Biological aggressiveness of hereditary prostate cancer: long-term evaluation following radical prostatectomy

Review on the Role of BRCA Mutations in Genomic Screening and Risk Stratification of Prostate Cancer

(1) Background: Somatic and germline alterations can be commonly found in prostate cancer (PCa) patients. The aim of our present study was to perform a comprehensive review of the current literature in order to examine the impact of BRCA mutations in the context of PCa as well as their significance as genetic biomarkers. (2) Methods: A narrative review of all the available literature was performed. Only "landmark" publications were included. (3) Results: Overall, the number of PCa patients who harbor a BRCA2 mutation range between 1.2% and 3.2%. However, BRCA2 and BRCA1 mutations are responsible for most cases of hereditary PCa, increasing the risk by 3-8.6 times and up to 4 times, respectively. These mutations are correlated with aggressive disease and poor prognosis. Gene testing should be offered to patients with metastatic PCa, those with 2-3 first-degree relatives with PCa, or those aged < 55 and with one close relative with breast (age ≤ 50 years) or invasive ovarian cancer. (4) Conclusions: The individualized assessment of BRCA mutations is an important tool for the risk stratification of PCa patients. It is also a population screening tool which can guide our risk assessment strategies and achieve better results for our patients and their families.

Matching BRCA and prostate cancer in a public health system: Report of the Italian Society for Uro-Oncology (SIUrO) consensus project

The recent approval of PARP inhibitors for the treatment of metastatic -castration-resistant prostate cancer (mCRPC) patients with BRCA mutations firstly introduced the possibility of proposing a targeted treatment in this disease. However, the availability of this therapeutic option raises a number of questions concerning the management of prostate cancer in everyday clinical practice: the timing and method of detecting BRCA mutations, the therapeutic implications of the detection, and the screening of the members of the family of a prostate cancer patient with a BRCA alteration. These challenging issues led the Italian Society for Uro-Oncology (SIUrO) to organise a Consensus Conference aimed to develop suggestions capable of supporting clinicians managing prostate cancer patients. The present paper described the development of the statements discussed during the consensus, which involved all of the most important Italian scientific societies engaged in the multi-disciplinary and multi-professional management of the disease.

Hereditary Prostate Cancer: Genes Related, Target Therapy and Prevention

Prostate cancer (PCa) is globally the second most diagnosed cancer type and the most common cause of cancer-related deaths in men. Family history of PCa, hereditary breast and ovarian cancer (HBOC) and Lynch syndromes (LS), are among the most important risk factors compared to age, race, ethnicity and environmental factors for PCa development. Hereditary prostate cancer (HPCa) has the highest heritability of any major cancer in men. The proportion of PCa attributable to hereditary factors has been estimated in the range of 5–15%. To date, the genes more consistently associated to HPCa susceptibility include mismatch repair (MMR) genes (MLH1, MSH2, MSH6, and PMS2) and homologous recombination genes (BRCA1/2, ATM, PALB2, CHEK2). Additional genes are also recommended to be integrated into specific research, including HOXB13, BRP1 and NSB1. Importantly, BRCA1/BRCA2 and ATM mutated patients potentially benefit from Poly (ADP-ribose) polymerase PARP inhibitors, through a mechanism of synthetic lethality, causing selective tumor cell cytotoxicity in cell lines. Moreover, the detection of germline alterations in MMR genes has therapeutic implications, as it may help to predict immunotherapy benefits. Here, we discuss the current knowledge of the genetic basis for inherited predisposition to PCa, the potential target therapy, and the role of active surveillance as a management strategy for patients with low-risk PCa. Finally, the current PCa guideline recommendations are reviewed.

Impact of family history on oncological outcomes in primary therapy for localized prostate cancer patients: a systematic review and meta-analysis

BACKGROUND

The influence of family history on oncological outcomes of prostate cancer remains controversial. We conducted a systematic literature review and meta-analysis to investigate the impact of family history of localized prostate cancer on oncological outcomes.

METHODS

On May 2020, we systematically searched MEDLINE, the Cochrane library, and Scopus for studies that compared patients who had localized prostate cancer with or without a positive family history of prostate cancer. Our aim was to evaluate the association of family history with biochemical recurrence-free survival, cancer-specific survival, and overall survival by means of a multivariate Cox regression analysis.

