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Clinical Evaluation of an Individualized Risk Prediction Tool for Men on Active Surveillance for Prostate Cancer. Urology 2018; 121:118-124. [PMID: 30171924 DOI: 10.1016/j.urology.2018.08.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/15/2018] [Accepted: 08/17/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine whether providing individualized predictions of health outcomes to men on active surveillance (AS) alleviates cancer-related anxiety and improves risk understanding. MATERIALS AND METHODS We consecutively recruited men from our large, institutional AS program before (n = 36) and after (n = 31) implementation of a risk prediction tool. Men in both groups were surveyed before and after their regular visits to assess their perceived cancer control, biopsy-specific anxiety, and burden from cancer-related information. We compared pre-/post-visit differences between men who were and were not shown the tool using two-sample t-tests. Satisfaction with and understanding of the predictions were elicited from men in the intervention period. RESULTS Men reported a relatively high level of cancer control at baseline. Men who were not shown the tool saw a 6.3 point increase (scaled from 0 to 100) in their perceived cancer control from before to after their visit whereas men who were shown the tool saw a 12.8 point increase, indicating a statistically significant difference between groups (p = .04). Biopsy-specific anxiety and burden from cancer information were not significantly different between groups. Men were satisfied with the tool and demonstrated moderate understanding. CONCLUSION Providing individualized predictions to men on AS helps them better understand their cancer risk and should be considered at other clinical sites.
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Rapport F, Hogden A, Gurney H, Gillatt D, Bierbaum M, Shih P, Churruca K. Communicating risk in active surveillance of localised prostate cancer: a protocol for a qualitative study. BMJ Open 2017; 7:e017372. [PMID: 28982830 PMCID: PMC5640046 DOI: 10.1136/bmjopen-2017-017372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION One in five men is likely to receive a diagnosis of prostate cancer (PCa) by the age of 85 years. Men diagnosed with low-risk PCa may be eligible for active surveillance (AS) to monitor their cancer to ensure that any changes are discovered and responded to in a timely way. Communication of risk in this context is more complicated than determining a numerical probability of risk, as patients wish to understand the implications of risk on their lives in concrete terms. Our study will examine how risk for PCa is perceived, experienced and communicated by patients using AS with their health professionals, and the implications for treatment and care. METHODS AND ANALYSIS This is a proof of concept study, testing out a multimethod, qualitative approach to data collection in the context of PCa for the first time in Australia. It is being conducted from November 2016 to December 2017 in an Australian university hospital urology clinic. Participants are 10 men with a diagnosis of localised PCa, who are using an AS protocol, and 5 health professionals who work with this patient group (eg, urologists and Pca nurses). Data will be collected using observations of patient consultations with health professionals, patient questionnaires and interviews, and interviews with healthcare professionals. Analysis will be conducted in two stages. First, observational data from consultations will be analysed thematically to encapsulate various dimensions of risk classification and consultation dialogue. Second, interview data will be coded to derive meaning in text and analysed thematically. Overarching themes will represent patient and health professional perspectives of risk communication. ETHICS AND DISSEMINATION Ethical approval for the study has been granted by Macquarie University Human Research Ethics Committee, approval 5201600638. Knowledge translation will be achieved through publications, reports and conference presentations to patients, families, clinicians and researchers.
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Affiliation(s)
- Frances Rapport
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Anne Hogden
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Howard Gurney
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - David Gillatt
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Mia Bierbaum
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Patti Shih
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Kate Churruca
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Effectiveness and safety of computed tomography-guided radiofrequency ablation of renal cancer: a 14-year single institution experience in 203 patients. Eur Radiol 2015; 26:1656-64. [PMID: 26373755 DOI: 10.1007/s00330-015-4006-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 08/07/2015] [Accepted: 09/03/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To define effectiveness and safety of CT-guided radiofrequency ablation (RFA) of renal tumours and prognostic indicators for treatment success. METHODS Patients with a single treatment of a solitary, biopsy-proven renal tumour with intent to cure over a 14-year period were included (n = 203). Probability of residual disease over time, complication rates and all-cause mortality were assessed in relation to multiple variables. RESULTS Mean tumour size was 2.5 cm (range 1.0-6.0). Mean follow-up was 34.1 months (range 1-131). There was an increase in likelihood of residual disease for tumours ≥3.5 cm (P < 0.05), clear cell subtype of renal cell carcinoma (P ≤ 0.005) and maximum treatment temperature ≤70 °C (P < 0.05). There was a decrease in likelihood of residual disease for exophytic tumours (P = 0.01) and no difference based on age, gender, tumour location or type of radio freqency (RF) electrode used. Major complications occurred in 3.9 %. Median post-treatment survival was 7 years for patients with tumours <4 cm, and 5-year overall survival was 80 %. Probability of minor complication increased with tumour size (P = 0.03), as did all-cause mortality (P = 0.005). CONCLUSIONS CT-guided RFA is safe and effective for early-stage renal cancer, particularly for exophytic tumours measuring <3.5 cm. Overall 5-year survival with tumours <4 cm is comparable to partial nephrectomy. KEY POINTS • Prognostic indicators for success of CT-guided RFA of renal tumours are reported. • Tumour size ≥3.5 cm confers an increased risk for residual tumour. • Clear cell renal cell carcinoma subtype confers increased risk for residual tumour. • Tmax <70 °C within the ablation zone confers increased risk for residual tumour. • Exophytic tumours have a lower probability of residual disease.
