Reduction of prostate cancer mortality in Tyrol, Austria, after introduction of prostate-specific antigen testing

Prostate cancer mortality in Brazil 1990-2019: geographical distribution and trends

INTRODUCTION:

To analyze the trend of prostate cancer mortality in the Brazilian population of 40 years of age and above.

METHODS:

Time series ecological study of the mortality rates due to prostate cancer in men of 40 years of age and above, using data from the Global Burden of Disease 2019 (GBD). Age-standardized mortality rates were calculated, as well as the age-standardized rates by the GBD for the global population, per 100,000 inhabitants, for Brazil and its States, from 1990 to 2019. The annual average percent change (AAPC) was calculated to identify the mortality trends in Brazil, through linear regression using the Joinpoint Regression Program.

RESULTS:

The standardized rates of prostate cancer mortality in Brazil were 76.89 in 1990 and 74.96 deaths for every 100 thousand men ≥ 40 years of age in 2019, with a stability trend. By age group, it was observed a decreasing trend up to 79 years of age, and an increasing trend as of 80 years of age. The state of Bahia showed the highest increase in mortality in the period (1.2%/year), followed by Maranhão and Pernambuco (1.0 and 0.9%/year). A decrease of prostate cancer mortality was found in the Federal District, Goiás, Minas Gerais, Rio de Janeiro, Rio Grande do Sul, Roraima, Santa Catarina, São Paulo, and Sergipe.

CONCLUSIONS:

In Brazil, the standardized mortality rates show a trend toward stability from 1990 to 2019 and no pattern was observed for the trends according to the Brazilian States.

Benefits and harms of prostate cancer screening - predictions of the ONCOTYROL prostate cancer outcome and policy model

Background

A recent recalibration of the ONCOTYROL Prostate Cancer Outcome and Policy (PCOP) Model, assuming that latent prostate cancer (PCa) detectable at autopsy might be detectable by screening as well, resulted in considerable worsening of the benefit-harm balance of screening. In this study, we used the recalibrated model to assess the effects of familial risk, quality of life (QoL) preferences, age, and active surveillance.

Methods

Men with average and elevated familial PCa risk were simulated in separate models, differing in familial risk parameters. Familial risk was assumed to affect PCa onset and progression simultaneously in the base-case, and separately in scenario analyses. Evaluated screening strategies included one-time screening at different ages, and screening at different intervals and age ranges. Optimal screening strategies were identified depending on age and individual QoL preferences. Strategies were additionally evaluated with active surveillance by biennial re-biopsy delaying treatment of localized cancer until grade progression to Gleason score ≥ 7.

Results

Screening men with average PCa risk reduced quality-adjusted life expectancy (QALE) even under favorable assumptions. Men with elevated familial risk, depending on age and disutilities, gained QALE. While for men with familial risk aged 55 and 60 years annual screening to age 69 was the optimal strategy over most disutility ranges, no screening was the preferred option for 65 year-old men with average and above disutilities.

Active surveillance greatly reduced overtreatment, but QALE gains by averted adverse events were opposed by losses due to delayed treatment and additional biopsies. The effect of active surveillance on the benefit-harm balance of screening differed between populations, as net losses and gains in QALE predicted for screening without active surveillance in men with average and familial PCa risk, respectively, were both reduced.

Conclusions

Assumptions about PCa risk and screen-detectable prevalence significantly affect the benefit-harm balance of screening. Based on the assumptions of our model, PCa screening should focus on candidates with familial predisposition with consideration of individual QoL preferences and age. Active surveillance may require treatment initiation before Gleason score progression to 7. Alternative active surveillance strategies should be evaluated in further modeling studies.

The ONCOTYROL Prostate Cancer Outcome and Policy Model: Effect of Prevalence Assumptions on the Benefit-Harm Balance of Screening

BACKGROUND

The ONCOTYROL Prostate Cancer Outcome and Policy (PCOP) model is a state-transition microsimulation model evaluating the benefits and harms of prostate cancer (PCa) screening. The natural history and detection component of the original model was based on the 2003 version of the Erasmus MIcrosimulation SCreening ANalysis (MISCAN) model, which was not calibrated to prevalence data. Compared with data from autopsy studies, prevalence of latent PCa assumed by the original model is low, which may bias the model toward screening. Our objective was to recalibrate the original model to match prevalence data from autopsy studies as well and compare benefit-harm predictions of the 2 model versions differing in prevalence.

