Trends in the curative treatment of localized prostate cancer after the introduction of prostate-specific antigen: data from the Rotterdam Cancer Registry

Treatment of local-regional prostate cancer detected by PSA screening: benefits and harms according to prognostic factors

Background:

Men with screen-detected prostate cancer can choose to undergo immediate curative treatment or enter into an expectant management programme. We quantified how the benefits and harms of immediate treatment vary according to the prognostic factors of clinical T-stage, Gleason score, and patient age.

Methods:

A microsimulation model based on European Randomized Study of Screening for Prostate Cancer data was used to predict the benefits and harms of immediate treatment versus delayed treatment of local–regional prostate cancer in men aged 55–74 years. Benefits included life-years gained and reduced probability of death from prostate cancer. Harms included lead time and probability of overdiagnosis.

Results:

The ratio of mean lead time to mean life-years gained ranged from 1.8 to 31.2, and the additional number of treatments required per prostate cancer death prevented ranged from 0.3 to 11.6 across the different prognostic groups. Both harm–benefit ratios were lowest, most favourable, for men aged 55–59 years and diagnosed with moderate-risk prostate cancer. Ratios were high for men aged 70–74 years regardless of clinical T-stage and Gleason score.

Conclusion:

Men aged 55–59 years with moderate-risk prostate cancer are predicted to derive greatest benefit from immediate curative treatment. Immediate treatment is least favourable for men aged 70–74 years with either low-risk or high-risk prostate cancer.

To be screened or not to be screened? Modeling the consequences of PSA screening for the individual

Background:

Screening with prostate-specific antigen (PSA) can reduce prostate cancer mortality, but may advance diagnosis and treatment in time and lead to overdetection and overtreatment. We estimated benefits and adverse effects of PSA screening for individuals who are deciding whether or not to be screened.

Methods:

Using a microsimulation model, we estimated lifetime probabilities of prostate cancer diagnosis and death, overall life expectancy and expected time to diagnosis, both with and without screening. We calculated anticipated loss in quality of life due to prostate cancer diagnosis and treatment that would be acceptable to decide in favour of screening.

Results:

Men who were screened had a gain in life expectancy of 0.08 years but their expected time to diagnosis decreased by 1.53 life-years. Of the screened men, 0.99% gained on average 8.08 life-years and for 17.43% expected time to diagnosis decreased by 8.78 life-years. These figures imply that the anticipated loss in quality of life owing to diagnosis and treatment should not exceed 4.8%, for screening to have a positive effect on quality-adjusted life expectancy.

Conclusion:

The decision to be screened should depend on personal preferences. The negative impact of screening might be reduced by screening men who are more willing to accept the side effects from treatment.

Cancer detection and cancer characteristics in the European Randomized Study of Screening for Prostate Cancer (ERSPC)--Section Rotterdam. A comparison of two rounds of screening

OBJECTIVES

To evaluate the features, rates, and characteristics of prostate cancer detected during two subsequent screening rounds.

METHODS

Data were retrieved from the database of European Randomized Study of Screening for Prostate Cancer (ERSPC), section Rotterdam. Men, ages 55-74 yr were screened with a 4-yr interval. Different biopsy indications were used in the first and second screens in the PSA range <4.0 ng/ml. Clinical features and a total of 1548 sextant biopsies were recorded for Gleason score and tumour extent, and 550 radical prostatectomy specimens were evaluated for Gleason score, pathologic T category, and tumour volume.

RESULTS

Clinical stage, Gleason score, involvement of biopsy by tumour, and PSA levels were more favourable in patients of the second round compared with those of the first round. The number of men chosen for watchful waiting increased from 98 (10%) to 123 (22%) in the second round (p<0.0001). In patients undergoing radical prostatectomy, median tumour volume in the first and second screening round was 0.65 and 0.45 ml (p=0.001). Minimal cancer (cancer <0.5 ml, organ-confined, no Gleason pattern 4 or 5) was found in 122 (31.6%) in the first and 60 (42.6%) in the second screening round (p=0.03). The 5-yr PSA progression-free survival after radical prostatectomy was 87%.