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Simpkin AJ, Rooshenas L, Wade J, Donovan JL, Lane JA, Martin RM, Metcalfe C, Albertsen PC, Hamdy FC, Holmberg L, Neal DE, Tilling K. Development, validation and evaluation of an instrument for active monitoring of men with clinically localised prostate cancer: systematic review, cohort studies and qualitative study. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03300] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundActive surveillance [(AS), sometimes called active monitoring (AM)],is a National Institute for Health and Care Excellence-recommended management option for men with clinically localised prostate cancer (PCa). It aims to target radical treatment only to those who would benefit most. Little consensus exists nationally or internationally about safe and effective protocols for AM/AS or triggers that indicate if or when men should move to radical treatment.ObjectiveThe aims of this project were to review how prostate-specific antigen (PSA) has been used in AM/AS programmes; to develop and test the validity of a new model for predicting future PSA levels; to develop an instrument, based on PSA, that would be acceptable and effective for men and clinicians to use in clinical practice; and to design a robust study to evaluate the cost-effectiveness of the instrument.MethodsA systematic review was conducted to investigate how PSA is currently used to monitor men in worldwide AM/AS studies. A model for PSA change with age was developed using Prostate testing for cancer and Treatment (ProtecT) data and validated using data from two PSA-era cohorts and two pre-PSA-era cohorts. The model was used to derive 95% PSA reference ranges (PSARRs) across ages. These reference ranges were used to predict the onset of metastases or death from PCa in one of the pre-PSA-era cohorts. PSARRs were incorporated into an active monitoring system (AMS) and demonstrated to 18 clinicians and 20 men with PCa from four NHS trusts. Qualitative interviews investigated patients’ and clinicians’ views about current AM/AS protocols and the acceptability of the AMS within current practice.ResultsThe systematic review found that the most commonly used triggers for clinical review of PCa were PSA doubling time (PSADT) < 3 years or PSA velocity (PSAv) > 1 ng/ml/year. The model for PSA change (developed using ProtecT study data) predicted PSA values in AM/AS cohorts within 2 ng/ml of observed PSA in up to 79% of men. Comparing the three PSA markers, there was no clear optimal approach to alerting men to worsening cancer. The PSARR and PSADT markers improved the modelc-statistic for predicting death from PCa by 0.11 (21%) and 0.13 (25%), respectively, compared with using diagnostic information alone [PSA, age, tumour stage (T-stage)]. Interviews revealed variation in clinical practice regarding eligibility and follow-up protocols. Patients and clinicians perceive current AM/AS practice to be framed by uncertainty, ranging from uncertainty about selection of eligible AM/AS candidates to uncertainty about optimum follow-up protocols and thresholds for clinical review/radical treatment. Patients and clinicians generally responded positively to the AMS. The impact of the AMS on clinicians’ decision-making was limited by a lack of data linking AMS values to long-term outcomes and by current clinical practice, which viewed PSA measures as one of several tools guiding clinical decisions in AM/AS. Patients reported that they would look to clinicians, rather than to a tool, to direct decision-making.LimitationsThe quantitative findings were severely hampered by a lack of clinical outcomes or events (such as metastases). The qualitative findings were limited through reliance on participants’ reports of practices and recollections of events rather than observations of actual interactions.ConclusionsPatients and clinicians found that the instrument provided additional, potentially helpful, information but were uncertain about the current usefulness of the risk model we developed for routine management. Comparison of the model with other monitoring strategies will require clinical outcomes from ongoing AM/AS studies.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Andrew J Simpkin
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Leila Rooshenas
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Julia Wade
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - J Athene Lane
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Richard M Martin
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Chris Metcalfe
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Peter C Albertsen
- Division of Urology, University of Connecticut Health Center, Farmington, CT, USA
| | - Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Lars Holmberg
- Faculty of Life Sciences & Medicine, King’s College London, London, UK
- Regional Cancer Centre, Uppsala/Örebro Region, Uppsala, Sweden
| | - David E Neal
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Kate Tilling
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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5
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Simpkin AJ, Tilling K, Martin RM, Lane JA, Hamdy FC, Holmberg L, Neal DE, Metcalfe C, Donovan JL. Systematic Review and Meta-analysis of Factors Determining Change to Radical Treatment in Active Surveillance for Localized Prostate Cancer. Eur Urol 2015; 67:993-1005. [PMID: 25616709 DOI: 10.1016/j.eururo.2015.01.004] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 01/02/2015] [Indexed: 10/24/2022]
Abstract
CONTEXT Many men with clinically localized prostate cancer are being monitored as part of active surveillance (AS) programs, but little is known about reasons for receiving radical treatment. OBJECTIVES A systematic review of the evidence about AS was undertaken, with a meta-analysis to identify predictors of radical treatment. EVIDENCE ACQUISITION A comprehensive search of the Embase, MEDLINE and Web of Knowledge databases to March 2014 was performed. Studies reporting on men with localized prostate cancer followed by AS or monitoring were included. AS was defined where objective eligibility criteria, management strategies, and triggers for clinical review or radical treatment were reported. EVIDENCE SYNTHESIS The 26 AS cohorts included 7627 men, with a median follow-up of 3.5 yr (range of medians 1.5-7.5 yr). The cohorts had a wide range of inclusion criteria, monitoring protocols, and triggers for radical treatment. There were eight prostate cancer deaths and five cases of metastases in 24,981 person-years of follow-up. Each year, 8.8% of men (95% confidence interval 6.7-11.0%) received radical treatment, most commonly because of biopsy findings, prostate-specific antigen triggers, or patient choice driven by anxiety. Studies in which most men changed treatment were those including only low-risk Gleason score 6 disease and scheduled rebiopsies. CONCLUSIONS The wide variety of AS protocols and lack of robust evidence make firm conclusions difficult. Currently, patients and clinicians have to make judgments about the balance of risks and benefits in AS protocols. The publication of robust evidence from randomized trials and longer-term follow-up of cohorts is urgently required. PATIENT SUMMARY We reviewed 26 studies of men on active surveillance for prostate cancer. There was evidence that studies including men with the lowest risk disease and scheduled rebiopsy had higher rates of radical treatment.