METHODS

For recalibration, we reprogrammed the natural history and detection component of the PCOP model as a deterministic Markov state-transition cohort model in the statistical software package R. All parameters were implemented as variables or time-dependent functions and calibrated simultaneously in a single run. Observed data used as calibration targets included data from autopsy studies, cancer registries, and the European Randomized Study of Screening for Prostate Cancer. Compared models were identical except for calibrated parameters.

RESULTS

We calibrated 46 parameters. Prevalence from autopsy studies could not be fitted using the original parameter set. Additional parameters, allowing for interruption of disease progression and age-dependent screening sensitivities, were needed. Recalibration to higher prevalence demonstrated a considerable increase of overdiagnosis and decline of screening sensitivity, which significantly worsened the benefit-harm balance of screening.

CONCLUSIONS

Our calibration suggests that not all cancers are at risk of progression, and screening sensitivity may be lower at older ages. PCa screening models that use calibration to simulate disease progression in the unobservable latent phase are highly sensitive to prevalence assumptions.

Proteomics analysis of urine reveals acute phase response proteins as candidate diagnostic biomarkers for prostate cancer

Despite the overall success of prostate specific antigen (PSA) in screening and detection of prostate cancer (PCa), its use has been limited due to the lack of specificity. The principal driving goal currently within PCa research is to identify non-invasive biomarker(s) for early detection of aggressive tumors with greater sensitivity and specificity than PSA. In this study, we focused on identification of non-invasive biomarkers in urine with higher specificity than PSA. We tested urine samples from PCa and benign prostatic hyperplasia (BPH) patients by 2-D DIGE coupled with MS and bioinformatics analysis. Statistically significant (p < 0.05), 1.8 fold variation or more in abundance, showed 41 spots, corresponding to 23 proteins. The Ingenuity Pathway Analysis showed significant association with the Acute Phase Response Signaling pathway. Nine proteins with differential abundances were included in this pathway: AMBP, APOA1, FGA, FGG, HP, ITIH4, SERPINA1, TF and TTR. The expression pattern of 4 acute phase response proteins differed from the defined expression in the canonical pathway. The urine levels of TF, AMPB and HP were measured by immunoturbidimetry in an independent validation set. The concentration of AMPB in urine was significantly higher in PCa while levels of TF and HP were opposite (p < 0.05). The AUC for the individual proteins ranged from 0.723 to 0.754. The combination of HP and AMBP yielded the highest accuracy (AUC = 0.848), greater than PSA. The proposed biomarker set is quickly quantifiable and economical with potential to improve the sensitivity and specificity of PCa detection.

Biomarkers in prostate cancer: new era and prospective

Currently, most men are diagnosed with prostate cancer (PCa) after a prostate-specific antigen (PSA) test shows an elevated level of the PSA protein. An elevated level suggests cancer may be present. If an elevation is detected, a biopsy to detect cancer is followed. But the PSA test is controversial. An elevated level does not always mean there is cancer present. The test often leads men to having unnecessary biopsies and treatments. Even if cancer is found on biopsy, many of these cancers are slow growing and would not impact the lives of the men who have them. Current advances in molecular techniques have provided new tools facilitating the discovery of new biomarkers for PCa. The purpose of this review is to examine the advances in PCa biomarkers and implication for possible improving disease outcome. The future of cancer prognosis may rely on small panels of markers that can accurately predict PCa presence, stage, and metastasis and can serve as prognosticators, targets, and/or surrogate endpoints of disease progression and response to therapy.

Genetic predisposition to prostate cancer: Update and future perspectives

OBJECTIVE

Prostate cancer is the second most frequent cancer in men worldwide and kills over 250,000 men worldwide every year. Prostate cancer is a heterogeneous disease at the clinical and the molecular level. The Scandinavian Twin Registry Study demonstrated that in contrast to most malignancies where environment was the overriding influence, heritable factors account for more than fifty percent of prostate cancers.

METHODS AND MATERIALS

We review the literature on prostate cancer risk variants (rare and common) including SNPs and Copy Number Variants (CNVs) and discuss the potential implications of significant variants for prostate cancer patient care.