CONCLUSIONS

Despite the 4-yr interval an important shift of all prognostic factors occurred in favour of round 2. In those men who underwent radical prostatectomy, 42.6% fulfilled the criteria of minimal cancer. These data suggest that overdiagnosis increases with repeat screening.

Gleason score, age and screening: modeling dedifferentiation in prostate cancer

Tumor differentiation as measured by the Gleason score is highly predictive of the course of prostatic cancer after diagnosis. Since the introduction of the prostate-specific antigen (PSA) test tumors are diagnosed with a favorable tumor stage and differentiation grade. Does screening with PSA just detect more tumors with favorable characteristics or is dedifferentiation actually being prevented by early detection and consequent treatment? The latter option implies that tumors dedifferentiate in the preclinical screen-detectable phase. To model the natural history of prostate cancer, we analyzed the age-specific distribution of clinical stage and Gleason score of 2,204 tumors diagnosed in the ERSPC-Rotterdam trial. We fitted 2 MISCAN simulation models to the observed data: Model I where tumors dedifferentiate before becoming screen-detectable and Model II where dedifferentiation occurs during the screen-detectable preclinical phase. The hypothesis of dedifferentiation during the screen-detectable phase was tested by a goodness of fit test of both models. In ERSPC-Rotterdam, we observed a significantly more favorable distribution of Gleason scores in screen-detected cancers compared to cancers found in the control arm, and in cancers detected in the second round compared to cancers detected in the first round of screening. Also, a significant association between Gleason score and age at diagnosis was found, most notably in cancers detected in the first round of screening. These findings were reproduced by Model II and less so by Model I, with a significant difference in goodness of fit between the 2 models (p < 0.001). This study provides epidemiological evidence of dedifferentiation as a major mechanism of progression in prostate cancer. Tumors dedifferentiate during the screen-detectable phase and consequently screening with PSA and early treatment can possibly prevent dedifferentiation.

The role of whole pelvic radiotherapy in locally advanced prostate cancer

Routine PSA testing has led to diagnosis and treatment of prostate cancer at earlier stages than previously. Earlier and technically-improved treatment, together with escalation of dose has enhanced cure rates. Although, the incidence of nodal metastases is now lower than in pre-PSA days, more extended pelvic lymphadenectomies have shown the actual rate of lymph node involvement to be higher than had been determined from standard radical prostate surgery. As in cancers in other sites, especially in their earlier stages, lymph node metastases may exist in the absence of haematogenous dissemination. This, together with the improved rates of control of the primary prostate tumour, suggests that elective irradiation of early-stage lymph nodes from prostate cancer should enhance survival in a manner analogous to improvements seen with this approach in other cancers. Although, the absolute incidence of positive nodes in locally advanced prostate cancer warrants elective radiotherapy, it is relatively low and the modest improvements to be expected may be undetected in the results of a small trial.

Situación epidemiológica del cáncer de próstata en España

Prostate cancer is the third most frequent neoplasms in Spanish men and the third cause of cancer death. Incidence grows up with the increase of age. 90% of cases are diagnostic in people over 65 years old. Etiology is quite unknown and has been associated with environmental exposure, life style, family sign and genetic factors. In 2002 mortality rate was 21.5/ 100.000 (situated among the lowest in Europe), with more than 5.000 deaths. Trend of mortality has grown up until 1998, from this year it has decreased due to improve on diagnostic and treatment. In order to study prostate cancer incidence we find a difficulty due to shortage of population cancer register. Estimations have found incidence rates of 45.33/100.000 which are among the lowest in Europe. Annual incidence of prostatic cancer has grown up in all Spanish registers, not only improve in register systems explains it, but also the development of diagnosis tests with a higher survival from the beginning of 90s (86% the first year after diagnosis and 65,5% five years after diagnosis), similar to other European countries. Blow up the cancer register system is necessary to know the incidence and prevalence, to assess survival and effectiveness of screening programs and to improve the knowledge of risk factors.

