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Al Shareef Z, Hachim MY, Bouzid A, Talaat IM, Al-Rawi N, Hamoudi R, Hachim IY. The prognostic value of Dickkopf-3 (Dkk3), TGFB1 and ECM-1 in prostate cancer. Front Mol Biosci 2024; 11:1351888. [PMID: 38855324 PMCID: PMC11157039 DOI: 10.3389/fmolb.2024.1351888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 05/06/2024] [Indexed: 06/11/2024] Open
Abstract
Prostate cancer (PCa) is considered one of the most common cancers worldwide. Despite advances in patient diagnosis, management, and risk stratification, 10%-20% of patients progress to castration-resistant disease. Our previous report highlighted a protective role of Dickkopf-3 (DKK3) in PCa stroma. This role was proposed to be mediated through opposing extracellular matrix protein 1 (ECM-1) and TGF-β signalling activity. However, a detailed analysis of the prognostic value of DKK3, ECM-1 and members of the TGF-β signalling pathway in PCa was not thoroughly investigated. In this study, we explored the prognostic value of DKK3, ECM-1 and TGFB1 using a bioinformatical approach through analysis of large publicly available datasets from The Cancer Genome Atlas Program (TGCA) and Pan-Cancer Atlas databases. Our results showed a significant gradual loss of DKK3 expression with PCa progression (p < 0.0001) associated with increased DNA methylation in its promoter region (p < 1.63E-12). In contrast, patients with metastatic lesions showed significantly higher levels of TGFB1 expression compared to primary tumours (p < 0.00001). Our results also showed a marginal association between more advanced tumour stage presented as positive lymph node involvement and low DKK3 mRNA expression (p = 0.082). However, while ECM1 showed no association with tumour stage (p = 0.773), high TGFB1 expression showed a significant association with more advanced stage presented as advanced T3 stage compared to patients with low TGFB1 mRNA expression (p < 0.001). Interestingly, while ECM1 showed no significant association with patient outcome, patients with high DKK3 mRNA expression showed a significant association with favourable outcomes presented as prolonged disease-specific (p = 0.0266), progression-free survival (p = 0.047) and disease-free (p = 0.05). In contrast, high TGFB1 mRNA expression showed a significant association with poor patient outcomes presented as shortened progression-free (p = 0.00032) and disease-free survival (p = 0.0433). Moreover, DKK3, TGFB1 and ECM1 have acted as immune-associated genes in the PCa tumour microenvironment. In conclusion, our findings showed a distinct prognostic value for this three-gene signature in PCa. While both DKK3 and TGFB1 showed a potential role as a clinical marker for PCa stratification, ECM1 showed no significant association with the majority of clinicopathological parameters, which reduce its clinical significance as a reliable prognostic marker.
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Affiliation(s)
- Zainab Al Shareef
- Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Mahmood Y. Hachim
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Amal Bouzid
- Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - Iman M. Talaat
- Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Natheer Al-Rawi
- Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
- College of Dental Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Rifat Hamoudi
- Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Ibrahim Y. Hachim
- Research Institute of Medical and Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
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Agarwal N, Saad F, Azad AA, Mateo J, Matsubara N, Shore ND, Chakrabarti J, Chen HC, Lanzalone S, Niyazov A, Fizazi K. TALAPRO-3 clinical trial protocol: phase III study of talazoparib plus enzalutamide in metastatic castration-sensitive prostate cancer. Future Oncol 2024; 20:493-505. [PMID: 37882449 DOI: 10.2217/fon-2023-0526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023] Open
Abstract
Poly(ADP-ribose) polymerase inhibitors in combination with androgen-receptor signaling inhibitors are a promising therapeutic option for patients with metastatic castration-sensitive prostate cancer (mCSPC) and homologous recombination repair (HRR) gene alterations. Here, we describe the design and rationale of the multinational, phase III, TALAPRO-3 study comparing talazoparib plus enzalutamide versus placebo plus enzalutamide in patients with mCSPC and HRR gene alterations. The primary end point is investigator-assessed radiographic progression-free survival (rPFS) per RECIST 1.1 in soft tissue, or per PCWG3 criteria in bone. The TALAPRO-3 study will demonstrate whether the addition of talazoparib can improve the efficacy of enzalutamide as assessed by rPFS in patients with mCSPC and HRR gene alterations undergoing androgen deprivation therapy. Clinical Trial Registration:NCT04821622 (ClinicalTrials.gov) Registry Name: Study of Talazoparib With Enzalutamide in Men With DDR Gene Mutated mCSPC. Date of Registration: 29 March 2021.
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Affiliation(s)
- Neeraj Agarwal
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84112, USA
| | - Fred Saad
- University of Montréal Hospital Center, Montréal, Québec, H2L 4M1, Canada
| | - Arun A Azad
- Peter MacCallum Cancer Centre, Melbourne, Victoria, 3000, Australia
| | - Joaquin Mateo
- Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron University Hospital, 08035, Barcelona, Spain
| | | | - Neal D Shore
- Carolina Urologic Research Center, Myrtle Beach, SC 29572, USA
| | | | | | | | | | - Karim Fizazi
- Institut Gustave Roussy, University of Paris Sud, Villejuif, 94800, France
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Shareef ZA, Hachim MY, Talaat IM, Bhamidimarri PM, Ershaid MNA, Ilce BY, Venkatachalam T, Eltayeb A, Hamoudi R, Hachim IY. DKK3's protective role in prostate cancer is partly due to the modulation of immune-related pathways. Front Immunol 2023; 14:978236. [PMID: 36845147 PMCID: PMC9947504 DOI: 10.3389/fimmu.2023.978236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 01/03/2023] [Indexed: 02/11/2023] Open
Abstract
While it is considered one of the most common cancers and the leading cause of death in men worldwide, prognostic stratification and treatment modalities are still limited for patients with prostate cancer (PCa). Recently, the introduction of genomic profiling and the use of new techniques like next-generation sequencing (NGS) in many cancers provide novel tools for the discovery of new molecular targets that might improve our understanding of the genomic aberrations in PCa and the discovery of novel prognostic and therapeutic targets. In this study, we investigated the possible mechanisms through which Dickkopf-3 (DKK3) produces its possible protective role in PCa using NGS in both the DKK3 overexpression PCa cell line (PC3) model and our patient cohort consisting of nine PCa and five benign prostatic hyperplasia. Interestingly, our results have shown that DKK3 transfection-modulated genes are involved in the regulation of cell motility, senescence-associated secretory phenotype (SASP), and cytokine signaling in the immune system, as well as in the regulation of adaptive immune response. Further analysis of our NGS using our in vitro model revealed the presence of 36 differentially expressed genes (DEGs) between DKK3 transfected cells and PC3 empty vector. In addition, both CP and ACE2 genes were differentially expressed not only between the transfected and empty groups but also between the transfected and Mock cells. The top common DEGs between the DKK3 overexpression cell line and our patient cohort are the following: IL32, IRAK1, RIOK1, HIST1H2BB, SNORA31, AKR1B1, ACE2, and CP. The upregulated genes including IL32, HIST1H2BB, and SNORA31 showed tumor suppressor functions in various cancers including PCa. On the other hand, both IRAK1 and RIOK1 were downregulated and involved in tumor initiation, tumor progression, poor outcome, and radiotherapy resistance. Together, our results highlighted the possible role of the DKK3-related genes in protecting against PCa initiation and progression.
