFU resulted in a viability of less than 10% at 72 h post-treatment, which was significant less than the viability of the cells treated with free Sorafenib (76%), Sorafenib-loaded TSLs (63%), or HIFU alone (44%). This synergy was not observed on cells treated with Sorafenib-loaded nontemperature sensitive liposomes and HIFU. According to cryo-SEM analysis, cells exposed to ablative HIFU exhibited significant mechanical disruption. Water bath immersion experiments also showed an important role of mechanical effects in the synergistic enhancement of TSL-mediated chemotherapy by ablative HIFU. This combination therapy can be an effective strategy for treatment of geriatric prostate cancer patients.

Evaluation of the utilization of external radiotherapy in the treatment of localized prostate cancer in Andalusia, Spain

BACKGROUND

Around 27,000 new cases of prostate cancer are diagnosed every year in Spain and 5400 die from this disease. Radiotherapy (RT), alone or combined, has proven to be effective as initial treatment in patients with localized disease. Our objective was to evaluate the use of external beam RT (EBRT) in our region, comparing the indication rate and irradiation rate and examining variability in its application among hospitals.

METHODS

We conducted a review of RT guidelines and indication studies for prostate cancer (% expected irradiation). Data were gathered from all twelve public healthcare centers in Andalusia (Spain) on RT-treated prostate cancer patients during 2013 (% actual irradiation) and from nine of the centers on RT discharge reports. Information was classified according to type of hospital, tumor risk category and RT treatment (technique, dosage, volume, toxicity).

RESULTS

The estimated RT rate was 67 % (1289/1917), 43 % were aged > 70 years, 44.7 % had ECOG performance status of 0); 44.7 % had high-risk tumors; 57 % underwent RT associated with hormone therapy; 70 % of patients receiving RT were treated with 3D planning (30 % IGRT); and doses were 70-76 Gy in 70 % of cases and >76 Gy in 10.7 %. Acute gastrointestinal and genitourinary toxicities were < grade 2 in 79 and 89 % of patients, respectively. An irradiation rate significantly below the mean for the study was found in four provinces. There was a significant difference among provinces in the distribution of risk groups.

CONCLUSIONS

Underutilization of EBRT was estimated to be around 30 % in prostate cancer patients, with an elevated variability in irradiation rates among hospitals related to differences in available technology and in the distribution of patients with different risk levels. These data should be a matter of concern to regional health managers, given the negative and measurable impact on the survival of patients.

Stromal expression of VEGF-A and VEGFR-2 in prostate tissue is associated with biochemical and clinical recurrence after radical prostatectomy

BACKGROUND

There is probably significant overtreatment of patients with prostate cancer due to a lack of sufficient diagnostic tools to predict aggressive disease. Vascular endothelial growth factors (VEGFs) and their receptors (VEGFRs) are potent mediators of angiogenesis and tumor proliferation, but have been examined to a limited extent in large prostate cancer studies. Meanwhile, recent promising results on VEGFR-2 inhibition have highlighted their importance, leading to the need for further investigations regarding their expression and prognostic impact.

DESIGN

Using tissue microarray and immunohistochemistry, the expression of VEGFs (VEGF-A and VEGF-C) and their receptors (VEGFR-2 and VEGFR-3) were measured in neoplastic tissue and corresponding stroma from radical prostatectomy specimens in 535 Norwegian patients. Their expression was evaluated semiquantatively and associations with event-free survival were calculated.

RESULTS

High expression of VEGFR-2 in either stroma or epithelium was independently associated with a higher incidence of prostate cancer relapse (HR = 4.56, P = 0.038). A high combined expression of either VEGF-A, VEGFR-2 or both in stroma was independently associated with a higher incidence of biochemical failure (HR = 1.77, P = 0.011).

CONCLUSIONS

This large study highlights the prognostic importance of VEGF-A and VEGFR-2 stromal expression. Analyses of these biomarkers may help distinguish which patients will benefit from radical treatment. Together with previous studies showing efficiency of targeting VEGFR-2 in prostate cancer, this study highlights its potential as a target for therapy, and may aid in future selection of prostate cancer patients for novel anti-angiogenic treatment.

Metabolic Syndrome Components are Associated with Increased Prostate Cancer Risk

Background

Our study investigated the associations of metabolic syndrome (MS) and metabolic indicators with prostate cancer (PCa) risk in the Chinese Han ethnic population.

Material/Methods

We studied 101 PCa patients (without/with MS) and 120 healthy controls. Clinical data, including waist circumference, BMI, TG, FINS, FBG, and PCa-related indicators, were collected. The correlations between MS and PCa were analyzed.

Results

Compared to PCa, PV and Gleason scores increased and PSA levels decreased in PCa with MS group (all P<0.001). PV was positively correlated with BMI, FINS, and HOMA-IR (r=0.459, P<0.001; r=0.421, P=0.001; r=0.490, P=0.003, respectively), and was negatively correlated with HDL-C (r=−0.378, P<0.001). PSA level in MS patients was negatively correlated with BMI (r=−0.125, P<0.001), TG (r=−0.256, P<0.001) and FBG (r=−0.183, P<0.001). Large PV, high TG, low HDL-C, high LDL-C, and high FBG were associated with an increased risk of PCa (P<0.001, OR=1.10, 95%CI: 1.009–3.304; P<0.001, OR=2.91, 95%CI: 1.612–5.241; P<0.001, OR=7.89, 95%CI: 3.908–15.947; P=0.015, OR=1.87, 95%CI: 1.131–3.077; P=0.004, OR=2.17, 95%CI: 1.280–3.686, respectively). MS-related indicators showed a positive relationship with PCa (P<0.001, OR=1.90, 95%CI: 1.107–10.629).

Conclusions

Our study shows that MS and metabolic indicators are associated with an increased risk of PCa, pointing to a novel therapeutic approach for PCa management.