Intention to test for prostate cancer

The aim of this study was to assess intention among men to take a prostate-specific antigen (PSA) test, when this test was: (i) offered by a doctor or (ii) based on the men's own initiative. A further aim was to use the Theory of Planned Behaviour (TPB) to predict the most important determinants for taking a PSA test. In addition, the intention to take a PSA test among men who had the opportunity to read a PSA leaflet published by the Swedish Cancer Society was compared with men who had not read the leaflet. A total of 1000 men, age range 40-70 years, were selected randomly from a population database. The TPB model was used to measure attitudes about PSA testing. The constructed questionnaire was posted to the selected sample. Half of the sample received only the TPB questionnaire and the other half also received a PSA leaflet. The response rate was approximately 63%. The results showed that men would be less likely to request a PSA test if their doctor did not suggest the test (mean approximately 3.8 (range 1-7 from not likely to very likely)). However, if they were offered the test, most would take it (mean approximately 6.0 (range 1-7)). The positive "Attitude factor" towards the test was the most salient predictor of both behaviours. In addition, the probability of requesting a test was higher among those who had already taken a PSA test. The men who did not receive the PSA leaflet reported a higher intention to take the test than those who had received it. Overall, 47% of the variance was explained concerning men's intention to take a PSA test when offered by a doctor and 25% of men's intention to request the PSA test themselves. In conclusion, the majority of men in this study had a positive attitude towards PSA testing. The results indicate that most men could be expected to accept screening. The intention to take the PSA test was lower among the men who had received the PSA leaflet.

Decreasing mortality rates for prostate cancer: possible role of hormonal therapy?

Within the last decade prostate cancer mortality rates have started to decrease in some countries. Although it is tempting to assume that these trends are a result of earlier diagnosis and aggressive therapeutic intervention, as a consequence of prostate-specific antigen screening, definitive results from randomized trials of screening will not be available for several years. Moreover, there is mounting evidence that the effects of screening cannot be entirely responsible for this reduction in mortality rates. This review explores the possibility that other factors, particularly the increased uptake of early hormonal therapy, are contributing to the observed changes in mortality.

Lead times and overdetection due to prostate-specific antigen screening: estimates from the European Randomized Study of Screening for Prostate Cancer

BACKGROUND

Screening for prostate cancer advances the time of diagnosis (lead time) and detects cancers that would not have been diagnosed in the absence of screening (overdetection). Both consequences have considerable impact on the net benefits of screening.

METHODS

We developed simulation models based on results of the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer (ERSPC), which enrolled 42,376 men and in which 1498 cases of prostate cancer were identified, and on baseline prostate cancer incidence and stage distribution data. The models were used to predict mean lead times, overdetection rates, and ranges (corresponding to approximate 95% confidence intervals) associated with different screening programs.

RESULTS

Mean lead times and rates of overdetection depended on a man's age at screening. For a single screening test at age 55, the estimated mean lead time was 12.3 years (range = 11.6-14.1 years) and the overdetection rate was 27% (range = 24%-37%); at age 75, the estimates were 6.0 years (range = 5.8-6.3 years) and 56% (range = 53%-61%), respectively. For a screening program with a 4-year screening interval from age 55 to 67, the estimated mean lead time was 11.2 years (range = 10.8-12.1 years), and the overdetection rate was 48% (range = 44%-55%). This screening program raised the lifetime risk of a prostate cancer diagnosis from 6.4% to 10.6%, a relative increase of 65% (range = 56%-87%). In annual screening from age 55 to 67, the estimated overdetection rate was 50% (range = 46%-57%) and the lifetime prostate cancer risk was increased by 80% (range = 69%-116%). Extending annual or quadrennial screening to the age of 75 would result in at least two cases of overdetection for every clinically relevant cancer detected.

CONCLUSIONS

These model-based lead-time estimates support a prostate cancer screening interval of more than 1 year.

[The prostate cancer in the community of Madrid in 2000. II Presentation and diagnosis]

OBJECTIVE

To know the presentation form, diagnostic method and clinical stage at the time of diagnosis in subjects with prostate cancer (PC) in the Autonomous Community of Madrid in 2000.