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Affiliation(s)
- Andrew J Simpkin
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
| | - Kate Tilling
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Richard M Martin
- School of Social and Community Medicine, University of Bristol, Bristol, UK; NIHR Bristol Nutrition Biomedical Research Unit, University of Bristol, Bristol, UK
| | - J Athene Lane
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - David E Neal
- Cancer Research UK, Cambridge Research Institute, Cambridge, UK
| | - Chris Metcalfe
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Azmi A, Dillon RA, Borghesi S, Dunne M, Power RE, Marignol L, O'Neill BDP. Active surveillance for low-risk prostate cancer: diversity of practice across Europe. Ir J Med Sci 2014; 184:305-11. [PMID: 24652265 DOI: 10.1007/s11845-014-1104-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 03/03/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Active surveillance (AS) is a recognised treatment option for low-risk prostate cancer (PCa). AIMS To review AS criteria in terms of patient selection, follow-up and indications for intervention. METHODS A total of 2,959 potential participants were identified and invited via email to complete an online survey. Only urologists practising in an EU country were eligible to participate. Statistical analyses were carried out using SPSS version 18.0. The χ (2) test was used to compare responses between those who do and do not follow an AS protocol. RESULTS Response rate was 8% (n = 226). Ninety-seven per cent urologists offer AS; 25% (n = 53/215) within a clinical trial and a further 28% (n = 60/215) using an official AS protocol. Gleason score ≤ 3 + 3 = 6 (87 %, n = 173/200) and prostate-specific antigen (PSA) ≤ 10 ng/ml (86%, n = 170/198) are the commonest selection criteria. There was a statistically significant association between having an AS protocol and using PSA as an eligibility criterion (p = 0.03). For urologists not following a protocol, 11% do not consider PSA as an eligibility criterion and 81% consider PSA ≤ 10 ng/ml to decide on AS, compared to 2 and 90%, respectively, who adhere to a protocol. Twenty-four per cent of urologists without a protocol do not re-biopsy in comparison to 11% with a protocol (p = 0.026). Gleason score progression trigger the most intervention (n = 168/192, 87%). CONCLUSIONS Urologists not adhering to an AS protocol or participating in a clinical trial appear to apply less rigorous criteria for both eligibility and monitoring in AS.
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Affiliation(s)
- A Azmi
- St. Luke's Radiation Oncology Centre, Beaumont Hospital, Dublin, Ireland,
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McFall SL, Mullen PD, Byrd TL, Cantor SB, Le YC, Torres-Vigil I, Pettaway C, Volk RJ. Treatment decisions for localized prostate cancer: a concept mapping approach. Health Expect 2014; 18:2079-90. [PMID: 24506829 DOI: 10.1111/hex.12175] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2014] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Few decision aids emphasize active surveillance (AS) for localized prostate cancer. Concept mapping was used to produce a conceptual framework incorporating AS and treatment. METHODS Fifty-four statements about what men need to make a decision for localized prostate cancer were derived from focus groups with African American, Latino and white men previously screened for prostate cancer and partners (n = 80). In the second phase, 89 participants sorted and rated the importance of statements. RESULTS An eight cluster map was produced for the overall sample. Clusters were labelled Doctor-patient exchange, Big picture comparisons, Weighing the options, Seeking and using information, Spirituality and inner strength, Related to active treatment, Side-effects and Family concerns. A major division was between medical and home-based clusters. Ethnic groups and genders had similar sorting, but some variation in importance. Latinos rated Big picture comparisons as less important. African Americans saw Spirituality and inner strength most important, followed by Latinos, then whites. Ethnic- and gender-specific concept maps were not analysed because of high similarity in their sorting patterns. CONCLUSIONS We identified a conceptual framework for management of early-stage prostate cancer that included coverage of AS. Eliciting the conceptual framework is an important step in constructing decision aids which will address gaps related to AS.
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Affiliation(s)
- Stephanie L McFall
- Institute for Social and Economic Research University of Essex, Colchester, UK
| | - Patricia D Mullen
- School of Public Health, The University of Texas Health Sciences Center, Houston, TX, USA
| | - Theresa L Byrd
- Department of Family and Community Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Scott B Cantor
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yen-Chi Le
- School of Public Health, The University of Texas Health Sciences Center, Houston, TX, USA
| | | | - Curtis Pettaway
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert J Volk
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Abstract
Mechanisms postulated to link folate and B12 metabolism with cancer, including genome-wide hypomethylation, gene-specific promoter hypermethylation, and DNA uracil misincorporation, have been observed in prostate tumor cells. However, epidemiological studies of prostate cancer risk, based on dietary intakes and blood levels of folate and vitamin B12 and on folate-pathway gene variants, have generated contradictory findings. In a meta-analysis, circulating concentrations of B12 (seven studies, OR = 1.10; 95% CI 1.01, 1.19; P = 0.002) and (in cohort studies) folate (five studies, OR = 1.18; 95% CI 1.00, 1.40; P = 0.02) were positively associated with an increased risk of prostate cancer. Homocysteine was not associated with risk of prostate cancer (four studies, OR = 0.91; 95% CI 0.69, 1.19; P = 0.5). In a meta-analysis of folate-pathway polymorphisms, MTR 2756A > G (eight studies, OR = 1.06; 95% CI 1.00, 1.12; P = 0.06) and SHMT1 1420C > T (two studies, OR = 1.11; 95% CI 1.00, 1.22; P = 0.05) were positively associated with prostate cancer risk. There were no effects due to any other polymorphisms, including MTHFR 677C > T (12 studies, OR = 1.04; 95% CI 0.97, 1.12; P = 0.3). The positive association of circulating B12 with an increased risk of prostate cancer could be explained by reverse causality. However, given current controversies over mandatory B12 fortification, further research to eliminate a causal role of B12 in prostate cancer initiation and/or progression is required. Meta-analysis does not entirely rule out a positive association of circulating folate with increased prostate cancer risk. As with B12, even a weak positive association would be a significant public health issue, given the high prevalence of prostate cancer and concerns about the potential harms versus benefits of mandatory folic acid fortification.