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Affiliation(s)
- Zainab Al Shareef
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Mahmood Y. Hachim
- College of Medicine, Mohammed bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Iman M. Talaat
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
- Pathology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Mai Nidal Asad Ershaid
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Burcu Yener Ilce
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Thenmozhi Venkatachalam
- Department of Physiology and Immunology, College of Medicine and Health Science, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Abdulla Eltayeb
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Rifat Hamoudi
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Ibrahim Y. Hachim
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
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Gallagher BD, Coughlin EC, Nair-Shalliker V, McCaffery K, Smith DP. Socioeconomic differences in prostate cancer treatment: A systematic review and meta-analysis. Cancer Epidemiol 2022; 79:102164. [DOI: 10.1016/j.canep.2022.102164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 03/18/2022] [Accepted: 04/16/2022] [Indexed: 11/02/2022]
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Incremental modification of robotic prostatectomy technique can lead to aggregated marginal gains to significantly improve functional outcomes without compromising oncological control. J Robot Surg 2021; 16:665-675. [PMID: 34370178 DOI: 10.1007/s11701-021-01295-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/31/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION AND OBJECTIVES Surgeons should aim for continuous quality improvement. The aim of this study was to evaluate the impact of incremental changes to Robot Assisted Radical Prostatectomy (RARP) technique on intra-operative and early post-operative outcomes. PATIENTS AND METHODS All cases of RARP performed by a single surgeon in a tertiary institution over a 2-year period were included in this evaluation. Routine clinical data were collected. Cases were retrospectively allocated to four groups depending on key technical steps (1 = standard anterior approach; 2 = anterior approach with preservation of endopelvic fascia, puboprostatic fascia and urachus; 3 = posterior approach for nerve spare, with preservation of endopelvic fascia, puboprostatic fascia and urachus; 4 = Retzius-sparing posterior approach). RESULTS 187 patients were allocated to groups: 1 = 22, 2 = 53, 3 = 90, 4 = 22. There were no significant differences in pre-operative characteristics, except age: 1 = 62.5, 2 = 62, 3 = 62.5, 4 = 58.5 (p = 0.02). Intra-operative differences were found in console time: 1 = 195, 2 = 167, 3 = 195 4 = 136.5 min (p < 0.001); and proportion of non-nerve sparing cases: 1 = 36%, 2 = 17%, 3 = 13%, 4 = 0% (p = 0.044). No significant differences were found in lymph node dissections, blood loss or complications. Post-operatively, no differences were found in length of stay, pathological characteristics, margin status, lymph node yield, complications or PSA levels. Significant differences were seen in pad-free continence at 6 weeks: 1 = 23%, 2 = 23%, 3 = 34%, 4 = 73% (p < 0.01); and social continence (using 1 pad) at 6-weeks: 1 = 59%, 2 = 87%, 3 = 81%, 4 = 95% (p = 0.01). Significant differences in pad-free continence persisted at 12 months: 1 = 63%, 2 = 81%, 3 = 78%, 4 = 100% (p = 0.019). CONCLUSION Our results suggest that aggregated marginal gains from incremental modification of RARP leads to significantly improved continence outcomes without compromising patient safety or oncological control.
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Chinegwundoh F, Perera R. Evaluating psychological support services available for men living with prostate cancer and their carers and families across England. BJU Int 2019; 125:630-631. [PMID: 31769921 DOI: 10.1111/bju.14959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Thurtle D, Rossi SH, Berry B, Pharoah P, Gnanapragasam VJ. Models predicting survival to guide treatment decision-making in newly diagnosed primary non-metastatic prostate cancer: a systematic review. BMJ Open 2019; 9:e029149. [PMID: 31230029 PMCID: PMC6596988 DOI: 10.1136/bmjopen-2019-029149] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Men diagnosed with non-metastatic prostate cancer require standardised and robust long-term prognostic information to help them decide on management. Most currently-used tools use short-term and surrogate outcomes. We explored the evidence base in the literature on available pre-treatment, prognostic models built around long-term survival and assess the accuracy, generalisability and clinical availability of these models. DESIGN Systematic literature review, pre-specified and registered on PROSPERO (CRD42018086394). DATA SOURCES MEDLINE, Embase and The Cochrane Library were searched from January 2000 through February 2018, using previously-tested search terms. ELIGIBILITY CRITERIA Inclusion required a multivariable model prognostic model for non-metastatic prostate cancer, using long-term survival data (defined as ≥5 years), which was not treatment-specific and usable at the point of diagnosis. DATA EXTRACTION AND SYNTHESIS Title, abstract and full-text screening were sequentially performed by three reviewers. Data extraction was performed for items in the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies checklist. Individual studies were assessed using the new Prediction model Risk Of Bias ASsessment Tool. RESULTS Database searches yielded 6581 studies after deduplication. Twelve studies were included in the final review. Nine were model development studies using data from over 231 888 men. However, only six of the nine studies included any conservatively managed cases and only three of the nine included treatment as a predictor variable. Every included study had at least one parameter for which there was high risk of bias, with failure to report accuracy, and inadequate reporting of missing data common failings. Three external validation studies were included, reporting two available models: The University of California San Francisco (UCSF) Cancer of the Prostate Risk Assessment score and the Cambridge Prognostic Groups. Neither included treatment effect, and both had potential flaws in design, but represent the most robust and usable prognostic models currently available. CONCLUSION Few long-term prognostic models exist to inform decision-making at diagnosis of non-metastatic prostate cancer. Improved models are required to inform management and avoid undertreatment and overtreatment of non-metastatic prostate cancer.
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Affiliation(s)
- David Thurtle
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Sabrina H Rossi
- Department of Surgery, University of Cambridge, Cambridge, UK
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Brendan Berry
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Paul Pharoah
- Cancer Epidemiology, University of Cambridge, Cambridge, UK
| | - Vincent J Gnanapragasam
- Department of Surgery, University of Cambridge, Cambridge, UK
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Gnanapragasam VJ, Barrett T, Thankapannair V, Thurtle D, Rubio-Briones J, Domínguez-Escrig J, Bratt O, Statin P, Muir K, Lophatananon A. Using prognosis to guide inclusion criteria, define standardised endpoints and stratify follow-up in active surveillance for prostate cancer. BJU Int 2019; 124:758-767. [PMID: 31063245 DOI: 10.1111/bju.14800] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To test whether using disease prognosis can inform a rational approach to active surveillance (AS) for early prostate cancer. PATIENTS AND METHODS We previously developed the Cambridge Prognostics Groups (CPG) classification, a five-tiered model that uses prostate-specific antigen (PSA), Grade Group and Stage to predict cancer survival outcomes. We applied the CPG model to a UK and a Swedish prostate cancer cohort to test differences in prostate cancer mortality (PCM) in men managed conservatively or by upfront treatment in CPG2 and 3 (which subdivides the intermediate-risk classification) vs CPG1 (low-risk). We then applied the CPG model to a contemporary UK AS cohort, which was optimally characterised at baseline for disease burden, to identify predictors of true prognostic progression. Results were re-tested in an external AS cohort from Spain. RESULTS In a UK cohort (n = 3659) the 10-year PCM was 2.3% in CPG1, 1.5%/3.5% in treated/untreated CPG2, and 1.9%/8.6% in treated/untreated CPG3. In the Swedish cohort (n = 27 942) the10-year PCM was 1.0% in CPG1, 2.2%/2.7% in treated/untreated CPG2, and 6.1%/12.5% in treated/untreated CPG3. We then tested using progression to CPG3 as a hard endpoint in a modern AS cohort (n = 133). During follow-up (median 3.5 years) only 6% (eight of 133) progressed to CPG3. Predictors of progression were a PSA density ≥0.15 ng/mL/mL and CPG2 at diagnosis. Progression occurred in 1%, 8% and 21% of men with neither factor, only one, or both, respectively. In an independent Spanish AS cohort (n = 143) the corresponding rates were 3%, 10% and 14%, respectively. CONCLUSION Using disease prognosis allows a rational approach to inclusion criteria, discontinuation triggers and risk-stratified management in AS.