RESULTS

Eleven studies with 39,716 patients were included in the systematic review, and eight studies with 33,027 patients for the meta-analysis. A positive family history was not associated with worse biochemical recurrence-free survival (pooled HR: 0.96; 95% CI: 0.79-1.17) or cancer-specific survival (pooled HR: 1.1; 95% CI: 0.52-2.35). Subgroup analyses showed no association between positive family history and poor biochemical recurrence-free survival in prostate cancer patients treated with radical prostatectomy (pooled HR: 0.99; 95% CI: 0.76-1.31) or radiation therapy (pooled HR: 0.93; 95% CI: 0.67-1.30).

CONCLUSIONS

This meta-analysis indicated that family history of prostate cancer does not increase the risk of biochemical recurrence or cancer-specific mortality in localized prostate cancer patients.

Germline genetics in localized prostate cancer

PURPOSE OF REVIEW

To provide the reader an understanding of the importance and limitations of prostate cancer (PCa) screening, the heritable component of PCa and the role that germline genetic markers can play in risk-adapted screening and treatment.

RECENT FINDINGS

Despite strong science supporting the association of germline genetic change with PCa risk and outcome, there has been a reluctance to pursue practical application of these technologies. Recent findings suggest that actionable information may now be garnered from this form of testing, which can help men at risk for and with PCa.

SUMMARY

This is an exciting time whereby germline genetic markers can help overcome some of the shortcomings of current PCa screening and treatment paradigms. Understanding their benefit and limitations while keeping the patient's best interest in mind will be the key for the responsible application of these exciting technologies.

Genetic testing for hereditary prostate cancer: Current status and limitations

A significant proportion of prostate cancer diagnoses may be associated with a strong hereditary component. Men who have multiple single-gene polymorphisms and a family history of prostate cancer have a significantly greater risk of developing prostate cancer. Numerous single-gene alterations have been confirmed to increase the risk of prostate cancer. These include breast cancer genes 1 and 2 (BRCA1 and BRCA2, respectively), mutL homolog 1 (MLH1), mutS homologs 2 and 6 (MSH2 and MSH6, respectively), postmeiotic segregation increased 2 (PMS2), homeobox B13 (HOXB13), checkpoint kinase 2 (CHEK2), nibrin (NBN), BRCA1-interacting protein C-terminal helicase 1 (BRIP1), and ataxia telangiectasia mutated (ATM). Currently, there are no uniform guidelines on the definition of hereditary prostate cancer and genetic testing. With the advent of next-generation sequencing, which is capable of testing multiple genes simultaneously, and the approval of olaparib for BRCA1/BRCA2 or ATM-mutated, metastatic, castrate-resistant prostate cancer, it is being recognized that the results of genetic testing have an impact on therapeutic strategies. In this review, the authors examine the role of genetic counseling and testing, the challenges of insurance coverage for testing, the available germline and somatic testing panels, and the complexity of each testing method and its implications. Cancer 2018. © 2018 American Cancer Society.

Uridine diphosphate-glucuronosyltransferase 2B15 D85Y gene polymorphism is associated with lower prostate cancer risk: a systematic review and meta-analysis

UGT2B15 (uridine diphosphate-glucuronosyltransferase 2B15) catalyzes the conversion of lipophilic C19 steroid androgens such as dihydrotestosterone (DHT) into water-soluble metabolites that can be excreted. Studies of the association between the UGT2B15 gene D85Y polymorphism and prostate cancer have yielded contradictory results. We therefore systematically searched in the PubMed, EMBASE, Science Direct/Elsevier, CNKI, and Cochrane Library databases, and identified six relevant studies with which to perform a meta-analysis of the relation between UGT2B15 D85Y polymorphism and prostate cancer risk. Our meta-analysis revealed a significant association between UGT2B15 D85Y gene polymorphism and prostate cancer in all genetic models (P<0.05). The combined odds ratios and 95% confidence intervals were as follows: additive model, 0.53 and 0.32-0.88; dominant model, 0.51 and 0.33-0.79; recessive model, 0.76 and 0.60-0.96; co-dominant model, 0.55 and 0.35-0.86; and allele model, 0.70 and 0.55-0.89. These results are consistent with the idea that the UGT2B15 D85Y enzyme variant reduces the risk of prostate cancer by efficiently metabolizing dihydrotestosterone (DHT), which is associated with prostate cancer progression.