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Donovan JL. Presenting treatment options to men with clinically localized prostate cancer: the acceptability of active surveillance/monitoring. J Natl Cancer Inst Monogr 2013; 2012:191-6. [PMID: 23271772 DOI: 10.1093/jncimonographs/lgs030] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Presenting treatment options to men with localized prostate cancer is difficult because of the lack of definitive evidence and the range of treatment options available. Active surveillance and monitoring programs are now a recognized treatment option for men with low-risk localized prostate cancer, but many patients are not fully aware of the details of such programs, and most still opt for immediate radical (surgery or radiotherapy) treatment. The provision of high-quality information with decision aids has been shown to increase the acceptability of active surveillance/monitoring programs. This chapter outlines techniques for providing high-quality information about active surveillance/monitoring, based on the findings of a randomized controlled trial of treatments for localized prostate cancer. The ProtecT (Prostate testing for cancer and Treatment) trial has randomized over 1500 men between active monitoring, radical surgery, and radical radiotherapy by ensuring that information was tailored to men's existing knowledge and views. Care was taken with the content, order, and enthusiasm of the presentation of treatments by recruitment staff, and clinicians and other health professionals were supported to feel comfortable with being open about the uncertainties in the evidence and helped to rephrase terminology likely to be misinterpreted by patients. These techniques of information provision should be added to the use of decision aids to enable patients diagnosed with clinically localized prostate cancer in routine practice to reach well-informed and reasoned decisions about their treatment, including full consideration of active surveillance and monitoring programs.
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Affiliation(s)
- Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Bristol, UK.
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Evaluation of Diffusion-Weighted MR Imaging at Inclusion in an Active Surveillance Protocol for Low-Risk Prostate Cancer. Invest Radiol 2013; 48:152-7. [DOI: 10.1097/rli.0b013e31827b711e] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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Penson DF. Factors influencing patients' acceptance and adherence to active surveillance. J Natl Cancer Inst Monogr 2012; 2012:207-12. [PMID: 23271775 PMCID: PMC3540870 DOI: 10.1093/jncimonographs/lgs024] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Clinical decision making in localized prostate cancer is a complicated, multidimensional process in which men often consider their own personal preferences, the advice of their healthcare providers, the opinions of their family and friends, and outside information sources. They synthesize all of this within the framework of their own unique socioeconomic situation, their social support network, and their preconceived impressions of their health and the health-care system. This is particularly germane when considering factors that influence a patient's acceptance of and adherence to active surveillance (AS). We propose a conceptual framework based on a previously described systematic-heuristic theoretical model of decision making in this setting. We identify a number of factors that patients systematically prioritize when considering AS. These include desire for cancer control or cure, age at diagnosis, and concern regarding side effects of treatment. The way patients value these factors and effectively decide on treatment is influenced by more heuristic factors, including physician recommendation, opinion of friends and family members, and overall decision uncertainty. These heuristic factors also play an important role in adherence when a patient elects AS. Finally, some of the factors, particularly the heuristic ones, are potentially modifiable and may serve as targets for future interventions to increase acceptance of and adherence to AS.
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Affiliation(s)
- David F Penson
- Center for Surgical Quality and Outcomes Research, Vanderbilt University Medical Center, 2525 West End Ave, Nashville, TN 37203-1738, USA.
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12
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Rowlands MA, Tilling K, Holly JMP, Metcalfe C, Gunnell D, Lane A, Davis M, Donovan J, Hamdy F, Neal DE, Martin RM. Insulin-like growth factors (IGFs) and IGF-binding proteins in active monitoring of localized prostate cancer: a population-based observational study. Cancer Causes Control 2012; 24:39-45. [PMID: 23085814 DOI: 10.1007/s10552-012-0087-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 10/10/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE Active monitoring of prostate cancer requires the selection of low-risk cancers and subsequent identification of disease progression. Our objective was to determine whether serum insulin-like growth factor (IGF)-I, IGF-II, IGF-binding protein (IGFBP)-2 or IGFBP-3 at diagnosis (potential biomarkers of prognosis), and repeated measures of IGFBP-2 (potential biomarker of tumour growth), were associated with annual change in PSA and PSA doubling time (PSADT), proxies for disease progression. METHODS We investigated associations of circulating IGFs and IGFBPs with PSA measures using multilevel models, in 909 men (recruited between 1999 and 2009) with PSA-detected clinically localized prostate cancer undergoing active monitoring in the United Kingdom. Each man had an average of 14 measurements of PSA during a mean of 4-year follow-up. RESULTS IGF-I, IGF-II, IGFBP-2, and IGFBP-3 were not associated with baseline PSA. There was weak evidence that IGF-I at diagnosis was positively associated with a rapid post-diagnosis PSADT (≤4 years vs. >4 years): OR 1.34 (95 % CI 0.98, 1.81) per SD increase in IGF-I. IGFBP-2 increased by 2.1 % (95 % CI 1.4, 2.8) per year between 50 and 70 years, with no association between serial IGFBP-2 levels and PSADT. There was no evidence that serum IGF-II, IGFBP-2, or IGFBP-3, or post-diagnosis IGFBP-2, were associated with PSA kinetics in men with PSA-detected localized prostate cancer. CONCLUSIONS The weak association of IGF-I with PSADT requires replication in larger datasets, and more definitive evidence will be provided on the maturity of long-term active monitoring cohorts with relevant clinical outcomes (metastasis and prostate cancer mortality).
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Affiliation(s)
- Mari-Anne Rowlands
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, UK.
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13
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Koscuiszka M, Hatcher D, Christos PJ, Rose AE, Greenwald HS, Chiu YL, Taneja SS, Mazumdar M, Lee P, Osman I. Impact of race on survival in patients with clinically nonmetastatic prostate cancer who deferred primary treatment. Cancer 2012; 118:3145-52. [PMID: 22020835 PMCID: PMC3623265 DOI: 10.1002/cncr.26619] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 08/26/2011] [Accepted: 09/19/2011] [Indexed: 11/07/2022]
Abstract
BACKGROUND Prostate cancer (PCa) racial disparity studies typically focus on survival differences after curative treatment. The authors of this report hypothesized that comparing mortality rates between African American (AA) and Caucasian American (CA) patients who deferred primary treatment for clinically nonmetastatic PCa may provide a better assessment of the impact of race on the natural course of PCa. METHODS The pathology database of the New York Veterans Administration Medical Center (VAMC), an equal access-of-care facility, was searched for patients with biopsy-proven PCa. Inclusion criteria included 1) no evidence of metastatic disease or death within 3 years after diagnosis, 2) no primary treatment, and 3) a minimum of 5 years of follow-up for survivors. RESULTS In total, 518 patients met inclusion criteria between 1990 and 2005. AA patients were younger (P = .02) and had higher median prostate-specific antigen (PSA) levels (P = .001) at the time of diagnosis compared with CA patients. In a multivariate model, higher Gleason score and PSA level were associated with increased mortality (P = .001 and P = .03, respectively), but race was not a predictor of death from PCa. CONCLUSIONS The current data suggested that race did not have a major impact on survival in patients with PCa who deferred primary treatment for clinically nonmetastatic disease.