RESULTS

The search for prostate cancer susceptibility genes has included both family-based studies and case-control studies utilizing a variety of approaches from array-based to sequencing-based studies. A major challenge is to identify genetic variants associated with more aggressive, potentially lethal prostate cancer and to understand their role in the progression of the disease.

CONCLUSION

Future risk models useful in the clinical setting will likely incorporate several risk loci rather than single variants and may be dependent on an individual patient's ethnic background.

Methods and rationale used in a matched cohort study of the incidence of new primary cancers following prostate cancer

Objectives

We describe several methodological issues that were addressed in conducting a Danish population-based matched cohort study comparing rates of new primary cancers (NPCs) in men with and without prostate cancer (PC).

Methods

We matched 30,220 men with PC to 151,100 men without PC (comparators) on age (±2 years) and PC diagnosis/index date. We focused on several methodological issues: 1) to address survival differences between the cohorts we compared rates with and without censoring comparators on the date their matched PC patient died or was censored; 2) to address diagnostic bias, we excluded men with a history of cancer from the comparator cohort; 3) to address prostate cancer immunity, we graphed the hazard of NPC in both cohorts, with and without prostate cancer as an outcome; 4) we used empirical Bayes methods to explore the effect of adjusting for multiple comparisons.

Results

After 18 months of follow-up, cumulative person-time was lower in the PC than comparator cohort due to higher mortality among PC patients. Terminating person-time in comparators at the matched PC patient’s death or loss to follow-up resulted in comparable person-time up to 30 months of follow-up and lower person-time among comparators thereafter. The hazard of NPC was lower among men with PC than comparators throughout follow-up. There was little difference in rates beyond the first four years of follow-up after removing PC as an outcome. Empirical Bayes adjustment for multiple comparisons had little effect on the estimates.

Conclusion

Addressing the issues of competing risks, treatment interference or diagnostic bias, prostate cancer immunity due to radical prostatectomy, and multiple comparisons lowered the deficit rate of NPCs among men with a history of PC compared with those without PC. However, the differing rates of NPCs may also be due to risk factor differences between the cohorts.

Distinct ERG rearrangement prevalence in prostate cancer: higher frequency in young age and in low PSA prostate cancer

Background:

The TMPRSS2-ERG gene fusion resulting in ERG overexpression has been found in around 50% of prostate cancers (PCa) and is a very early event in tumorigenesis. Most studies have reported on selected surgical cohorts with inconsistent results. We hypothesized that ERG gene rearrangements impact tumor development and investigated the frequency of ERG overexpression in the context of clinicopathological tumor characteristics.

Methods:

ERG overexpression (ERG+ or ERG-) was determined by immunohistochemistry (IHC) in 1039 radical prostatectomy (RP) tumors and association with PSA, D'Amico risk score, histopathology, biochemical recurrence, body mass index and age of PCa cases was analyzed.

Results:

ERG+ was associated with younger age at diagnosis (P<0.0001), lower serum PSA (P=0.002) and lower prostate volume (PV) (P=0.001). It was most frequent in the youngest age quartile (⩽55 years, 63.9% ERG+) and decreased constantly with increasing age to 40.8% in the oldest age quartile (⩾67 years, P<0.0001). In the PSA range <4 ng ml⁻¹ the frequency of ERG positivity was 60.2% compared with 47.5 and 49.1% in the PSA ranges 4–10 and ⩾10 ng ml⁻¹, respectively. In the first age quartile, ERG+ patients had lower median serum PSA and fPSA% and smaller PV. In the highest age quartile tumor volume (TV) was increased. Similar differences were observed in the low PSA range. Multivariate analysis identified the first age quartile as a predictor for ERG status (odds ratios (OR) 2.05, P=0.007). No association was found with the D'Amico progression risk score and with biochemical tumor recurrence.

Conclusions:

ERG+ tumors manifest clinically at lower PSA levels and their prevalence is age dependent. This suggests acceleration of tumor development by ERG overexpression that results in earlier tumor detection in young patients. Long-term results are warranted to determine the impact of ERG overexpression on disease outcome.