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Affiliation(s)
- Vincent J Gnanapragasam
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK.,Department of Urology, Cambridge University Hospitals NHS Trust, Cambridge, UK.,Cambridge Urology Translational Research and Clinical Trials Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Tristan Barrett
- Department of Radiology, University of Cambridge, Cambridge, UK
| | | | - David Thurtle
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK
| | | | | | - Ola Bratt
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Par Statin
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Kenneth Muir
- Department of Public Health and Epidemiology, University of Manchester, Manchester, UK
| | - Artitaya Lophatananon
- Department of Public Health and Epidemiology, University of Manchester, Manchester, UK
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Smith-Palmer J, Takizawa C, Valentine W. Literature review of the burden of prostate cancer in Germany, France, the United Kingdom and Canada. BMC Urol 2019; 19:19. [PMID: 30885200 PMCID: PMC6421711 DOI: 10.1186/s12894-019-0448-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 03/07/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Prostate cancer is the most frequently reported cancer in males in Europe, and is associated with substantial morbidity and mortality. The aim of the current review was to characterize the clinical, economic and humanistic burden of disease associated with prostate cancer in France, Germany, the UK and Canada. METHODS Literature searches were conducted using the PubMed, EMBASE and Cochrane Library databases to identify studies reporting incidence and/or mortality rates, costs and health state utilities associated with prostate cancer in the settings of interest. For inclusion, studies were required to be published in English in full-text form from 2006 onwards. RESULTS Incidence studies showed that in all settings the incidence of prostate cancer has increased substantially over the past two decades, driven in part by increased uptake of prostate specific antigen (PSA) screening leading to earlier identification of tumors, but which has also led to over-treatment, compounding the economic burden of disease. Mortality rates have declined over the same time frame, driven by earlier detection and improvements in treatment. Both prostate cancer itself, as well as treatment and treatment-related complications, are associated with reduced quality of life. CONCLUSIONS Prostate cancer is associated with a significant clinical and economic burden, whilst earlier detection and aggressive treatment is associated with improved survival, over-treatment of men with indolent tumors compounds the already significant burden of disease and treatment can lead to long-term side effects including impotence and impaired urinary and/or bowel function. There is currently an unmet clinical need for diagnostic and/or prognostic tools that facilitate personalized prostate cancer treatment, and potentially reduce the clinical, economic and humanistic burden of invasive cancer treatment.
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Affiliation(s)
- J. Smith-Palmer
- Ossian Health Economics and Communications GmbH, Bäumleingasse 20, 4051 Basel, Switzerland
| | - C. Takizawa
- Genomic Health International, Geneva, Switzerland
| | - W. Valentine
- Ossian Health Economics and Communications GmbH, Bäumleingasse 20, 4051 Basel, Switzerland
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Thurtle DR, Greenberg DC, Lee LS, Huang HH, Pharoah PD, Gnanapragasam VJ. Individual prognosis at diagnosis in nonmetastatic prostate cancer: Development and external validation of the PREDICT Prostate multivariable model. PLoS Med 2019; 16:e1002758. [PMID: 30860997 PMCID: PMC6413892 DOI: 10.1371/journal.pmed.1002758] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 02/04/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Prognostic stratification is the cornerstone of management in nonmetastatic prostate cancer (PCa). However, existing prognostic models are inadequate-often using treatment outcomes rather than survival, stratifying by broad heterogeneous groups and using heavily treated cohorts. To address this unmet need, we developed an individualised prognostic model that contextualises PCa-specific mortality (PCSM) against other cause mortality, and estimates the impact of treatment on survival. METHODS AND FINDINGS Using records from the United Kingdom National Cancer Registration and Analysis Service (NCRAS), data were collated for 10,089 men diagnosed with nonmetastatic PCa between 2000 and 2010 in Eastern England. Median follow-up was 9.8 years with 3,829 deaths (1,202 PCa specific). Totals of 19.8%, 14.1%, 34.6%, and 31.5% of men underwent conservative management, prostatectomy, radiotherapy (RT), and androgen deprivation monotherapy, respectively. A total of 2,546 men diagnosed in Singapore over a similar time period represented an external validation cohort. Data were randomly split 70:30 into model development and validation cohorts. Fifteen-year PCSM and non-PCa mortality (NPCM) were explored using separate multivariable Cox models within a competing risks framework. Fractional polynomials (FPs) were utilised to fit continuous variables and baseline hazards. Model accuracy was assessed by discrimination and calibration using the Harrell C-index and chi-squared goodness of fit, respectively, within both validation cohorts. A multivariable model estimating individualised 10- and 15-year survival outcomes was constructed combining age, prostate-specific antigen (PSA), histological grade, biopsy core involvement, stage, and primary treatment, which were each independent prognostic factors for PCSM, and age and comorbidity, which were prognostic for NPCM. The model demonstrated good discrimination, with a C-index of 0.84 (95% CI: 0.82-0.86) and 0.84 (95% CI: 0.80-0.87) for 15-year PCSM in the UK and Singapore validation cohorts, respectively, comparing favourably to international risk-stratification criteria. Discrimination was maintained for overall mortality, with C-index 0.77 (95% CI: 0.75-0.78) and 0.76 (95% CI: 0.73-0.78). The model was well calibrated with no significant difference between predicted and observed PCa-specific (p = 0.19) or overall deaths (p = 0.43) in the UK cohort. Key study limitations were a relatively small external validation cohort, an inability to account for delayed changes to treatment beyond 12 months, and an absence of tumour-stage subclassifications. CONCLUSIONS 'PREDICT Prostate' is an individualised multivariable PCa prognostic model built from baseline diagnostic information and the first to our knowledge that models potential treatment benefits on overall survival. Prognostic power is high despite using only routinely collected clinicopathological information.
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Affiliation(s)
- David R. Thurtle
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, United Kingdom
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - David C. Greenberg
- National Cancer Registration and Analysis Service (Eastern Region), Fulbourn, Cambridge, United Kingdom
| | - Lui S. Lee
- Department of Urology, Singapore General Hospital, Singapore
| | - Hong H. Huang
- Department of Urology, Singapore General Hospital, Singapore
| | - Paul D. Pharoah
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Vincent J. Gnanapragasam
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, United Kingdom
- Department of Urology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
- Cambridge Urology Translational Research and Clinical Trials, Cambridge, United Kingdom
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11
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Bennett D, Kearney T, Donnelly DW, Downing A, Wright P, Wilding S, Wagland R, Watson E, Glaser A, Gavin A. Factors influencing job loss and early retirement in working men with prostate cancer-findings from the population-based Life After Prostate Cancer Diagnosis (LAPCD) study. J Cancer Surviv 2018; 12:669-678. [PMID: 30058009 PMCID: PMC6153559 DOI: 10.1007/s11764-018-0704-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 07/13/2018] [Indexed: 12/17/2022]
Abstract
Purpose To investigate factors associated with job loss and early retirement in men diagnosed with prostate cancer (PCa) 18–42 months previously. Methods Men ≤ 60 years at diagnosis who completed the Life After Prostate Cancer Diagnosis (LAPCD) survey were identified. Men who moved from employment at diagnosis to unemployment (EtoU) or retirement (EtoR) at survey (18–42 months post-diagnosis) were compared to men remaining in employment (EtoE). Sociodemographic, clinical and patient-reported factors were analysed in univariable and multivariable analysis. Results There were 3218 men (81.4%) in the EtoE, 245 (6.2%) in EtoU and 450 (11.4%) in the EtoR groups. Men with stage IV disease (OR = 4.7 95% CI 3.1–7.0, relative to stage I/II) and reporting moderate/big bowel (OR = 2.5, 95% CI 1.6–3.9) or urinary problems (OR = 2.0, 95% CI 1.4–3.0) had greater odds of becoming unemployed. Other clinical (≥ 1 comorbidities, symptomatic at diagnosis) and sociodemographic (higher deprivation, divorced/separated), living in Scotland or Northern Ireland (NI)) factors were predictors of becoming unemployed. Men who were older, from NI, with stage IV disease and with caring responsibilities had greater odds of retiring early. Self-employed and non-white men had lesser odds of retiring early. Conclusion PCa survivors who retire early following diagnosis do not report worse urinary or bowel problems compared to men remaining in employment. However, we identified clinical and sociodemographic factors which increased unemployment risk in PCa survivors. Implications for Cancer Survivors Targeted support and engagement with PCa survivors at risk of unemployment, including their families and employers, is needed. Electronic supplementary material The online version of this article (10.1007/s11764-018-0704-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Damien Bennett
- Northern Ireland Cancer Registry, Mulhouse Building, Queen's University Belfast, Mulhouse Rd., Belfast, BT12 6DP, Northern Ireland.