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Affiliation(s)
- Michael Koscuiszka
- Department of Urology, New York University School of Medicine, New York, New York
| | - David Hatcher
- Department of Urology, New York University School of Medicine, New York, New York
| | - Paul J. Christos
- Division of Biostatistics and Epidemiology, Weill Medical College of Cornell University, New York, New York
| | - Amy E. Rose
- Department of Urology, New York University School of Medicine, New York, New York
| | | | - Ya-lin Chiu
- Division of Biostatistics and Epidemiology, Weill Medical College of Cornell University, New York, New York
| | - Samir S. Taneja
- Department of Urology, New York University School of Medicine, New York, New York
| | - Madhu Mazumdar
- Division of Biostatistics and Epidemiology, Weill Medical College of Cornell University, New York, New York
| | - Peng Lee
- Department of Urology, New York University School of Medicine, New York, New York
- Department of Pathology, New York University School of Medicine, New York, New York
- New York Harbor Healthcare System, New York, New York
| | - Iman Osman
- Department of Urology, New York University School of Medicine, New York, New York
- New York University Cancer Institute, New York, New York
- New York Harbor Healthcare System, New York, New York
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14
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Behbahani TE, Ellinger J, Caratozzolo DG, Müller SC. Pathological outcomes of men eligible for active surveillance after undergoing radical prostatectomy: are results predictable? Clin Genitourin Cancer 2011; 10:32-6. [PMID: 22104434 DOI: 10.1016/j.clgc.2011.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Revised: 07/28/2011] [Accepted: 09/08/2011] [Indexed: 10/15/2022]
Abstract
INTRODUCTION To analyze pathological results in patients with prostate cancer eligible for active surveillance (AS) after radical prostatectomy and available prediction systems. METHODS A retrospective analysis was performed of 612 patients who underwent radical prostatectomy during a 14-year period. Subsequently, we selected those patients who would have been eligible for AS according to 2 different published criteria. Group AS-A matched the following criteria: ≤T2a; Gleason Score ≤6; and prostate-specific antigen <10 ng/mL, while group AS-B applied to different criteria: ≤T2a; Gleason Score <7; and prostate-specific antigen ≤15 ng/mL. Pathological outcomes were compared with results of the 2001 Partin tables. RESULTS Altogether, 125 (20.4%) patients were included in group AS-A and 159 (25.9%) in group AS-B. We detected 32 cases of >pT2c (25.6%) for group AS-A and 47 cases (29.6%) for AS-B, respectively. Gleason score upgrading was recorded in 34.4% (AS-A) and 38.3% (AS-B). Results of the Partin tables showed good discrimination among patients at risk for positive lymph nodes but limited discrimination for organ-confined disease, seminal vesicle. CONCLUSIONS Overall >25% of patients eligible for AS showed either upstaging or Gleason score upgrading, which could not be measured with the examined predictive tools. Patients should be informed about the risks of inaccurate preoperative diagnostic.
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15
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El seguimiento en los supervivientes de cáncer: una responsabilidad compartida. Med Clin (Barc) 2011; 137:163-5. [DOI: 10.1016/j.medcli.2011.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Accepted: 03/08/2011] [Indexed: 11/22/2022]
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16
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Soloway MS, Soloway CT, Eldefrawy A, Acosta K, Kava B, Manoharan M. Careful selection and close monitoring of low-risk prostate cancer patients on active surveillance minimizes the need for treatment. Eur Urol 2010; 58:831-5. [PMID: 20800964 DOI: 10.1016/j.eururo.2010.08.027] [Citation(s) in RCA: 202] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Accepted: 08/12/2010] [Indexed: 01/22/2023]
Abstract
BACKGROUND With the advent of prostate-specific antigen (PSA) screening and the increase in the number of transrectal ultrasound-guided biopsy cores, there has been a dramatic rise in the incidence of low-risk prostate cancer (LRPC). Because > 97% of men with LRPC are likely to die of something other than prostate cancer, it is critical that patients give thought to whether early curative treatment is the only option at diagnosis. OBJECTIVE To identify a group of men with LRPC who may not require initial treatment and monitor them on our active surveillance (AS) protocol, to determine the percentage treated and the outcome and to analyze the quality-of-life data. DESIGN, SETTING, AND PARTICIPANTS We defined patients eligible for AS as Gleason ≤ 6, PSA ≤ 10, and two or fewer biopsy cores with ≤ 20% tumor in each core. MEASUREMENTS Kaplan Meier analysis was used to predict the 5-year treatment free survival. Logistic regression determined the predictors of treatment. Data on sexual function, continence, and outcome were obtained and analyzed. RESULTS AND LIMITATIONS The AS cohort consisted of 230 patients with a mean age of 63.4 yr; 86% remained on AS for a mean follow-up of 44 mo. Thirty-two of the 230 patients (14%) were treated for a mean follow-up of 33 mo. Twelve had a total prostatectomy (TP). The pathologic stage of these patients was similar to initially treated TP patients with LRPC. Fourteen underwent radiation therapy, and six underwent androgen-deprivation therapy. Fifty percent of patients had no tumor on the first rebiopsy, and only 5% of these patients were subsequently treated. PSA doubling time and clinical stage were not predictors of treatment. No patient progressed after treatment. Among the AS patients, 30% had incontinence, yet < 15% were bothered by it. As measured by the Sexual Health Inventory for Men, 49% of patients had, at a minimum, moderate (≤ 16) erectile dysfunction. CONCLUSIONS If guidelines for AS are narrowly defined to include only patients with Gleason 6, tumor volume ≤ 20% in one or two biopsy cores, and PSA levels ≤ 10, few patients are likely to require treatment. Progression-free survival of those treated is likely to be equivalent to patients with similar clinical findings treated at diagnosis.