Identification of functionally active, low frequency copy number variants at 15q21.3 and 12q21.31 associated with prostate cancer risk

Copy number variants (CNVs) are a recently recognized class of human germ line polymorphisms and are associated with a variety of human diseases, including cancer. Because of the strong genetic influence on prostate cancer, we sought to identify functionally active CNVs associated with susceptibility of this cancer type. We queried low-frequency biallelic CNVs from 1,903 men of Caucasian origin enrolled in the Tyrol Prostate Specific Antigen Screening Cohort and discovered two CNVs strongly associated with prostate cancer risk. The first risk locus (P = 7.7 × 10(-4), odds ratio = 2.78) maps to 15q21.3 and overlaps a noncoding enhancer element that contains multiple activator protein 1 (AP-1) transcription factor binding sites. Chromosome conformation capture (Hi-C) data suggested direct cis-interactions with distant genes. The second risk locus (P = 2.6 × 10(-3), odds ratio = 4.8) maps to the α-1,3-mannosyl-glycoprotein 4-β-N-acetylglucosaminyltransferase C (MGAT4C) gene on 12q21.31. In vitro cell-line assays found this gene to significantly modulate cell proliferation and migration in both benign and cancer prostate cells. Furthermore, MGAT4C was significantly overexpressed in metastatic versus localized prostate cancer. These two risk associations were replicated in an independent PSA-screened cohort of 800 men (15q21.3, combined P = 0.006; 12q21.31, combined P = 0.026). These findings establish noncoding and coding germ line CNVs as significant risk factors for prostate cancer susceptibility and implicate their role in disease development and progression.

Serum-autoantibodies for discovery of prostate cancer specific biomarkers

BACKGROUND

The currently used prostate cancer serum marker has a low cancer specificity and improved diagnostics are needed. Here we evaluated whether autoantibodies are present in sera of prostate cancer patients and whether they are useful diagnostic markers for prostate cancer.

METHODS

Sera from 20 prostate cancer patients and 20 healthy controls were incubated on expression clone arrays containing more than 37,000 recombinant human proteins. Functional annotation clustering of the identified autoantigens was performed using the DAVID database. Autoantigens identified in the prostate cancer group were validated on microarrays using sera of 40 prostate cancer patients, 40 patients with elevated PSA levels but prostate cancer negative biopsies (benign disease), and 40 healthy controls.

RESULTS

We detected autoantibodies against 408 different antigens in sera of prostate cancer patients. One hundred seventy-four of these were exclusively detected in the cancer group compared to the healthy control group. Functional annotation clustering revealed an enrichment of RNA-associated, cytoskeleton, and nuclear proteins. The autoantibody panel was validated in serum samples of independent prostate cancer patients. Autoantibody profiles discriminated between prostate cancer patients and benign disease patients with an ROC curve AUC of 0.71. TTLL12, a protein recently described to be over-expressed in prostate cancer, was the highest ranked discrimination autoantigen.

CONCLUSION

A variety of autoantibodies were identified in sera of prostate cancer patients and provide a first step towards autoantibody diagnostics. Serum autoantibodies reflect the disease and represent valuable tools not only for prostate cancer, but also for other diseases affecting the immune response.

East meets West: ethnic differences in prostate cancer epidemiology between East Asians and Caucasians

Prostate cancer is the most prevalent cancer in males in Western countries. The reported incidence in Asia is much lower than that in African Americans and European Caucasians. Although the lack of systematic prostate cancer screening system in Asian countries explains part of the difference, this alone cannot fully explain the lower incidence in Asian immigrants in the United States and west-European countries compared to the black and non-Hispanic white in those countries, nor the somewhat better prognosis in Asian immigrants with prostate cancer in the United States. Soy food consumption, more popular in Asian populations, is associated with a 25% to 30% reduced risk of prostate cancer. Prostate-specific antigen (PSA) is the only established and routinely implemented clinical biomarker for prostate cancer detection and disease status. Other biomarkers, such as urinary prostate cancer antigen 3 RNA, may increase accuracy of prostate cancer screening compared to PSA alone. Several susceptible loci have been identified in genetic linkage analyses in populations of countries in the West, and approximately 30 genetic polymorphisms have been reported to modestly increase the prostate cancer risk in genome-wide association studies. Most of the identified polymorphisms are reproducible regardless of ethnicity. Somatic mutations in the genomes of prostate tumors have been repeatedly reported to include deletion and gain of the 8p and 8q chromosomal regions, respectively; epigenetic gene silencing of glutathione S-transferase Pi (GSTP1); as well as mutations in androgen receptor gene. However, the molecular mechanisms underlying carcinogenesis, aggressiveness, and prognosis of prostate cancer remain largely unknown. Gene-gene and/or gene-environment interactions still need to be learned. In this review, the differences in PSA screening practice, reported incidence and prognosis of prostate cancer, and genetic factors between the populations in East and West factors are discussed.