| | - Therese Kearney
- Northern Ireland Cancer Registry, Mulhouse Building, Queen's University Belfast, Mulhouse Rd., Belfast, BT12 6DP, Northern Ireland
| | - David W Donnelly
- Northern Ireland Cancer Registry, Mulhouse Building, Queen's University Belfast, Mulhouse Rd., Belfast, BT12 6DP, Northern Ireland
| | - Amy Downing
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, LS2 9JT, UK.,Leeds Institute of Data Analytics, University of Leeds, Leeds, LS2 9JT, UK
| | - Penny Wright
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, LS2 9JT, UK
| | - Sarah Wilding
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, LS2 9JT, UK.,Leeds Institute of Data Analytics, University of Leeds, Leeds, LS2 9JT, UK
| | - Richard Wagland
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Eila Watson
- Faculty Health and Life Sciences, Oxford Brookes University, Oxford, OX3 0BP, UK
| | - Adam Glaser
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, LS2 9JT, UK.,Leeds Institute of Data Analytics, University of Leeds, Leeds, LS2 9JT, UK
| | - Anna Gavin
- Northern Ireland Cancer Registry, Mulhouse Building, Queen's University Belfast, Mulhouse Rd., Belfast, BT12 6DP, Northern Ireland
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12
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Jaulim A, Srinivasan A, Hori S, Kumar N, Warren AY, Shah NC, Gnanapragasam VJ. A comparison of operative and margin outcomes from surgeon learning curves in robot assisted radical prostatectomy in a changing referral practice. Ann R Coll Surg Engl 2018; 100:226-229. [PMID: 29484935 PMCID: PMC5930106 DOI: 10.1308/rcsann.2018.0001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2017] [Indexed: 01/01/2023] Open
Abstract
Introduction The aim of this study was to explore the impact of increasing proportions of high risk referrals on surgical margin outcomes of a surgeon's learning curve in robotic prostatectomy. Methods All patients in this study underwent robot assisted radical prostatectomy (RARP) performed by three different consultant urological surgeons. Data collected included preoperative clinical stage, Gleason score and prostate specific antigen levels, which were used to risk stratify patients according to National Institute for Health and Care Excellence criteria. Oncological clearance was assessed by overall and stage specific positive margin status. Comparisons were made between each surgeon for the first and second 50 consecutive cases. Results For the three surgeons, there was a progressive increase in the proportion of high risk cases referred accompanied by a corresponding decline in low risk disease (p<0.001). Postoperative pathology also showed an upward trend in pT3 cases across the three eras. There was no statistical difference in overall positive margin rates between the surgeons. The overall rates were 12%, 20% and 23% for the first 50 cases, and 32%, 36% and 21% for the second 50 cases for the three surgeons respectively. Conclusions Our series demonstrates an upward trend in the risk profile of men referred for robotic prostatectomy over a nine-year period. Despite this, there was minimal impact on pathological and surgical outcomes among our surgeons, who were at the initial stages of their RARP learning curve. Our results suggest that there is no requirement for an active case selection bias against patients with high risk disease for surgeons newly embarking on their RARP learning experience.
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Affiliation(s)
- A Jaulim
- Cambridge University Hospitals NHS Foundation Trust, UK
- *Contributed equally
| | - A Srinivasan
- Cambridge University Hospitals NHS Foundation Trust, UK
- *Contributed equally
| | - S Hori
- Cambridge University Hospitals NHS Foundation Trust, UK
- *Contributed equally
| | - N Kumar
- Cambridge University Hospitals NHS Foundation Trust, UK
| | - AY Warren
- Cambridge University Hospitals NHS Foundation Trust, UK
| | - NC Shah
- Cambridge University Hospitals NHS Foundation Trust, UK
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13
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Heo JE, Ahn HK, Kim J, Chung BH, Lee KS. Changes in Clinical Characteristics of Patients with an Initial Diagnosis of Prostate Cancer in Korea: 10-Year Trends Reported by a Tertiary Center. J Korean Med Sci 2018; 33:e42. [PMID: 29349937 PMCID: PMC5777916 DOI: 10.3346/jkms.2018.33.e42] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/13/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The Korea Central Cancer Registry reported that incidence rates of prostate cancer have not increased continuously. We used recent trends in the incidence of prostate cancer to generate a preliminary report of the Korean population with prostate cancer. METHODS Patients initially diagnosed with prostate cancer by prostate biopsy from 2006 to 2015 at our tertiary center were selected. All patients were categorized according to age (< 65, 65-75, > 75 years), time period (2006-2010 vs. 2011-2015), and risk classification. Patients with insufficient data were excluded from the analysis. RESULTS Of 675 patients (median prostate-specific antigen [PSA], 9.09 ng/mL), those with a Gleason score (GS) of 6 (32.3%) comprised the largest proportion in our cohort. The proportion with a GS of 8 increased for those aged 65-75 years, despite the lack of increase in PSA. Treatment patterns changed for those with very low to low risk cancer. The overall survival (OS) rate and the cancer-specific survival (CSS) rate for all patients at 5 years were 87% and 90%, respectively. Patients with a low body mass index (BMI; ≤ 23 kg/m²) had worse median OS and CSS rates. CONCLUSION Significant differences in risk classifications and initial treatments were found between 2006-2010 and 2011-2015. Although PSA did not change, the GS did change. Lower BMI (≤ 23 kg/m²) had worse effects on OS and CSS rates for Korean prostate cancer patients.
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Affiliation(s)
- Ji Eun Heo
- Department of Urology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Kyu Ahn
- Department of Urology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jinu Kim
- Department of Urology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Ha Chung
- Department of Urology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang Suk Lee
- Department of Urology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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14
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Trends in prostate cancer incidence between 1996 and 2013 in two Swiss regions by age, grade, and T-stage. Cancer Causes Control 2017; 29:269-277. [PMID: 29204913 DOI: 10.1007/s10552-017-0993-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 11/28/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To investigate differences in prostate cancer incidence between two distinct Swiss regions from 1996 to 2013 stratified by age group, grade, and T-stage. METHODS The dataset included 17,495 men living in Zurich and 3,505 men living in Ticino, diagnosed with prostate cancer between 1996 and 2013. We computed age-standardized incidence rates per 100,000 person-years using the European Standard Population. Trends were assessed using JoinPoint regression analysis Software. RESULTS Age-standardized incidence rates were generally higher in Zurich compared to Ticino but the difference decreased over time. Incidence rates increased significantly up to 2002 in Zurich and 2007 in Ticino and then decreased. A statistically significant increase was observed for men aged < 65 years, for grade 3 tumors, and for T-stage 2 and 3 tumors. The largest decrease was seen for grade 1 tumors. Furthermore, the incidence of tumors of unknown grade or T-stage decreased significantly in both regions. CONCLUSIONS The trends in prostate cancer incidence rates were similar in both regions, although on a higher level in Zurich compared to Ticino. However, the difference decreased over time. The distribution of T-stage and grade did not explain the difference in incidence rates. Different use of opportunistic screening may play a role.
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15
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Bhatt NR, Kelly T, Domanska K, Fogarty C, Durkan G, Flood HD, Giri SK. Increasing detection of significant prostate cancer in younger men - ten year trends in prostate cancer risk profile in the Mid-West of Ireland. Cent European J Urol 2017; 70:143-147. [PMID: 28721280 PMCID: PMC5510348 DOI: 10.5173/ceju.2017.1361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 05/03/2017] [Accepted: 05/11/2017] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Although PSA (prostate specific antigen) based screening for prostate cancer (PCa) is controversial, an increasing number of men are undergoing Transrectal Ultrasound Guided prostate biopsy (TRUSPB) through primary care-based PSA testing and referral to hospitals. The aim of our study was to investigate presenting risk profiles of PCa over the last decade in a cohort of men in Ireland and to examine any change in the same over this time period. MATERIAL AND METHODS The hospital patient administration system was analysed for patients who underwent TRUSPB from January 2005 to December 2015. Clinically significant PCa was defined as Gleason score of 7 or above. RESULTS Complete data was available on 2391 TRUSPB patients: number of biopsies increased by 53%, median age decreased by 0.9%, median PSA decreased by 6% (p = 0.001, ANOVA) and abnormal DRE increased by 9% (p = 0.001, chi square). Overall positive biopsy was 44% and significant cancer rate was 21%. There was a significant change in trend of detection (p = 0.02) with average annual increase in significant cancer of 3%. The median age of the significant cancer cohort reduced by 1% and the PSA at diagnosis reduced by 9%. In younger men (<50 years), the rate of significant cancer detection increased by 18%. CONCLUSIONS Significant PCa detection increased across all age groups but recently, a younger patient profile was diagnosed with high-grade disease. This paves the way for future research on early-onset PCa. Younger patients with significant disease would result in increasing number of patients being eligible for radical treatment with implications on health resource planning and provision.