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Affiliation(s)
- Mark S Soloway
- Department of Urology, Miller School of Medicine, University of Miami, Miami, Florida, USA.
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17
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Gravas S, de Reijke T. Is Focal Therapy an Alternative to Active Surveillance? J Endourol 2010; 24:855-60. [DOI: 10.1089/end.2009.0525] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Stavros Gravas
- Department of Urology, University of Thessaly, Larissa, Greece
| | - Theo de Reijke
- Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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18
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The unintended burden of increased prostate cancer detection associated with prostate cancer screening and diagnosis. Urology 2009; 75:399-405. [PMID: 19931892 DOI: 10.1016/j.urology.2009.08.078] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 07/14/2009] [Accepted: 08/06/2009] [Indexed: 12/31/2022]
Abstract
The increasing incidence of prostate cancer is associated with the intensity of screening for prostate-specific antigen. Although some men may benefit from the early detection of prostate cancer through screening, all men diagnosed with prostate cancer experience an effect on their mental and physical well-being and that of their families. In light of the recent publication of the United States Preventive Services Task Force recommendations concerning prostate-specific antigen testing, this article reviews the quality-of-life implications of prostate cancer screening and diagnosis, and explores risk reduction in screened men as a potential strategy to manage these issues.
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19
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Affiliation(s)
- David E Neal
- Department of Oncology, University of Cambridge, Cambridge CB2 0QQ, UK.
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20
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Metcalfe C, Tilling K, Davis M, Lane JA, Martin RM, Kynaston H, Powell P, Neal DE, Hamdy F, Donovan JL. Current strategies for monitoring men with localised prostate cancer lack a strong evidence base: observational longitudinal study. Br J Cancer 2009; 101:390-4. [PMID: 19603015 PMCID: PMC2720224 DOI: 10.1038/sj.bjc.6605181] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: The UK National Institute for Health and Clinical Excellence (NICE) guidance recommends conservative management of men with ‘low-risk’ localised prostate cancer, monitoring the disease using prostate-specific antigen (PSA) kinetics and re-biopsy. However, there is little evidence of the changes in PSA level that should alert to the need for clinical re-assessment. Methods: This study compares the alerts resulting from PSA kinetics and a novel longitudinal reference range approach, which incorporates age-related changes, during the monitoring of 408 men with localised prostate cancer. Men were monitored by regular PSA tests over a mean of 2.9 years, recording when a man's PSA doubling time fell below 2 years, PSA velocity exceeded 2 ng ml–1 per year, or when his upper 10% reference range was exceeded. Results: Prostate-specific antigen doubling time and PSA velocity alerted a high proportion of men initially but became unresponsive to changes with successive tests. Calculating doubling time using recent PSA measurements reduced the decline in response. The reference range method maintained responsiveness to changes in PSA level throughout the monitoring. Conclusion: The increasing unresponsiveness of PSA kinetics is a consequence of the underlying regression model. Novel methods are needed for evaluation in cohorts currently being managed by monitoring. Meanwhile, the NICE guidance should be cautious.
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Affiliation(s)
- C Metcalfe
- Department of Social Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
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21
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McIntosh HM, Neal RD, Rose P, Watson E, Wilkinson C, Weller D, Campbell C. Follow-up care for men with prostate cancer and the role of primary care: a systematic review of international guidelines. Br J Cancer 2009; 100:1852-60. [PMID: 19436297 PMCID: PMC2714251 DOI: 10.1038/sj.bjc.6605080] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 04/07/2009] [Accepted: 04/08/2009] [Indexed: 11/24/2022] Open
Abstract
The optimal role for primary care in providing follow-up for men with prostate cancer is uncertain. A systematic review of international guidelines was undertaken to help identify key elements of existing models of follow-up care to establish a theoretical basis for evaluating future complex interventions. Many guidelines provide insufficient information to judge the reliability of the recommendations. Although the PSA test remains the cornerstone of follow-up, the diversity of recommendations on the provision of follow-up care reflects the current lack of research evidence on which to base firm conclusions. The review highlights the importance of transparent guideline development procedures and the need for robust primary research to inform future evidence-based models of follow-up care for men with prostate cancer.
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Affiliation(s)
- H M McIntosh
- Community Health Sciences - General Practice, University of Edinburgh, 20 West Richmond Street, Edinburgh EH9 9DX, UK.
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22
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Weissbach L, Altwein J. Active surveillance or active treatment in localized prostate cancer? DEUTSCHES ARZTEBLATT INTERNATIONAL 2009; 106:371-6. [PMID: 19623304 DOI: 10.3238/arztebl.2009.0371] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Accepted: 01/22/2009] [Indexed: 11/27/2022]
Abstract
BACKGROUND At present, one in six men over age 50 carries the diagnosis of prostate cancer, but only one in 33 will die of the disease. In view of these facts, conservative strategies such as active surveillance (AS) are important in the management of prostate cancer. METHODS To obtain information on active surveillance, the Medline database was searched from January 2002 to April 2008 for the terms "prostate cancer" OR "prostatic neoplasms," AND "active surveillance" OR "expectant management". In addition a manual search was performed in the reference lists of relevant publications on the treatment of prostate cancer and on active surveillance. RESULTS 88 relevant publications about active surveillance were found. The studies varied in methodological quality but consistently showed low rates of tumor progression and high rates of tumor-specific survival with active surveillance (99% to 100%). All 7 guidelines on the treatment of prostate cancer that have been published since 2006 list active surveillance in their recommendations as a therapeutic option for prostate cancer if there is a low risk of progression. In fact, the National Institute of Clinical Excellence (U.K.) recommends the active surveillance exclusively as the treatment strategy for such cases. CONCLUSIONS The guideline recommendations reflect a changed attitude toward the treatment of prostate cancer in the light of the early detection of these tumors and the data now available regarding active surveillance. A corresponding change in actual medical practice would be desirable. The treatment of prostate cancer should always be adapted to the individual needs of the patient, and risky treatments should only be used when absolutely necessary.