Impact of a family history of prostate cancer on clinicopathologic outcomes and survival following radical prostatectomy

PURPOSE

While a family history (FH) of prostate cancer represents an established risk factor for prostate cancer diagnosis, conflicting data exist regarding the oncologic importance of FH. Herein, we evaluated the association of FH with clinicopathologic outcomes among men undergoing radical prostatectomy (RP).

METHODS

We identified 16,472 men who underwent RP between 1987 and 2010 at Mayo Clinic. Patients were considered to have a positive FH if at least one first-degree relative had been diagnosed with prostate cancer. Survival was estimated using the Kaplan-Meier method. The associations of FH with clinicopathologic features and survival were evaluated using logistic and Cox regression analyses.

RESULTS

Overall, 5323 (32.3 %) men reported a FH of prostate cancer. Median follow-up was 9.9 years (IQR 5.9, 15.5). Patients with a FH were significantly more likely to have low-risk disease (47.7 vs. 43.0 %; p < 0.0001) and were significantly more likely to have organ-confined disease at RP (79.2 vs. 74.4 %; p < 0.0001). Men with FH had a significantly higher 10-year cancer-specific (99 vs. 97 %; p < 0.001) and overall survival (92 vs. 85 %; p < 0.001) than men without FH. Moreover, on multivariable analysis, FH of prostate cancer remained independently associated with reduced cancer-specific (HR 0.68; p = 0.003) and all-cause mortality (HR 0.69; p < 0.0001).

CONCLUSION

In this surgical population, FH of prostate cancer was associated with lower-risk disease at diagnosis, more favorable pathology at RP, and significantly better cancer-specific and overall survival. These results may be utilized for patient counseling.

Effect of family history on outcome in German patients treated with radical prostatectomy for clinically localised prostate cancer

OBJECTIVE

The outcome of prostate cancer (CaP) patients treated with radical prostatectomy (RP) might be influenced by family history (FH) in a subset of patients. We analysed the effect of sporadic, familial and hereditary CaP stratified by risk on clinico-pathologic characteristics and biochemical recurrence-free survival (bRFS) following RP.

MATERIALS AND METHODS

Data of 8041 German patients treated with RP between 1994 and 2008 in Germany were analysed. We evaluated the impact of FH stratified by D'Amico's risk classification on pathologic characteristics using Cochran-Mantel-Haenszel tests. The impact of FH stratified by risk on bRFS was analysed in a proportional hazards regression.

RESULTS

Five thousand seven hundred and fifty six (71.6%) had sporadic, 1779 (22.1%) familial and 506 (6.3%) hereditary CaP. Adjusted for risk group, FH was associated with age of onset <65 years (p<0.001) but not with pathological characteristics or bRFS. The subgroup of patients with high risk and hereditary CaP numerically had the lowest bRFS rate at 5 (52.9%) and 10 (30.7%) years. However, this observation was statistically insignificant (p = 0.267). Familial and hereditary CaP patients were 1-2 years younger than sporadic cases at CaP diagnosis.

CONCLUSION

Sporadic, familial and hereditary CaP have the same pathologic characteristics and bRFS rate following RP. Patients with a positive family history are diagnosed earlier than sporadic patients. Stratification in subgroups by risk group did not add further information.

Genetics of prostate cancer risk

For decades, physicians and researchers have recognized that family history is a significant risk factor for prostate cancer. The identification of the genes responsible for inherited risk, however, proved difficult. With the sequencing of the human genome and the completion of the initial phases of the International HapMap Project, the tools are available to scan the entire genome and find genetic markers for disease. Since 2006, more than 30 inherited variants strongly associated with prostate cancer have been reported. As the inherited component of the disease is revealed, efforts are ongoing to translate genetic findings into the clinic.

The potentially curable prostate cancer patient and the pathways leading to diagnosis and treatment

OBJECTIVE

Potentially curable prostate cancer is a diagnostic challenge for the general practitioner (GP). In a defined catchment area we wanted to discover why patients consulted their GPs and the reasons for their referral to the urologist.

MATERIAL AND METHODS

Patients remitted to our "early prostate cancer clinic" with suspected potentially curable prostate cancer between January 1997 and December 2000 were included in the study. Patient information was registered according to a prospectively designed protocol.