The Clinical Value of Performing an MRI before Prostate Biopsy

PURPOSE

Prostate cancer foci have a characteristic feature in magnetic resonance imaging (MRI). We aimed to assess the clinical value of MRI before prostate biopsy in prostate cancer detection.

MATERIALS AND METHODS

From March 2009 to June 2010, 154 patients were enrolled in this study. A total of 51 patients with a clinical suspicion of prostate cancer underwent prostate MRI by a 3T scanner before transrectal ultrasound (TRUS)-guided biopsies. A total of 103 patients with a clinical suspicion of prostate cancer underwent prostate MRI after biopsies. The sensitivity, specificity, and positive predictive value (PPV) were evaluated. In addition, tumor location of pathologic findings and ADC mapping on MRI were matched and compared.

RESULTS

The sensitivity of MRI before and after biopsy was 84.8% and 92.4%, respectively. The PPV of MRI before and after biopsy was 75.7% and 92.4%, respectively. The MRI location match percentage before and after biopsy was 89.3% and 94.1%, respectively.

CONCLUSIONS

Compared with other previous reports, our results show that the prostate cancer detection sensitivity of MRI is on the rise. Furthermore, MRI before prostate biopsy can provide more information by which to identify prostate cancer during prostate biopsy and thus reduce the false-negative rate.

Prostate-specific antigen testing in Tyrol, Austria: prostate cancer mortality reduction was supported by an update with mortality data up to 2008

Objectives

The objective of this study was to update an in-depth analysis of the time trend for prostate cancer (PCA) mortality in the population of Tyrol by 5 years, namely to 2008. In Tyrol, prostate-specific antigen (PSA) tests were introduced in 1988/89; more than three-quarters of all men in the age group 45–74 had at least one PSA test in the past decade.

Methods

We applied the same model as in a previous publication, i.e., an age-period-cohort model using Poisson regression, to the mortality data covering more than three decades from 1970 to 2008.

Results

For Tyrol from 2004 to 2008 in the age group 60+ period terms show a significant reduction in prostate cancer mortality with a risk ratio of 0.70 (95% confidence interval 0.57, 0.87) for Tyrol, and for Austria excluding Tyrol a moderate reduction with a risk ratio of 0.92 (95% confidence interval 0.87, 0.97), each compared to the mortality rate in the period 1989–1993.

Conclusions

This update strengthens our previously published results, namely that PSA testing offered to a population at no charge can reduce prostate cancer mortality. The extent of mortality reduction is in line with that reported in the other recent publications. However, our data do not permit us to fully assess the harms associated with PCA screening, and no recommendation for PSA screening can be made without a careful evaluation of overdiagnosis and overtreatment.

Exploratory study of a KLK2 polymorphism as a prognostic marker in prostate cancer

OBJECTIVES

An association of a single nucleotide polymorphism (SNP) of the KLK2 gene (rs198977; c.748C>T; R250W) with risk for developing prostate cancer has been observed. We evaluated the role of R250W SNP for prognosis in prostate cancer.

METHODS

The c.748C>T SNP was genotyped from blood DNA of 182 patients after completing initial cancer treatments. For evaluating prognosis of genotype groups, associations were performed with Gleason score (GS) and biochemical recurrence free survival (bRFS) in patients demonstrating PSA-recurrence after initial cancer therapy.

RESULTS

Overall distribution of the CC, CT and TT genotypes for the SNP was 48%, 44% and 8%, respectively. The distribution of high (8-10), moderate (5-7) and low (2-4) GS among the genotype groups was 17%, 74% and 9% for CC group compared to 25%, 74% and 1% for the CT/TT (P=0.04). Median bRFS time for CT/TT group was 36.5 months compared to 44.5 months for the CC group (P=0.16), while genotype groups combined with morphology revealed significantly different bRFS (P=0.004).