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Affiliation(s)
- Nikita R Bhatt
- Department of Urology, University Hospital Limerick, Limerick, Ireland
| | - Tetyana Kelly
- Department of Urology, University Hospital Limerick, Limerick, Ireland
| | - Kasia Domanska
- University of Limerick Graduate Entry Medical School, Limerick, Ireland
| | - Colette Fogarty
- University of Limerick Graduate Entry Medical School, Limerick, Ireland
| | - Garrett Durkan
- Department of Urology, University Hospital Limerick, Limerick, Ireland
| | - Hugh D Flood
- Department of Urology, University Hospital Limerick, Limerick, Ireland
| | - Subhasis K Giri
- Department of Urology, University Hospital Limerick, Limerick, Ireland
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Neal D, Lilja H. Circulating Tumor Cell Count as an Indicator of Treatment Benefit in Advanced Prostate Cancer. Eur Urol 2016; 70:993-994. [DOI: 10.1016/j.eururo.2016.06.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 06/08/2016] [Indexed: 10/21/2022]
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Patel KM, Gnanapragasam VJ. Novel concepts for risk stratification in prostate cancer. JOURNAL OF CLINICAL UROLOGY 2016; 9:18-23. [PMID: 28344812 PMCID: PMC5356178 DOI: 10.1177/2051415816673502] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 09/07/2016] [Indexed: 01/15/2023]
Abstract
Since Partin introduced the analysis of prostate-specific antigen, clinical T-stage and Gleason scores to estimate the risk of progression in men with localised prostate cancer, our understanding of factors that modify this risk has changed drastically. There are now multiple risk stratification tools available, including look-up tables, risk stratification/classification analyses, regression-tree analyses, nomograms and artificial neural networks. Concurrently, descriptions of novel biopsy strategies, imaging modalities and biomarkers are frequently published with the aim of improving risk stratification. With an abundance of new information available, incorporating advances into clinical practice can be confusing. This article aims to outline the major novel concepts in prostate cancer risk stratification for men with biopsy confirmed prostate cancer. We will detail which of these novel techniques and tools are likely to be adopted to aid treatment decisions and enable more accurate post-diagnosis, pretreatment risk stratification.
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Affiliation(s)
- Keval M Patel
- Cancer Research UK Cambridge Institute, University of Cambridge, UK; Academic Urology Group, University of Cambridge, UK
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18
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Gnanapragasam VJ, Hori S, Johnston T, Smith D, Muir K, Alonzi R, Winkler M, Warren A, Staffurth J, Khoo V, Tree A, Macneill A, McMenemin R, Mason M, Cathcart P, de Souza N, Sooriakumaran P, Weston R, Wylie J, Hall E, Lane A, Cross W, Syndikus I, Koupparis A. Clinical management and research priorities for high-risk prostate cancer in the UK: Meeting report of a multidisciplinary panel in conjunction with the NCRI Prostate Cancer Clinical Studies Localised Subgroup. JOURNAL OF CLINICAL UROLOGY 2016. [DOI: 10.1177/2051415816651362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The management of high-risk prostate cancer has become increasingly sophisticated, with refinements in radical therapy and the inclusion of adjuvant local and systemic therapies. Despite this, high-risk prostate cancer continues to have significant treatment failure rates, with progression to metastasis, castrate resistance and ultimately disease-specific death. In an effort to discuss the challenges in this field, the UK National Clinical Research Institute’s Prostate Cancer Clinical Studies localised subgroup convened a multidisciplinary national meeting in the autumn of 2014. The remit of the meeting was to debate and reach a consensus on the key clinical and research challenges in high-risk prostate cancer and to identify themes that the UK would be best placed to pursue to help improve outcomes. This report presents the outcome of those discussions and the key recommendations for future research in this highly heterogeneous disease entity.
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Affiliation(s)
| | - S Hori
- Academic Urology Group, University of Cambridge, UK
| | - T Johnston
- Academic Urology Group, University of Cambridge, UK
| | - D Smith
- Prostate Cancer Support Association, UK
| | - K Muir
- Institute of Public Health, University of Manchester, UK
| | - R Alonzi
- Department of Clinical Oncology, Mount Vernon Cancer Centre, UK
| | - M Winkler
- Department of Urology, Charing Cross Hospital, UK
| | - A Warren
- Department of Pathology, Addenbrookes Hospital, UK
| | - J Staffurth
- Institute of Cancer and Genetics, Cardiff University, UK
| | - V Khoo
- Department of Clinical Oncology, Royal Marsden Hospital, UK
| | - A Tree
- Department of Clinical Oncology, Royal Marsden Hospital, UK
| | - A Macneill
- Department of Urology, Western General Hospital, NHS Lothian, UK
| | | | - M Mason
- Institute of Cancer and Genetics, Cardiff University, UK
| | - P Cathcart
- Department of Urology, UCL Hospitals, UK
| | | | | | - R Weston
- Department of Urology, Royal Liverpool University Hospital, UK
| | - J Wylie
- Department of Oncology, Christie Hospital, UK
| | - E Hall
- Clinical Trials and Statistics Unit; Institute of Cancer Research, UK
| | - A Lane
- Department of Social Medicine, University of Bristol, UK
| | - W Cross
- Department of Urology, St. James’s University Hospital, UK
| | - I Syndikus
- Radiotherapy Department, Clatterbridge Cancer Centre, UK
| | - A Koupparis
- Department of Urology, Bristol Urological Institute, UK
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19
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Johnston TJ, Shaw GL, Lamb AD, Parashar D, Greenberg D, Xiong T, Edwards AL, Gnanapragasam V, Holding P, Herbert P, Davis M, Mizielinsk E, Lane JA, Oxley J, Robinson M, Mason M, Staffurth J, Bollina P, Catto J, Doble A, Doherty A, Gillatt D, Kockelbergh R, Kynaston H, Prescott S, Paul A, Powell P, Rosario D, Rowe E, Donovan JL, Hamdy FC, Neal DE. Mortality Among Men with Advanced Prostate Cancer Excluded from the ProtecT Trial. Eur Urol 2016; 71:381-388. [PMID: 27720537 PMCID: PMC5289293 DOI: 10.1016/j.eururo.2016.09.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 09/26/2016] [Indexed: 11/21/2022]
Abstract
Background Early detection and treatment of asymptomatic men with advanced and high-risk prostate cancer (PCa) may improve survival rates. Objective To determine outcomes for men diagnosed with advanced PCa following prostate-specific antigen (PSA) testing who were excluded from the ProtecT randomised trial. Design, setting, and participants Mortality was compared for 492 men followed up for a median of 7.4 yr to a contemporaneous cohort of men from the UK Anglia Cancer Network (ACN) and with a matched subset from the ACN. Outcome measurements and statistical analysis PCa-specific and all-cause mortality were compared using Kaplan-Meier analysis and Cox's proportional hazards regression. Results and limitations Of the 492 men excluded from the ProtecT cohort, 37 (8%) had metastases (N1, M0 = 5, M1 = 32) and 305 had locally advanced disease (62%). The median PSA was 17 μg/l. Treatments included radical prostatectomy (RP; n = 54; 11%), radiotherapy (RT; n = 245; 50%), androgen deprivation therapy (ADT; n = 122; 25%), other treatments (n = 11; 2%), and unknown (n = 60; 12%). There were 49 PCa-specific deaths (10%), of whom 14 men had received radical treatment (5%); and 129 all-cause deaths (26%). In matched ProtecT and ACN cohorts, 37 (9%) and 64 (16%), respectively, died of PCa, while 89 (22%) and 103 (26%) died of all causes. ProtecT men had a 45% lower risk of death from PCa compared to matched cases (hazard ratio 0.55, 95% confidence interval 0.38–0.83; p = 0.0037), but mortality was similar in those treated radically. The nonrandomised design is a limitation. Conclusions Men with PSA-detected advanced PCa excluded from ProtecT and treated radically had low rates of PCa death at 7.4-yr follow-up. Among men who underwent nonradical treatment, the ProtecT group had a lower rate of PCa death. Early detection through PSA testing, leadtime bias, and group heterogeneity are possible factors in this finding. Patient summary Prostate cancer that has spread outside the prostate gland without causing symptoms can be detected via prostate-specific antigen testing and treated, leading to low rates of death from this disease.