RESULTS

Of the 872 patients examined, prostate cancer was diagnosed in 41.3% (360/872). Median age was 63.1 years and median total prostate-specific antigen (PSA) level was 8.6 microg/l. The main reason for referral to a urologist was elevated PSA alone. However, the majority of the patients had no urological symptoms when they consulted their GP. As no local or national screening recommendations existed, we believe that opportunistic PSA screening has been common.

CONCLUSIONS

The most important reason for referring patients to our specialist clinic was elevated PSA, often detected by means of opportunistic PSA screening. This study shows the effect of PSA testing in real-life practice.

Characteristics of patients with familial versus sporadic prostate cancer

PURPOSE

There are conflicting reports concerning whether prostate cancer in families with multiple affected members has different clinical and pathological features than sporadic cases. In our study we compared the clinical characteristics, pathological outcomes and the 7-year biochemical progression-free rate in patients with apparent sporadic prostate cancer, affected sibling pairs, families with multiple affected members and families meeting the Johns Hopkins criteria for hereditary prostate cancer.

MATERIALS AND METHODS

From 1983 to 2003, 3,478 men underwent radical retropubic prostatectomy by a single surgeon (WJC). Of these men 1,186 reported family history status. We compared age at surgery, prostate specific antigen at diagnosis, pathological tumor stage, Gleason score, tumor characteristics and 7-year biochemical progression-free survival rates in the groups using chi-square, 1-way ANOVA or Cox proportional hazards regression analysis.

RESULTS

The 7-year biochemical progression-free survival rates were 81% for sporadic cases, 71% for sibling pairs, 72% for hereditary cases and 81% for high density family members (p = 0.3). Of the clinical and pathological features examined only age (p <0.0001) and positive surgical margin rate (p = 0.03) were significantly different among groups.

CONCLUSIONS

In our study population clinicopathological features and progression-free survival are similar between sporadic and familial prostate cancer cases. The sibling pairs had a trend toward less favorable tumor features and progression-free survival, but the difference was not statistically significant.

Impact of Familial and Hereditary Prostate Cancer on Cancer Specific Survival After Radical Retropubic Prostatectomy

PURPOSE

Men with a family history of prostate cancer are at higher risk for prostate cancer. There are conflicting data regarding the impact of hereditary forms of prostate cancer on long-term outcomes after radical prostatectomy. We examined the impact of familial and hereditary prostate cancer treatment in the prostate specific antigen era.

MATERIALS AND METHODS

Patients who underwent radical prostatectomy for prostate cancer from 1987 to 1997 were surveyed (3,560 responders) to determine the family history of prostate cancer. Patients were categorized as having familial prostate cancer if they had at least 1 first-degree relative with prostate cancer. Hereditary prostate cancer was defined as nuclear families with 3 cases of prostate cancer, families with prostate cancer in each of 3 generations and families with 2 men diagnosed before age 55 years. Sporadic prostate cancer was defined as patients with no family history. Clinical and pathological features, and long-term outcome measures, including biochemical recurrence-free, systemic progression-free and cancer specific survival, were compared among patients with familial, hereditary and sporadic prostate cancer.

RESULTS

A total of 865 and 133 patients were categorized as having familial prostate cancer and hereditary prostate cancer, respectively. Preoperatively prostate specific antigen was higher in patients with hereditary prostate cancer than in the other 2 groups (p = 0.04). Ten-year biochemical progression-free, systemic progression-free and cancer specific survival were equivalent.

CONCLUSIONS

Except for preoperative prostate specific antigen, clinicopathological features and long-term oncological outcomes are equivalent after radical prostatectomy in patients with familial, hereditary and sporadic prostate cancer.

Prevalence, treatment modalities and prognosis of familial prostate cancer in a screened population

PURPOSE

A family history of prostate cancer is an important risk factor for this disease. The clinical presentation and prognosis of familial disease remain uncertain. In this study these entities are evaluated in the first and second rounds of a screening program in The Netherlands.

MATERIALS AND METHODS

Of all men randomized in the Rotterdam section of the ERSPC, 19,970 men were eligible for screening. Information regarding the family history was obtained by a self-administered questionnaire at baseline.