CONCLUSIONS

This exploratory analysis in prostate cancer patients revealed the W allele of the KLK2 R250W SNP to be less likely associated with low GS morphology. Further studies will be needed to confirm this observation in larger cohorts.

Novel diagnostic biomarkers for prostate cancer

Prostate cancer is the most frequently diagnosed malignancy in American men, and a more aggressive form of the disease is particularly prevalent among African Americans. The therapeutic success rate for prostate cancer can be tremendously improved if the disease is diagnosed early. Thus, a successful therapy for this disease depends heavily on the clinical indicators (biomarkers) for early detection of the presence and progression of the disease, as well as the prediction after the clinical intervention. However, the current clinical biomarkers for prostate cancer are not ideal as there remains a lack of reliable biomarkers that can specifically distinguish between those patients who should be treated adequately to stop the aggressive form of the disease and those who should avoid overtreatment of the indolent form.

A biomarker is a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention. A biomarker reveals further information to presently existing clinical and pathological analysis. It facilitates screening and detecting the cancer, monitoring the progression of the disease, and predicting the prognosis and survival after clinical intervention. A biomarker can also be used to evaluate the process of drug development, and, optimally, to improve the efficacy and safety of cancer treatment by enabling physicians to tailor treatment for individual patients. The form of the prostate cancer biomarkers can vary from metabolites and chemical products present in body fluid to genes and proteins in the prostate tissues.

Current advances in molecular techniques have provided new tools facilitating the discovery of new biomarkers for prostate cancer. These emerging biomarkers will be beneficial and critical in developing new and clinically reliable indicators that will have a high specificity for the diagnosis and prognosis of prostate cancer. The purpose of this review is to examine the current status of prostate cancer biomarkers, with special emphasis on emerging markers, by evaluating their diagnostic and prognostic potentials. Both genes and proteins that reveal loss, mutation, or variation in expression between normal prostate and cancerous prostate tissues will be covered in this article. Along with the discovery of prostate cancer biomarkers, we will describe the criteria used when selecting potential biomarkers for further development towards clinical use. In addition, we will address how to appraise and validate candidate markers for prostate cancer and some relevant issues involved in these processes. We will also discuss the new concept of the biomarkers, existing challenges, and perspectives of biomarker development.

Impact of PSA testing and prostatic biopsy on cancer incidence and mortality: comparative study between the Republic of Ireland and Northern Ireland

OBJECTIVES

To investigate the impact of different PSA testing policies and health-care systems on prostate cancer incidence and mortality in two countries with similar populations, the Republic of Ireland (RoI) and Northern Ireland (NI).

METHODS

Population-level data on PSA tests, prostate biopsies and prostate cancer cases 1993-2005 and prostate cancer deaths 1979-2006 were compiled. Annual percentage change (APC) was estimated by joinpoint regression.

RESULTS

Prostate cancer rates were similar in both areas in 1994 but increased rapidly in RoI compared to NI. The PSA testing rate increased sharply in RoI (APC = +23.3%), and to a lesser degree in NI (APC = +9.7%) to reach 412 and 177 tests per 1,000 men in 2004, respectively. Prostatic biopsy rates rose in both countries, but were twofold higher in RoI. Cancer incidence rates rose significantly, mirroring biopsy trends, in both countries reaching 440 per 100,000 men in RoI in 2004 compared to 294 in NI. Median age at diagnosis was lower in RoI (71 years) compared to NI (73 years) (p < 0.01) and decreased significantly over time in both countries. Mortality rates declined from 1995 in both countries (APC = -1.5% in RoI, -1.3% in NI) at a time when PSA testing was not widespread.

CONCLUSIONS

Prostatic biopsy rates, rather than PSA testing per se, were the main driver of prostate cancer incidence. Because mortality decreases started before screening became widespread in RoI, and mortality remained low in NI, PSA testing is unlikely to be the explanation for declining mortality.

Racial differences in PSA screening interval and stage at diagnosis

OBJECTIVES

This study examined PSA screening interval of black and white men aged 65 or older and its association with prostate cancer stage at diagnosis.