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Affiliation(s)
- Lothar Weissbach
- Privatärztliche Urologische Gemeinschaftspraxis in der EuromedClinic Fürth, Fürth, Germany.
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23
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Del Giudice ME, Grunfeld E, Harvey BJ, Piliotis E, Verma S. Primary care physicians' views of routine follow-up care of cancer survivors. J Clin Oncol 2009; 27:3338-45. [PMID: 19380442 DOI: 10.1200/jco.2008.20.4883] [Citation(s) in RCA: 189] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Routine follow-up of adult cancer survivors is an important clinical and health service issue. Because of a lack of evidence supporting advantages of long-term follow-up care in oncology clinics, there is increasing interest for the locus of this care to be provided by primary care physicians (PCPs). However, current Canadian PCP views on this issue have been largely unknown. METHODS A mail survey of a random sample of PCPs across Canada, stratified by region and proximity to urban centers, was conducted. Views on routine follow-up of adult cancer survivors and modalities to facilitate PCPs in providing this care were determined. RESULTS A total of 330 PCPs responded (adjusted response rate, 51.7%). After completion of active treatment, PCPs were willing to assume exclusive responsibility for routine follow-up care after 2.4 +/- 2.3 years had elapsed for prostate cancer, 2.6 +/- 2.6 years for colorectal cancer, 2.8 +/- 2.5 years for breast cancer, and 3.2 +/- 2.7 years for lymphoma. PCPs already providing this care were willing to provide exclusive care sooner. The most useful modalities PCPs felt would assist them in assuming exclusive responsibility for follow-up cancer care were (1) a patient-specific letter from the specialist, (2) printed guidelines, (3) expedited routes of rereferral, and (4) expedited access to investigations for suspected recurrence. CONCLUSION With appropriate information and support in place, PCPs reported being willing to assume exclusive responsibility for the follow-up care of adult cancer survivors. Insights gained from this survey may ultimately help guide strategies in providing optimal care to these patients.
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Tilling K, Garmo H, Metcalfe C, Holmberg L, Hamdy FC, Neal DE, Adolfsson J, Martin RM, Davis M, Fall K, Lane JA, Adami HO, Bill-Axelson A, Johansson JE, Donovan JL. Development of a new method for monitoring prostate-specific antigen changes in men with localised prostate cancer: a comparison of observational cohorts. Eur Urol 2009; 57:446-52. [PMID: 19303695 DOI: 10.1016/j.eururo.2009.03.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2008] [Accepted: 03/04/2009] [Indexed: 11/30/2022]
Abstract
BACKGROUND Prostate-specific antigen (PSA) measurements are increasingly used to monitor men with localised prostate cancer (PCa), but there is little consensus about the method to use. OBJECTIVE To apply age-specific predictions of PSA level (developed in men without cancer) to one cohort of men with clinically identified PCa and one cohort of men with PSA-detected PCa. We hypothesise that among men with clinically identified cancer, the annual increase in PSA level would be steeper than in men with PSA-detected cancer. DESIGN, SETTING, AND PARTICIPANTS The Scandinavian Prostate Cancer Group 4 (SPCG-4) cohort consisted of 321 men assigned to the watchful waiting arm of the SPCG-4 trial. The UK cohort consisted of 320 men with PSA-detected PCa in the Prostate testing for cancer and Treatment (ProtecT) study who opted for monitoring. Multilevel models describing changes in PSA level were fitted to the two cohorts, and average PSA level at age 50, change in PSA level with age, and predicted PSA values were derived. MEASUREMENTS PSA level. RESULTS AND LIMITATIONS In the SPCG-4 cohort, mean PSA at age 50 was similar to the cancer-free cohort but with a steeper yearly increase in PSA level (16.4% vs 4.0%). In the UK cohort, mean PSA level was higher than that in the cancer-free cohort (due to a PSA biopsy threshold of 3.0 ng/ml) but with a similar yearly increase in PSA level (4.1%). Predictions were less accurate for the SPCG-4 cohort (median difference between observed and predicted PSA level: -2.0 ng/ml; interquartile range [IQR]: -7.6-0.7 ng/ml) than for the UK cohort (median difference between observed and predicted PSA level: -0.8 ng/ml; IQR: -2.1-0.1 ng/ml). CONCLUSIONS In PSA-detected men, yearly change in PSA was similar to that in cancer-free men, whereas in men with symptomatic PCa, the yearly change in PSA level was considerably higher. Our method needs further evaluation but has promise for refining active monitoring protocols.
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Affiliation(s)
- Kate Tilling
- Department of Social Medicine, Bristol University, Canynge Hall, Bristol, UK.
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25
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Editorial Comment. J Urol 2008. [DOI: 10.1016/j.juro.2008.06.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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26
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Jhavar S, Bartlett J, Kovacs G, Corbishley C, Dearnaley D, Eeles R, Khoo V, Huddart R, Horwich A, Thompson A, Norman A, Brewer D, Cooper CS, Parker C. Biopsy tissue microarray study of Ki-67 expression in untreated, localized prostate cancer managed by active surveillance. Prostate Cancer Prostatic Dis 2008; 12:143-7. [DOI: 10.1038/pcan.2008.47] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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27
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28
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Smith JA. Radical prostatectomy for low risk carcinoma of the prostate. World J Urol 2008; 26:443-6. [DOI: 10.1007/s00345-008-0293-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Accepted: 06/03/2008] [Indexed: 10/21/2022] Open
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29
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The decision-related psychosocial concerns of men with localised prostate cancer: targets for intervention and research. World J Urol 2008; 26:469-74. [PMID: 18548254 DOI: 10.1007/s00345-008-0279-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2008] [Accepted: 05/07/2008] [Indexed: 10/22/2022] Open
Abstract
PURPOSE To describe decision-related psychosocial issues relevant for men with clinically localised prostate cancer. METHODS Searches were conducted across three electronic databases to search the health and psychological literature for articles examining decision-related psychosocial issues for men with localised prostate cancer and their partners. Medline, PsycINFO and CINAHL databases were examined for the period from 1990 to December 2007. RESULTS Most men with localised prostate cancer want active involvement in decision-making. Difficulty in making the decision is common and decision-related distress may persist over time. Cancer-specific psychological distress (such as fear of recurrence but not overall anxiety) appears to be related to changes in PSA levels; and this distress influences treatment pathways. Decision support interventions are acceptable to men, improve knowledge and might reduce decision and cancer-related distress. However, the quality of intervention studies to date is low. CONCLUSION Clinicians should seek to involve men and their partners in treatment decision making concurrent with decision and psychological support. There is a need for high quality randomised control trials to identify the optimal approach to decision support for men with clinically localised prostate cancer.