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Affiliation(s)
| | - Greg L Shaw
- Academic Urology Group, University of Cambridge, Cambridge, UK; Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Cambridge, UK
| | - Alastair D Lamb
- Academic Urology Group, University of Cambridge, Cambridge, UK; Cancer Research UK Cambridge Institute, Li Ka Shing Centre, Cambridge, UK
| | - Deepak Parashar
- Statistics and Epidemiology Unit & Cancer Research Centre, University of Warwick, Coventry, UK
| | - David Greenberg
- National Cancer Registration Service - Eastern Office, Public Health England, Cambridge, UK
| | - Tengbin Xiong
- Academic Urology Group, University of Cambridge, Cambridge, UK
| | | | | | - Peter Holding
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - Michael Davis
- 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
| | - Jon Oxley
- Department of Cellular Pathology, North Bristol NHS Trust, Bristol, UK
| | - Mary Robinson
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
| | - Malcolm Mason
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff, UK
| | - John Staffurth
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff, UK
| | - Prasad Bollina
- Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - James Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Andrew Doble
- Department of Urology, Addenbrooke's Hospital, Cambridge, UK
| | - Alan Doherty
- Department of Urology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Gillatt
- Department of Urology, Southmead Hospital and Bristol Urological Institute, Bristol, UK
| | - Roger Kockelbergh
- Department of Urology, University Hospitals of Leicester, Leicester, UK
| | - Howard Kynaston
- Department of Urology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Steve Prescott
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alan Paul
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Philip Powell
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Derek Rosario
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Edward Rowe
- Department of Urology, Southmead Hospital and Bristol Urological Institute, Bristol, UK
| | - Jenny L Donovan
- 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
- Academic Urology Group, University of Cambridge, Cambridge, UK; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
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Utilization of prostate brachytherapy for low risk prostate cancer: Is the decline overstated? J Contemp Brachytherapy 2016; 8:289-93. [PMID: 27648081 PMCID: PMC5018529 DOI: 10.5114/jcb.2016.61942] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 08/09/2016] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Several prior studies have suggested that brachytherapy utilization has markedly decreased, coinciding with the recent increased utilization of intensity modulated radiation therapy, as well as an increase in urologist-owned centers. We sought to investigate the brachytherapy utilization in a large, hospital-based registry. MATERIAL AND METHODS Men with prostate cancer diagnosed between 2004-2012 and treated with either external beam radiation and/or prostate brachytherapy were abstracted from the National Cancer Database. In order to be included, men had to be clinically staged as T1c-T2aNx-0Mx-0, Gleason 6, PSA ≤ 10.0 ng/ml. Descriptive statistics were used to analyze brachytherapy utilization over time and were compared via χ(2). Multivariate logistic regression was used to assess for covariables associated with increased brachytherapy usage. RESULTS There were 89,413 men included in this study, of which 37,054 (41.6%) received only external beam radiation, and 52,089 (58.4%) received prostate brachytherapy. The use of brachytherapy declined over time from 62.9% in 2004 to 51.3% in 2012 (p < 0.001). This decline was noted in both academic facilities (60.8% in 2004 to 47.0% in 2012, p < 0.001) as well as in non-academic facilities (63.7% in 2004 to 53.0% in 2012, p < 0.001). The decline was more pronounced in patients who lived closer to treatment facilities than those who lived further. The use of intensity modulated radiation therapy increased during this same time period from 18.4% in 2004 to 38.2% in 2012 (p < 0.001). On multivariate analysis, treatment at an academic center, increasing age, decreasing distance from the treatment center, and years of diagnosis from 2006-2012 were significantly associated with reduced brachytherapy usage. CONCLUSIONS In this hospital-based registry, prostate brachytherapy usage has declined for low risk prostate cancer as intensity modulated radiation therapy usage has increased. However, it still remains the treatment of choice for 51.3% of patients as of 2012.
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Gnanapragasam VJ, Lophatananon A, Wright KA, Muir KR, Gavin A, Greenberg DC. Improving Clinical Risk Stratification at Diagnosis in Primary Prostate Cancer: A Prognostic Modelling Study. PLoS Med 2016; 13:e1002063. [PMID: 27483464 PMCID: PMC4970710 DOI: 10.1371/journal.pmed.1002063] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 05/24/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Over 80% of the nearly 1 million men diagnosed with prostate cancer annually worldwide present with localised or locally advanced non-metastatic disease. Risk stratification is the cornerstone for clinical decision making and treatment selection for these men. The most widely applied stratification systems use presenting prostate-specific antigen (PSA) concentration, biopsy Gleason grade, and clinical stage to classify patients as low, intermediate, or high risk. There is, however, significant heterogeneity in outcomes within these standard groupings. The International Society of Urological Pathology (ISUP) has recently adopted a prognosis-based pathological classification that has yet to be included within a risk stratification system. Here we developed and tested a new stratification system based on the number of individual risk factors and incorporating the new ISUP prognostic score. METHODS AND FINDINGS Diagnostic clinicopathological data from 10,139 men with non-metastatic prostate cancer were available for this study from the Public Health England National Cancer Registration Service Eastern Office. This cohort was divided into a training set (n = 6,026; 1,557 total deaths, with 462 from prostate cancer) and a testing set (n = 4,113; 1,053 total deaths, with 327 from prostate cancer). The median follow-up was 6.9 y, and the primary outcome measure was prostate-cancer-specific mortality (PCSM). An external validation cohort (n = 1,706) was also used. Patients were first categorised as low, intermediate, or high risk using the current three-stratum stratification system endorsed by the National Institute for Health and Care Excellence (NICE) guidelines. The variables used to define the groups (PSA concentration, Gleason grading, and clinical stage) were then used to sub-stratify within each risk category by testing the individual and then combined number of risk factors. In addition, we incorporated the new ISUP prognostic score as a discriminator. Using this approach, a new five-stratum risk stratification system was produced, and its prognostic power was compared against the current system, with PCSM as the outcome. The results were analysed using a Cox hazards model, the log-rank test, Kaplan-Meier curves, competing-risks regression, and concordance indices. In the training set, the new risk stratification system identified distinct subgroups with different risks of PCSM in pair-wise comparison (p < 0.0001). Specifically, the new classification identified a very low-risk group (Group 1), a subgroup of intermediate-risk cancers with a low PCSM risk (Group 2, hazard ratio [HR] 1.62 [95% CI 0.96-2.75]), and a subgroup of intermediate-risk cancers with an increased PCSM risk (Group 3, HR 3.35 [95% CI 2.04-5.49]) (p < 0.0001). High-risk cancers were also sub-classified by the new system into subgroups with lower and higher PCSM risk: Group 4 (HR 5.03 [95% CI 3.25-7.80]) and Group 5 (HR 17.28 [95% CI 11.2-26.67]) (p < 0.0001), respectively. These results were recapitulated in the testing set and remained robust after inclusion of competing risks. In comparison to the current risk stratification system, the new system demonstrated improved prognostic performance, with a concordance index of 0.75 (95% CI 0.72-0.77) versus 0.69 (95% CI 0.66-0.71) (p < 0.0001). In an external cohort, the new system achieved a concordance index of 0.79 (95% CI 0.75-0.84) for predicting PCSM versus 0.66 (95% CI 0.63-0.69) (p < 0.0001) for the current NICE risk stratification system. The main limitations of the study were that it was registry based and that follow-up was relatively short. CONCLUSIONS A novel and simple five-stratum risk stratification system outperforms the standard three-stratum risk stratification system in predicting the risk of PCSM at diagnosis in men with primary non-metastatic prostate cancer, even when accounting for competing risks. This model also allows delineation of new clinically relevant subgroups of men who might potentially receive more appropriate therapy for their disease. Future research will seek to validate our results in external datasets and will explore the value of including additional variables in the system in order in improve prognostic performance.