METHODS

SEER-Medicare data were examined for 18,067 black and white men diagnosed with prostate cancer between 1994 and 2002. Logistic regression was used to assess the association between race, PSA screening interval, and stage at diagnosis. Analysis also controlled for age, marital status, comorbidity, diagnosis year, geographic region, income, and receipt of surgery.

RESULTS

Compared to whites, blacks diagnosed with prostate cancer were more likely to have had a longer PSA screening interval prior to diagnosis, including a greater likelihood of no pre-diagnosis use of PSA screening. Controlling for PSA screening interval was associated with a reduction in blacks' relative odds of being diagnosed with advanced (stage III or IV) prostate cancer, to a point that the stage at diagnosis was not statistically different from that of whites (OR=1.12, 95% CI=0.98-1.29). Longer intra-PSA intervals were systematically associated with greater odds of diagnosis with advanced disease.

CONCLUSIONS

More frequent or systematic PSA screening may be a pathway to reducing racial differences in prostate cancer stage at diagnosis, and, by extension, mortality.

Genetic variation of genes involved in dihydrotestosterone metabolism and the risk of prostate cancer

PURPOSE

Dihydrotestosterone (DHT) is an important factor in prostate cancer (PCA) genesis and disease progression. Given PCA's strong genetic component, we evaluated the possibility that variation in genes involved in DHT metabolism influence PCA risk.

EXPERIMENTAL DESIGN

We investigated copy number variants (CNV) and single nucleotide polymorphisms (SNP). We explored associations between CNV of uridine diphospho-glucuronosyltransferase (UGT) genes from the 2B subclass, given their prostate specificity and/or involvement in steroid metabolism and PCA risk. We also investigated associations between SNPs in genes (HSD3B1, SRD5A1/2, and AKR1C2) involved in the conversion of testosterone to DHT, and in DHT metabolism and PCA risk. The population consisted of 426 men (205 controls and 221 cases) who underwent prostate-specific antigen screening as part of a PCA early detection program in Tyrol, Austria.

RESULTS

No association between CNV in UGT2B17 and UGT2B28 and PCA risk was identified. Men carrying the AA genotype at SNP rs6428830 (HSD3B1) had an odds ratio (OR) of 2.0 [95% confidence intervals (95% CI), 1.1-4.1] compared with men with GG, and men with AG or GG versus AA in rs1691053 (SRD5A1) had an OR of 1.8 (95% CI, 1.04-3.13). Individuals carrying both risk alleles had an OR of 3.1 (95% CI, 1.4-6.7) when compared with men carrying neither (P = 0.005). Controls with the AA genotype on rs7594951 (SRD5A2) tended toward higher serum DHT levels (P = 0.03).

CONCLUSIONS

This is the first study to implicate the 5alpha-reductase isoform 1 (SRD5A1) and PCA risk, supporting the rationale of blocking enzymatic activity of both isoforms of 5alpha-reductase for PCA chemoprevention.

New developments in the medical management of prostate cancer

Prostate cancer is a substantial public health burden and a leading cause of cancer-related morbidity and mortality in the United States despite the observation that annual prostate cancer-specific mortality rates have been declining during the previous decade. Although the reasons for this positive development are unclear, a combination of factors may have contributed. This update will review ongoing developments and summarize therapeutic advances in prostate cancer treatment on the basis of the current understanding of prostate cancer biology. Literature for this review was selected in 2009 by searching PubMed for the following keywords: prostatic neoplasms, castration, androgen receptor, hormonal, and chemotherapy. Emphasis is placed on published clinical studies in advanced prostate cancer therapeutics in the past 5 to 10 years. Also included in the review are novel hormonal agents targeting the androgen receptor currently in development for the treatment of advanced prostate cancer.

Are survival rates for Tyrol published in the Eurocare studies biased?

OBJECTIVE

To investigate whether survival rates published in the EUROCARE studies for Tyrol are distorted, we evaluated data quality in the Cancer Registry of Tyrol.