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30
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Barry MJ, Kaufman DS, Wu CL. Case records of the Massachusetts General Hospital. Case 15-2008. A 55-year-old man with an elevated prostate-specific antigen level and early-stage prostate cancer. N Engl J Med 2008; 358:2161-8. [PMID: 18480209 DOI: 10.1056/nejmcpc0707057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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31
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Dall'Era MA, Konety BR. Active surveillance for low-risk prostate cancer: selection of patients and predictors of progression. ACTA ACUST UNITED AC 2008; 5:277-83. [DOI: 10.1038/ncpuro1058] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2007] [Accepted: 01/22/2008] [Indexed: 12/15/2022]
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32
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Dall'Era MA, Cooperberg MR, Chan JM, Davies BJ, Albertsen PC, Klotz LH, Warlick CA, Holmberg L, Bailey DE, Wallace ME, Kantoff PW, Carroll PR. Active surveillance for early-stage prostate cancer. Cancer 2008; 112:1650-9. [DOI: 10.1002/cncr.23373] [Citation(s) in RCA: 226] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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33
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Griffin CR, Yu X, Loeb S, Desireddi VN, Han M, Graif T, Catalona WJ. Pathological Features After Radical Prostatectomy in Potential Candidates for Active Monitoring. J Urol 2007; 178:860-3; discussion 863. [PMID: 17631347 DOI: 10.1016/j.juro.2007.05.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2006] [Indexed: 11/17/2022]
Abstract
PURPOSE There are numerous reports on the results of watchful waiting or active monitoring protocols for men with low volume, biopsy Gleason grade 6 or less prostate cancer. When counseling patients with low grade prostate cancer about treatment options, it is useful to know the results of surgical treatment in this population. MATERIALS AND METHODS In a contemporary radical prostatectomy series there were 455 patients with biopsy Gleason grade 3 + 3 prostate cancer and information on the number of positive biopsy cores. Of these men 292 had low volume disease on the basis of 2 or fewer positive cores. RESULTS Overall 245 of 292 men (84%) with low volume Gleason 3 + 3 prostate cancer on biopsy had organ confined disease. The Gleason score in the prostatectomy specimen was 7 or greater in 78 men (27%), 25 (8%) had extracapsular tumor extension and 29 (10%) had positive surgical margins. In these patients preoperative variables were not reliable predictors of adverse pathological features. CONCLUSIONS More than a third of Gleason 3 + 3 tumors on biopsy were upgraded in the radical prostatectomy specimen or had other adverse pathological features. Our results suggest that low volume Gleason 3 + 3 prostate cancer is frequently under staged, and that immediate therapy with radical prostatectomy is associated with favorable outcomes.
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Affiliation(s)
- Christopher R Griffin
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA
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34
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Venkitaraman R, Norman A, Woode-Amissah R, Fisher C, Dearnaley D, Horwich A, Huddart R, Khoo V, Thompson A, Parker C. Predictors of histological disease progression in untreated, localized prostate cancer. J Urol 2007; 178:833-7. [PMID: 17631355 DOI: 10.1016/j.juro.2007.05.038] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Indexed: 11/19/2022]
Abstract
PURPOSE Active surveillance for early prostate cancer is a policy of close monitoring with radical treatment targeted at cases with evidence of disease progression. There is no consensus on the need for or optimum timing of repeat biopsies as part of active surveillance. MATERIALS AND METHODS In a prospective cohort study of active surveillance 119 patients with untreated localized prostate cancer (T1/2a), prostate specific antigen less than 15 ng/ml, Gleason score 3 + 4 or less and 50% or less positive cores underwent repeat biopsy after 18 to 24 months. Histological disease progression was defined as primary Gleason grade 4 or greater, greater than 50% positive cores or a Gleason score increase from 6 or less to 7 or greater. The risk of histological disease progression was analyzed with respect to baseline clinical factors. RESULTS Median patient age was 66 years and median initial prostate specific antigen was 6.6 ng/ml. Histological disease progression was seen in 33 of 119 cases (28%). On multivariate analysis prostate specific antigen density (p = 0.002) and maximum percent involvement of any core (p = 0.04) were significant independent determinants of histological disease progression. Progression was seen in 22 of 40 cases (55%) with prostate specific antigen density 0.2 ng/ml/ml or greater and greater than 15% maximum involvement of any core. Progression was seen in 2 of 33 cases (6%) with prostate specific antigen density less than 0.2 ng/ml/ml and 15% or less maximum involvement of any core. CONCLUSIONS Repeat biopsy should be an integral part of active surveillance for untreated localized prostate cancer. Immediate repeat biopsy should be considered in patients who elect active surveillance but who have prostate specific antigen density greater than 0.2 ng/ml/ml. These findings must be validated in a cohort of patients with extended biopsies at diagnosis and followup.
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Affiliation(s)
- Ramachandran Venkitaraman
- Academic Unit of Radiotherapy and Oncology, Institute of Cancer Research, Royal Marsden National Health Service Foundation Trust, Sutton, United Kingdom
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