RESULTS

In the prevalence screen the cancer detection rate in 1,364 men (7.1%) with a positive family history was 7.7% (106 cancers in 1,364 screened men with a positive family history) while the positive predictive value of the biopsies was 32.2% (154 cancers of 532 biopsies). In 12,803 sporadic cases the detection rate was 4.7% and the positive predictive value was 23.6% (p <0.0001 and 0.003, RR 1.63). No clinicopathological differences were found in the 1,559 men diagnosed in the first and second rounds. The overall biochemical-free survival rate after a mean followup of 56.8 months (range 0 to 129.9) was 76.8%, and was not significantly different in familial and sporadic cases (p = 0.840). These findings were consistent for the specific treatment modalities as well.

CONCLUSIONS

Although screened men 55 to 75 years old with a father or a brother having prostate cancer themselves are at a substantially greater risk for the disease, the clinical presentation, treatment modalities and prognosis by biochemical progression are not different compared to sporadic cases.

Familial and Hereditary Prostate Cancer by Definition in an Italian Surgical Series: Clinical Features and Outcome

OBJECTIVE

To evaluate the clinical impact of different definitions of hereditary prostate cancer (PCa), the relative risk (RR) of relatives of PCa cases and differences in clinical-pathological features and outcome as function of a family history in a surgical series exposed to Mediterranean diet.

METHODS

We classified as Sporadic (SPC), Familial (FPC) or Hereditary (HPC) 606 consecutive PCa cases, 65 years old or less at diagnosis, underwent radical retropubic prostatectomy between January 1, 1987 and December 31, 2002 (mean follow-up: 6.4 years). The disease-free, overall and PCa-specific survival were also compared between SPC and non-SPC (NSPC) cases.

RESULTS

Overall 12.5% of cases had a positive family history. We found 14 (2.3%) HPC cases versus 16 (2.6%) taking account of X-linked transmission. Relatives of early-onset PCa cases had a higher RR to PCa (4.3) compared to late-onset PCa cases. NSPC cases had a lower frequency of positive margins status (p=0.011), perineural infiltration (p=0.028) and positive lymph nodes (p=0.005) than SPC cases, but no differences were found in major prognostic factors (preoperative PSA, Gleason sum, pathological stage) and outcome endpoints as function of a family history.

CONCLUSIONS

A positive family history is an important risk factor to PCa. HPC frequency is probably underestimated because of exclusion of X-linked transmission. We support the similarity between SPC and NSPC with respect to biological aggressiveness.

Time trends in pathologic features of radical prostatectomy—impact of family history

We investigated whether the clinical or pathological features of patients with a family history of prostate cancer treated by radical prostatectomy differ from patients without a family history. A retrospective analysis of patients treated by radical prostatectomy between 1989 through 2000 was performed. The clinical and pathologic features of patients with a family history (defined as at least one first-degree relative with prostate cancer, N = 103) were compared with those with no family history (N = 456). In addition, the patients were stratified into two groups, those treated from 1989 through 1992 and those treated after 1992. In the entire cohort from 1989 through 2000, patients with a family history had a greater proportion of well-differentiated tumors than the NFH group (26.2% vs. 17.8%; P = 0.05). From 1989 to 1992 there was no statistical difference between patients with a family history (FH) and those without a family history (NFH) with respect to age, prostate specific antigen (PSA), PSA density, clinical or pathologic stage, Gleason grade, or total tumor volume. However, after 1992 the FH group tended to be younger than the NFH group (61.1 vs. 63.4; P = 0.02) and have a lower PSA (6.8 vs. 7.9; P = 0.01) at the time of diagnosis. We believe these differences are predominantly driven by more aggressive screening in patients with a family history of prostate cancer rather than any true genetic differences.

Molecular genetics of human prostate cancer

Multiple factors contribute to the high incidence and prevalence of prostate cancer including race, ethnicity, diet, environment, widespread awareness through prostate-specific antigen screening and genetics. Linkage analysis has identified several candidate sites for hereditary prostate cancer gene loci. Molecular studies have also identified genes that are frequently altered in sporadic prostate cancer. It appears that due to the heterogeneity of prostate cancer, multiple genes may be involved in the neoplastic process.

Molecular pathways to prostate cancer

PURPOSE

Prostate cancer continues to be a prevalent disease in the United States and western countries. Advances in the fields of molecular biology and genetics coupled with new developments in biotechnology have increased our understanding of events associated with the initiation and progression of prostate cancer. We reviewed recent scientific discoveries relating to genetic predisposition, somatic alterations and epigenetic phenomena involved in the pathogenesis of prostate cancer.