MATERIAL AND METHOD

Data from 1745 patients with histologically confirmed prostate cancer obtained from 15 Hospitals participating in the study was analysed. The variables studied were: associated disease, reason for visiting the hospital, digital rectal examination (DRE), PSA, diagnostic method, graded Gleason score, tests performed in the tumoral extension study and tumour staging. The qualitative variables are given in percentages of the overall number and the quantitative variables are expressed as the median, standard deviation, maximum and minimum values and 25%, 50% (median) and 75% percentiles.

RESULTS

67% cases had an associated disease. In most (75%) patients the reason for visiting the hospital was prostatic syndrome. DRE revealed that 42.7% has no tumour. At the time of diagnosis half the patients had PSA levels lower than or equal to 11 ng/ml. Transrectal ultrasound-guided biopsy was used for diagnosis in 93% subjects. The most commonly reported Gleason scores were 6 (31.3%) and 7 (28.7%). In 75% subjects the disease was considered to be clinically limited to the prostate, in 12.5% locally advanced and in 12.5% metastatic.

CONCLUSIONS

Most patients came to the hospital because of symptoms not related to PC. Transrectal ultrasound-guided biopsy is confirmed as the choice technique for PC diagnosis. When a comparison is made to historical series in our Autonomous Community a pattern of earlier diagnosis can be seen.

[The prostate cancer in the community of Madrid in 2000 I.- Incidence]

OBJECTIVE

To know the incidence in the year 2000 of prostate cancer in the Autonomous Community of Madrid and its breakdown by Health Areas.

MATERIAL AND METHOD

Study of histologically confirmed prostate cancer case reports and retrospective data acquisition for 2000 in the Autonomous Community of Madrid, both from Public and Private Health Care hospitals.

RESULTS

Gross incidence of prostate cancer in the Autonomous Community of Madrid was 100.4 cases per 100,000 males. The incidence adjusted for the Spanish, European and Worldwide population was 120.1, 103.5 and 68.6 cases per 100,000 males, respectively. Mean age at diagnosis was 70 +/- 7.8 (40-94) years, median of 70 years. The age group with higher incidence was 70 to 79 years.

CONCLUSIONS

The incidence of prostate cancer in the Autonomous Community of Madrid is lower than that in the US but higher than in most countries or regions in the EU. The different way of using PSA testing in the Health Areas of the Autonomous Community may explain the differences seen in terms of incidence by Area.

Health-related quality-of-life effects of radical prostatectomy and primary radiotherapy for screen-detected or clinically diagnosed localized prostate cancer

PURPOSE

The current study was undertaken within the framework of a screening trial to compare the health-related quality-of-life (HRQOL) outcomes of two primary treatment modalities for localized prostate cancer: radical prostatectomy and external-beam radiotherapy.

PATIENTS AND METHODS

We conducted a prospective longitudinal cohort study among 278 patients with early screen-detected (59%) or clinically diagnosed (41%) prostate cancer using both generic and disease-specific HRQOL measures (SF-36, UCLA Prostate Cancer Index [urinary and bowel modules] and items relating to sexual functioning) at three points in time: t1 (baseline), t2 (6 months later), and t3 (12 months after t1).

RESULTS

Questionnaires were completed by 88% to 93% of all initially enrolled patients. Patients referred for primary radiotherapy were significantly older than prostatectomy patients (63 v 68 years, P <.01). Analyses (adjusted for age and pretreatment level of functioning) revealed poorer levels of generic HRQOL after radiotherapy. Prostatectomy patients reported significantly higher (P <.01) posttreatment incidences of urinary incontinence (39% to 49%) and erectile dysfunction (80% to 91%) than radiotherapy patients (respectively, 6% to 7% and 41% to 55%). Bowel problems (urgency) affected 30% to 35% of the radiotherapy group versus 6% to 7% of the prostatectomy group (P <.01). Patients with screen-detected and clinically diagnosed cancer reported similar posttreatment HRQOL.

CONCLUSION

Prostatectomy and radiotherapy differed in the type of HRQOL impairment. Because the HRQOL effects may be valued differently at the individual level, patients should be made fully aware of the potential benefits and adverse consequences of therapies for early prostate cancer. Differences in posttreatment HRQOL were not related to the method of cancer detection.