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Affiliation(s)
- Vincent J. Gnanapragasam
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, United Kingdom
- * E-mail:
| | - Artitaya Lophatananon
- Institute of Population Health, University of Manchester, Manchester, United Kingdom
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Karen A. Wright
- National Cancer Registration Service Eastern Office, Public Health England, Cambridge, United Kingdom
| | - Kenneth R. Muir
- Institute of Population Health, University of Manchester, Manchester, United Kingdom
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Anna Gavin
- Northern Ireland Cancer Registry, Centre for Public Health, Queen’s University Belfast, Belfast, United Kingdom
| | - David C. Greenberg
- National Cancer Registration Service Eastern Office, Public Health England, Cambridge, United Kingdom
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Thomas C, Giesswein A, Hainz M, Stein R, Rubenwolf P, Roos FC, Neisius A, Nestler S, Hampel C, Jäger W, Wiesner C, Thüroff JW. Concomitant Gleason Score ≥7 prostate cancer is an independent prognosticator for poor survival in nonmetastatic bladder cancer patients undergoing radical cystoprostatectomy. Int Urol Nephrol 2015; 47:1789-96. [DOI: 10.1007/s11255-015-1110-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 09/05/2015] [Indexed: 12/16/2022]
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Narita S, Mitsuzuka K, Tsuchiya N, Koie T, Kawamura S, Ohyama C, Tochigi T, Yamaguchi T, Arai Y, Habuchi T. Reassessment of the risk factors for biochemical recurrence in D'Amico intermediate-risk prostate cancer treated using radical prostatectomy. Int J Urol 2015; 22:1029-35. [DOI: 10.1111/iju.12898] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/12/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Shintaro Narita
- Department of Urology; Akita University Graduate School of Medicine; Akita Japan
| | - Koji Mitsuzuka
- Department of Urology; Tohoku University Graduate School of Medicine; Sendai Japan
| | - Norihiko Tsuchiya
- Department of Urology; Akita University Graduate School of Medicine; Akita Japan
| | - Takuya Koie
- Department of Urology; Hirosaki University Graduate School of Medicine; Hirosaki Japan
| | | | - Chikara Ohyama
- Department of Urology; Hirosaki University Graduate School of Medicine; Hirosaki Japan
| | - Tatsuo Tochigi
- Department of Urology; Miyagi Cancer Center; Natori Japan
| | - Takuhiro Yamaguchi
- Department of Medical Sciences and Biostatistics; Tohoku University Graduate School of Medicine; Sendai Japan
| | - Yoichi Arai
- Department of Urology; Tohoku University Graduate School of Medicine; Sendai Japan
| | - Tomonori Habuchi
- Department of Urology; Akita University Graduate School of Medicine; Akita Japan
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24
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McLaren DB, Kerr G, Law AB, Brush JP, Keanie J, Malik J, Keough W, Ronaldson T, Lee J, Kehoe T. The Importance of Prostate-specific Antigen (PSA) Nadir and Early Identification of PSA Relapse after 10 Years of Prostate Iodine 125 Seed Brachytherapy in Edinburgh. Clin Oncol (R Coll Radiol) 2015; 27:519-26. [PMID: 26093507 DOI: 10.1016/j.clon.2015.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 04/10/2015] [Accepted: 05/12/2015] [Indexed: 11/26/2022]
Abstract
AIMS To analyse our 5 and 10 year prostate brachytherapy outcome data and to assess the impact of PSA nadir on relapse free survival and whether an alternative definition of PSA relapse could detect men destined to fail by the Phoenix definition at an earlier time point. MATERIALS AND METHODS 474 men were treated over a 10 year period between 20012 and 2011 and divided into 2 five year cohorts for the purpose of the analysis. RESULTS The risk of relapse is strongly predicted by post treat prostate-specific antigen (PSA) nadir. After 3 years post-treatment, PSA nadir plus 0.4 ng/ml identified men at risk of relapse 17 months earlier than the Phoenix definition. CONCLUSION The Phoenix definition of nadir plus 2.0 ng/ml does not allow the early identification of men destined to relapse. The initiation of salavage therapy at the earliest opportunity could potentially affect subsequent survival and an outline randomised controlled trial proposal is presented.
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Affiliation(s)
| | - G Kerr
- Edinburgh Cancer Centre, Edinburgh, UK
| | - A B Law
- Edinburgh Cancer Centre, Edinburgh, UK
| | - J P Brush
- Western General Hospital, Edinburgh, UK
| | - J Keanie
- Western General Hospital, Edinburgh, UK
| | - J Malik
- Edinburgh Cancer Centre, Edinburgh, UK
| | - W Keough
- Edinburgh Cancer Centre, Edinburgh, UK
| | | | - J Lee
- Edinburgh Cancer Centre, Edinburgh, UK
| | - T Kehoe
- Edinburgh Cancer Centre, Edinburgh, UK
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25
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Verma R, Treasure P, Hughes R. Development and evaluation of radiographer led telephone follow up following radical radiotherapy to the prostate. A report of a Macmillan Cancer Support Sponsored Pilot project at Mount Vernon Hospital. Radiography (Lond) 2015. [DOI: 10.1016/j.radi.2014.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Lu W, Du S, Wang J. Berberine inhibits the proliferation of prostate cancer cells and induces G₀/G₁ or G₂/M phase arrest at different concentrations. Mol Med Rep 2014; 11:3920-4. [PMID: 25572870 DOI: 10.3892/mmr.2014.3139] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 09/19/2014] [Indexed: 11/05/2022] Open
Abstract
Prostate cancer is the second most common disease of the male reproductive system. Berberine is a quaternary ammonium salt that is extracted from plants. The aim of the current study was to explore the antitumor activity of berberine in prostate cancer cells and identify the underlying mechanism of its effects. PC3 human and RM‑1 mouse prostate cancer cells were treated with increasing concentrations of berberine, followed by analysis of the cell viability with an MTT assay. The results demonstrated that berberine markedly inhibited the proliferation of PC3 and RM‑1 cells, and that the inhibitory effects to PC3 and RM‑1 were enhanced in a concentration‑ and time‑dependent manner. Flow cytometry was used to analyze the cell cycle of PC3 human prostate cancer cells, and the results demonstrated that G0/G1 phase arrest was induced following treatment with 10 µM berberine (P<0.05). However, with an increased concentration of berberine (50 µM) the survival rate of PC3 cells at the G2/M phase was significantly increased compared with the cells treated with 10 µM berberine, which suggests that different cell cycle signaling pathways were activated when PC3 cells were treated with low and high concentrations of berberine. Thus, clarifying the mechanism underlying these effects in prostate cancer may provide novel molecular targets for prostate cancer therapy.