MATERIALS AND METHODS

Reports published in the scientific literature with relevance to the molecular biology, genetics and epigenetics of prostate cancer were identified using the MEDLINE data base. Particular emphasis was placed on articles that investigated the contribution of somatic alterations to prostate cancer.

RESULTS

A multitude of genes have recently been identified that are believed to be relevant to prostate carcinogenesis. A contemporary model for prostate cancer progression should include the potential contribution of inflammation to the development of preneoplastic or neoplastic lesions. Abnormal methylation of important growth regulatory or caretaker genes represents an alternative pathway to cancer in addition to aneuploidy, loss of heterozygosity and gene mutations.

CONCLUSIONS

The identification of molecular markers specific to early and late events in prostate cancer progression is critical for the development of improved detection and prognostication strategies. While there is evidence to support the association between inflammation and prostate cancer, the exact mechanisms by which these processes occur are not well defined. The significant contribution of somatic and epigenetic defects to prostate carcinogenesis underscores the need to develop therapeutic approaches that specifically target these molecular alterations.

Populations at high risk for prostate cancer

Although prostate cancer tends to be a slow-growing neoplasm affecting older men, there is clearly a subset of patients at high risk for developing early and possibly more aggressive disease. This group of high-risk patients includes men with a family history of prostate cancer and various histologic features such as PIN and ASAP identified on an initial biopsy. Black American men have a much higher risk of developing prostate cancer when compared with white men and especially Asian men. This finding may reflect both genetic and environmental factors. Screening men at increased risk of developing prostate cancer appears to be a logical strategy, especially in light of recent reports that suggest a benefit to aggressive treatment.

Association of prostate cancer family history with histopathological and clinical characteristics of prostate tumors

Genetic factors may be used not only to assess risk of prostate cancer development but also to evaluate prostate cancer outcomes including clinical prognosis, treatment methods, and treatment response. To assess the role of family history on prostate cancer outcomes, we evaluated tumor characteristics, diagnostic precursors and biochemical (prostate specific antigen) relapse-free survival in men with and without a family history of prostate cancer. A total of 684 prostate cancer cases unselected for family history were identified from an ongoing hospital based prostate cancer case-control study between 1995 and 2002. Self-reported family history was grouped within the following categories: none, any, moderate (one affected first or second degree relative) and high (2 or more affected first or second degree relatives). We further considered groups defined by early (before age 60) and late (after age 60) age at diagnosis. Overall, tumor stage was not significantly associated with any (odds ratio [OR] = 1.43 95% confidence interval [CI] = 1.00-2.05) or moderate (OR = 1.48, 95% CI = 1.0-2.19) family histories. Men diagnosed before age 60, however, had higher tumor stages if they had any (OR = 2.19, 95% CI = 1.28-3.75) or moderate (OR = 2.15, 95% CI = 1.2-3.9) family histories. Men diagnosed after age 60 with any family history were significantly more likely to experience biochemical (PSA) failure (Hazard ratio [HR] = 2.60, 95%CI = 1.08-6.25). Men with any and moderate family histories were at significantly increased risk of biochemical failure (HR = 2.49, 95%CI = 1.25-4.95 and HR = 2.46, 95% CI = 1.17-5.16, respectively). Moderate family history increased probability of seminal vesicle invasion (OR = 2.14, 95%CI = 1.06-4.34). Our results suggest that a family history of prostate cancer may be associated with predictors of clinical outcome in prostate cancer cases unselected for a family history of prostate cancer.

Molecular Techniques and Prostate Cancer Diagnostic

Recent advances in molecular techniques have given the opportunity to assess genomic and proteomic alterations comprehensively and rapidly in routinely acquired tissue samples. In particular, new markers derived from qualitative and quantitative DNA, RNA, and protein analysis have provided additional objective information to supplant and extend the morphologic interpretations and have been increasingly integrated into the final surgical pathology diagnosis. In this review several recently developed molecular techniques are described and illustrated. The focus is on prostate cancer diagnostics, as an example of their application.

Familial prostate cancer cases before and after radical prostatectomy do not show any aggressiveness compared with sporadic cases

OBJECTIVES

To compare the clinical and biologic features at diagnosis between sporadic and familial clinically localized prostate cancer (CaP), and to compare the prognosis of familial with that of sporadic cases after radical prostatectomy in southwestern Europe.

METHODS

Eighty-five sporadic (one case of CaP) and 37 familial (two or more CaP cases in the family) patients with clinically localized CaP undergoing radical prostatectomy were compared regarding preoperative (mean age, clinical status, mean prostate-specific antigen level, and mean Gleason score at diagnosis) and postoperative (pT, pN, and pathologic Gleason score) parameters using the Student t test, Fisher's exact test, and the chi-square test. The biochemical relapse-free survival for each group was compared using the Kaplan-Meier method and the log-rank test.

RESULTS

The mean follow-up was about 51.8 months (range 1 to 156) in the sporadic group and 35 months (range 1 to 96) in the familial group. No specific preoperative and postoperative clinical or biologic feature was associated with familial CaP. Biochemical relapse occurred in 40.5% (15 of 37) of cases when the proband had a positive family history of CaP versus 32.9% (28 of 85) in the sporadic cases (P = 0.42). Biochemical relapse-free survival curves did not display any difference (P = 0.46) between familial and sporadic CaP.

CONCLUSIONS

In this population, the outcome after radical prostatectomy is similar in those with and without a family history. Thus, the natural history of CaP seems to follow the same path whether the triggering point is inherited or acquired for this subset of patients during this period.

Hereditary prostate cancer: clinical aspects

PURPOSE

We review the current epidemiological and genetic knowledge regarding hereditary prostate cancer, and outline its clinical implications.

MATERIALS AND METHODS

Published articles on hereditary prostate cancer were identified using the MEDLINE data base.

RESULTS

A risk of prostate cancer, particularly early onset disease, is strongly affected by family history (number of relatives with prostate cancer and their age at diagnosis). A family history of prostate cancer increases the positive predictive value of prostate specific antigen testing and, hence, heredity should always be assessed when deciding whether to perform biopsies in a man with a prostate specific antigen level of 3 to 10 ng./ml. Epidemiological studies indicate that dominantly inherited susceptibility genes with high penetrance cause 5% to 10% of all prostate cancer cases, and as much as 30% to 40% of early onset disease. More than a half dozen chromosome loci that may comprise such genes have been mapped, but as of May 2002 no prostate cancer susceptibility gene of major importance had been cloned. Most likely, environmental factors and comparatively common variants of several other genes affect prostate cancer risk in families with or without multiple cases of the disease. On average, hereditary prostate cancer is diagnosed 6 to 7 years earlier than sporadic prostate cancer, but does not otherwise differ clinically from the sporadic form. As a consequence of the earlier onset, a greater proportion of men with hereditary prostate cancer die of the disease than those with nonhereditary prostate cancer. At present, the only clinically applicable measure to reduce prostate cancer mortality in families with hereditary disease is screening, with the aim of diagnosing the disease when it is still in a curable stage.

CONCLUSIONS

Hereditary susceptibility is now considered the strongest risk factor for prostate cancer and has profound clinical importance. The genetic mechanism behind such susceptibility has turned out to be more complex than initially thought, and will probably not be completely understood for many years to come.

Biochemical recurrence after radical prostatectomy in black and white American men with a positive or negative family history of prostate cancer

PURPOSE

We investigated the impact of a family history of prostate cancer on predicting biochemical recurrence in black and white American men.

MATERIAL AND METHODS

Between January 1991 and December 1996, 910 men underwent radical retropubic prostatectomy for clinically localized prostate cancer, of whom 676 had data available on prostate cancer family history. Statistical analysis was performed to identify any correlation among the known predictors of biochemical outcome and family history in each race.

RESULTS

Median followup was 34 months (range 2 to 103). We identified 355 (52%) and 321 (48%) white and black American men, respectively, for whom data were available on prostate cancer family history, including 177 (26%) with a positive and 499 (74%) with a negative history. Family history was positive in 94 black (29%) and 83 white (23%) men. No significant difference was noted in the incidence of familial prostate cancer in the 2 races (p = 0.10). In black men the biochemical failure rate was 32% and 26% in those with a positive and negative history (log rank test p = 0.51), while in white men the rate was 17% and 18%, respectively (log rank test p = 0.79). A family history positive for prostate cancer was not associated with biochemical failure in either race.