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Affiliation(s)
- Wei Lu
- Department of Urology, Jilin Province People's Hospital, Changchun, Jilin 130021, P.R. China
| | - Shanshan Du
- Department of Urology, Jilin Province People's Hospital, Changchun, Jilin 130021, P.R. China
| | - Jiaqiang Wang
- Department of Urology, Jilin Province People's Hospital, Changchun, Jilin 130021, P.R. China
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27
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Gnanapragasam VJ, Payne H, Syndikus I, Kynaston H, Johnstone T. Primary radical therapy selection in high-risk non-metastatic prostate cancer. Clin Oncol (R Coll Radiol) 2014; 27:136-44. [PMID: 25441052 DOI: 10.1016/j.clon.2014.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/02/2014] [Accepted: 10/07/2014] [Indexed: 10/24/2022]
Abstract
As the incidence of prostate cancer rises, the detection and management of men with high-risk non-metastatic prostate cancer is becoming increasingly important. The benefits of radical treatment have been clearly shown in this group from a number of publications. The current mainstays of treatment are radical prostatectomy (with selective use of adjuvant radiation) and radical radiotherapy with concurrent androgen deprivation. The outcomes from these two approaches seem to be remarkably similar and are considered equally valid options for primary treatment. The choice of therapy is critically dependent on a number of factors, but ultimately left to the decision of the patients with advice from clinicians. Clinicians themselves, however, are known to be biased towards their particular skill set and experiences. Attempts at randomised comparisons between these two modalities have so far failed and are confounded by patient-clinician bias, the continual advances in therapy as well as the long natural history of the disease. In the lack of level 1 comparable evidence, this article explores the existing literature as to the key factors that should be considered in radical treatment selection for high-risk prostate cancer. These factors include disease aggressiveness, comorbidity and life expectancy, functional outcomes and the consequences of therapy failure with regards to salvage treatment. We propose that these factors may be useful in developing a decision guide for rationale radical therapy selection in the light of two apparently equally effective treatments. Ultimately, however, there is an urgent need for added clinical and biological markers that can provide a more precise approach to therapy selection.
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Affiliation(s)
- V J Gnanapragasam
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK; Translational Prostate Cancer Group, Hutchison/MRC Research Centre, University of Cambridge, Cambridge, UK.
| | - H Payne
- Department of Oncology, University College London, London, UK
| | | | - H Kynaston
- Department of Urology, University Hospital of Wales, Cardiff, UK
| | - T Johnstone
- Academic Urology Group, Department of Surgery, University of Cambridge, Cambridge, UK
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28
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O’Kelly F, McGuire BB, Flynn RJ, Grainger R, McDermott TED, Thornhill JA. The clinic-pathological characteristics of prostate cancer in an Irish subpopulation with a serum PSA less than 4.0ng/ml. JOURNAL OF CLINICAL UROLOGY 2014. [DOI: 10.1177/2051415814530290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Prostate specific antigen (PSA) has been used as a biomarker for prostate cancer for the last 20 years. Traditionally, a serum PSA <4 ng/ml has been used as a general cut-off between normal and abnormal readings. There is evidence to demonstrate that men with a normal serum PSA can develop prostate cancer. The aim of this study was to investigate the clinico-pathological features of prostate cancer in a non-screened Irish cohort with serum PSA <4 ng/ml. Methods: A retrospective analysis was performed of all patients who underwent radical retropubic prostatectomy (RRP) in a tertiary referral unit over a 10-year period (2000–2010). Clinico-pathological characteristics were collated including those from trans-rectal ultrasound-guided (TRUS) prostate biopsies and radical prostatectomy specimens. Results: Between 2000 and 2010, 651 men underwent an RRP, with 43 (6.6%) having a serum PSA <4 ng/ml. The median PSA was 3.2 ng/ml (range 0.8–4.0). Nineteen (44.2%) had palpable disease on direct rectal examination (DRE). Following prostatectomy, 28 (65.12%) had Gleason 6 disease, 14 (32.56%) had Gleason 7 disease and one (2.32%) had Gleason 8 disease. Five (11.63%) patients were upgraded from TRUS biopsy to final histopathology. Six (13.95%) patients had pathological evidence of extracapsular extension on final pathology. Three (6.98%) patients experienced biochemical recurrence and received salvage radiation therapy after a median time of 24 months. The median follow-up was 106 months (range 36–158). Twenty (46.51%) patients had a first-degree family history of prostate cancer. Conclusions: A PSA cut-off of 4 ng/ml has commonly been used in the detection of prostate cancer. Our study emphasizes that this cut-off is inappropriate and that no specific level of PSA can be used. Management decisions need to be individualized based on index of suspicion with concomitant counselling and rectal examination.
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Affiliation(s)
- F O’Kelly
- Department of Urological Surgery, Tallaght Hospital, Dublin, Ireland
| | - BB McGuire
- Department of Urological Surgery, Tallaght Hospital, Dublin, Ireland
| | - RJ Flynn
- Department of Urological Surgery, Tallaght Hospital, Dublin, Ireland
| | - R Grainger
- Department of Urological Surgery, Tallaght Hospital, Dublin, Ireland
| | - TED McDermott
- Department of Urological Surgery, Tallaght Hospital, Dublin, Ireland
| | - JA Thornhill
- Department of Urological Surgery, Tallaght Hospital, Dublin, Ireland
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29
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Lane JA, Donovan JL, Davis M, Walsh E, Dedman D, Down L, Turner EL, Mason MD, Metcalfe C, Peters TJ, Martin RM, Neal DE, Hamdy FC. Active monitoring, radical prostatectomy, or radiotherapy for localised prostate cancer: study design and diagnostic and baseline results of the ProtecT randomised phase 3 trial. Lancet Oncol 2014; 15:1109-18. [PMID: 25163905 DOI: 10.1016/s1470-2045(14)70361-4] [Citation(s) in RCA: 163] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Prostate cancer is a major public health problem with considerable uncertainties about the effectiveness of population screening and treatment options. We report the study design, participant sociodemographic and clinical characteristics, and the initial results of the testing and diagnostic phase of the Prostate testing for cancer and Treatment (ProtecT) trial, which aims to investigate the effectiveness of treatments for localised prostate cancer. METHODS In this randomised phase 3 trial, men aged 50-69 years registered at 337 primary care centres in nine UK cities were invited to attend a specialist nurse appointment for a serum prostate-specific antigen (PSA) test. Prostate biopsies were offered to men with a PSA concentration of 3·0 μg/L or higher. Consenting participants with clinically localised prostate cancer were randomly assigned to active monitoring (surveillance strategy), radical prostatectomy, or three-dimensional conformal external-beam radiotherapy by a computer-generated allocation system. Randomisation was stratified by site (minimised for differences in participant age, PSA results, and Gleason score). The primary endpoint is prostate cancer mortality at a median 10-year follow-up, ascertained by an independent committee, which will be analysed by intention to treat in 2016. This trial is registered with ClinicalTrials.gov, number NCT02044172, and as an International Standard Randomised Controlled Trial, number ISRCTN20141297. FINDINGS Between Oct 1, 2001, and Jan 20, 2009, 228,966 men were invited to attend an appointment with a specialist nurse. Of the invited men, 100,444 (44%) attended their initial appointment and 82,429 (82%) of attenders had a PSA test. PSA concentration was below the biopsy threshold in 73,538 (89%) men. Of the 8566 men with a PSA concentration of 3·0-19·9 μg/L, 7414 (87%) underwent biopsies. 2896 men were diagnosed with prostate cancer (4% of tested men and 39% of those who had a biopsy), of whom 2417 (83%) had clinically localised disease (mostly T1c, Gleason score 6). With the addition of 247 pilot study participants recruited between 1999 and 2001, 2664 men were eligible for the treatment trial and 1643 (62%) agreed to be randomly assigned (545 to active monitoring, 545 to radiotherapy, and 553 to radical prostatectomy). Clinical and sociodemographic characteristics of randomly assigned participants were balanced across treatment groups. INTERPRETATION The ProtecT trial randomly assigned 1643 men with localised prostate cancer to active monitoring, radiotherapy, or surgery. Participant clinicopathological features are more consistent with contemporary patient characteristics than in previous prostate cancer treatment trials. FUNDING UK National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
| | | | | | | | | | - Liz Down
- University of Bristol, Bristol, UK
| | | | | | | | | | | | - David E Neal
- Cambridge University and Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
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