CONCLUSIONS

Biochemical recurrence was not significantly worse in patients with a family history of prostate cancer than in those with nonfamilial disease in either race.

Early-onset hereditary prostate cancer is not associated with specific clinical and biological features

BACKGROUND

Familial prostate cancer (CaP) accounts for 15-20% of all CaP, and hereditary CaP for 5-10% of patients. Few data are available concerning their clinical and biological features.

METHODS

We compared diagnostic modalities, age, clinical stage, PSA, and tumor grade at diagnosis in CaP patients according to familial CaP profile: hereditary (HR) (> or =3 CaP), familial nonhereditary (FNH) (= 2 CaP), and sporadic CaP. Only cases diagnosed after January 1, 1987 (PSA-available period) were included. We considered as informative sporadic (IS) cases those probands with 2+ nonaffected brothers at least 50 years old. Finally, 267 CaP (230 probands and 37 affected brothers) were studied.

RESULTS

In multivariate analysis, the only specific parameter significantly associated with HR and FNH CaP was early age at diagnosis; mean ages were 65.3 years (HR), 67 years (FNH), and 70.9 years (IS) (P < 0. 0001). No significant difference was observed concerning clinical stage, PSA, and tumor grade. In addition, diagnostic modalities were similar in the three groups.

CONCLUSIONS

Our data confirm the occurrence of early-onset CaP in hereditary families. Although the clinical and biological presentation of HR CaP remains controversial, the lack of specific features observed in our study leads us to conclude that there is no difference in the aggressiveness of the disease in hereditary compared to sporadic CaP.

Diagnosis of localized prostate cancer: 10 years of progress

Advances in the diagnosis of early stage disease, and particularly the introduction of prostate-specific antigen (PSA) testing, have had a dramatic effect on the presentation and clinical management of prostate cancer during the past ten years. As a result, there have been significant epidemiological changes in countries where early diagnosis is recommended. The importance of PSA testing for the diagnosis of localized prostate cancer has become well established in clinical practice and this is reflected by improved outcomes from definitive treatment. The contribution of PSA-related parameters and molecular forms of PSA both to cancer detection and prediction of pathological stage continue to be explored. Concerns about the reliability of the standard sextant biopsy technique for cancer detection relate to the need for re-biopsy in a growing number of patients with negative biopsies and an increasing proportion of patients with low volume, multifocal disease. In men with cancer, additional prognostic information can be derived from biopsy findings, with important therapeutic implications. This relates also to the need for reliable markers indicating pathological stage and risk of progression. The opportunities for the prevention of prostate cancer have grown with improved understanding of its biology and the genetic basis of the early steps associated with malignant transformation. In the future, the need for therapeutic intervention is likely to be most influenced by successful prevention strategies.

New insights and candidate genes and their implications for care of patients with hereditary prostate cancer

A positive family history is a risk factor for prostate cancer. Most studies based on segregation analysis suggest autosomal dominant transmission of susceptibility genes. Multiple loci on chromosome 1 and chromosome X have been associated with prostate cancer by linkage analysis. The candidate gene approach has also revealed multiple genetic markers that are associated with increased risk for the disease. The genetic studies in prostate cancer suggest there are multiple genes involved in the development and progression of prostate cancer.

Cancer screening in the elderly population

This article reviews the current state of knowledge regarding cancer screening in the geriatric population. Care of the elderly requires knowledge of underlying physiologic changes, comorbidities, quality-of-life factors, and life expectancies. There is always the danger that ageism may prevent elderly cancer patients from receiving the proper treatment. On the other hand, overzealous treatment can lead to adverse results if elderly patients are not properly targeted based on current evidence of the benefits and risks of specific screening practices.

Screening for prostate cancer. The challenge of promoting informed decision making in the absence of definitive evidence of effectiveness

Evidence demonstrating the burden of prostate cancer upon men in the United States is incontrovertible; less compelling, however, is proof of benefit from early detection efforts. Nevertheless, the absence of definitive evidence does not lessen the interest of men in prostate testing or the obligation of physicians to help interested men make well-informed decisions, which integrate personal circumstance and preference with the best available data. This article provides the counseling physician with the information required to frame the current prostate testing debate and an approach to support informed decision making by men who can benefit from their assistance.