MATERIAL AND METHODS

Potential errors in completeness of Tyrolean incidence data were assessed by applying semi-quantitative and quantitative methods, in part by comparing indices for Tyrol with those of neighboring countries published in Cancer Incidence in Five Continents. Validity of patient survival status was checked for all cancer patients diagnosed in 1997 (n2 556). For all 1 026 of these patients still alive at end of 2007, we reassessed survival status. Finally, we re-abstracted date of diagnosis for a subset of 295 patients.

RESULTS

Quality indices on completeness showed no greater bias with the exception of borderline ovarian cancer, which was in part miscoded in the early nineties. Some differences for bladder cancer and prostate cancer between Tyrol and neighboring countries are due to PSA testing and pathology diagnosis. Concerning patient survival status, four cases were erroneously assessed as alive, five cases died outside Austria, three cases were proven not to belong to the population of Tyrol at time of diagnosis and 21 cases emigrated. Absolute errors in survival rates were less than 0.5 for up to five-year survival rates and less than 1.0 for ten-year survival rates.

CONCLUSIONS

Evaluation of data quality in the Cancer Registry of Tyrol demonstrated that the survival rates published for Tyrol are only minimally biased by registration or analysis procedures. However, access to data on emigration,which until now is not possible because of data protection restrictions, would reduce the bias in patient survival status, bearing in mind that the extent of emigration of cancer patients is expected to increase in Austria over the coming years.

Risk factors, prevention and early detection of prostate cancer

Approximately one in six men in the United States will develop prostate cancer during their lifetime. Genetic and environmental variables play a role in determining prostate cancer risk. This article highlights the latest evidence regarding the risk factors for prostate cancer. The current screening strategies using prostate-specific antigen and digital rectal examination are also discussed, as well as the limitations of these protocols and potential methods for improving early detection.

Mitochondrial haplogroups and control region polymorphisms are not associated with prostate cancer in Middle European Caucasians

BACKGROUND

Besides being responsible for energy production in the cell, mitochondria are central players in apoptosis as well as the main source of harmful reactive oxygen species. Therefore, it can be hypothesised that sequence variation in the mitochondrial genome is a contributing factor to the etiology of diseases related to these different cellular events, including cancer. The aim of the present study was to assess the frequency of haplogroups and polymorphisms in the control region (CR) of mitochondrial DNA of peripheral blood mononuclear cells from patients with prostate carcinoma (n = 304) versus patients screened for prostate disease but found to be negative for cancer on biopsy (n = 278) in a Middle European population.

METHODOLOGY/PRINCIPAL FINDINGS

The nine major European haplogroups and the CR polymorphisms were identified by means of primer extension analysis and DNA sequencing, respectively. We found that mitochondrial haplogroup frequencies and CR polymorphisms do not differ significantly between patients with or without prostate cancer, implying no impact of inherited mitochondrial DNA variation on predisposition to prostate carcinoma in a Middle European population.

CONCLUSIONS/SIGNIFICANCE

Our results contrast with a recent report claiming an association between mtDNA haplogroup U and prostate cancer in a North American population of caucasian descent.

[Prostate carcinoma]

Prostate cancer is the most common malignancy in men in Europe, North America, and in some African states. Early diagnosis in an asymptomatic stage is possible through the combination of digitorectal examination, PSA serum testing, and systematic biopsy. However, general screening is so far not recommended by the Urologic Societies, because the efficiency is not yet proved. Imaging is also not recommended for first-line screening. Novel functional methods of transrectal ultrasound (TRUS) and endorectal MRI can improve accuracy of tumor detection to more than 90% and can be used for TRUS- and now also MRI-guided biopsy leading to two- to threefold higher tumor detection rates. There is general agreement that all men over 50 years of age should be informed about the possibilities, benefits, and risks of the available methods for early tumor detection.

Effect of body mass index and waist circumference on prostate specific antigen and prostate volume in a generally healthy Korean population

PURPOSE

We examined the influences of age, body mass index and waist circumference on prostate specific antigen before and after adjusting for prostate volume. We also examined associations among age, body mass index, waist circumference and prostate volume.

MATERIALS AND METHODS

We analyzed 38,380 Korean men 30 to 79 years old who received regular checkups at our health examination center. We had prostate volume data for 3,593 of them. We divided the subjects into 5 groups by age, 4 groups by body mass index and waist circumference (using Asia-Pacific obesity reference values), and quartiles for prostate volume. We compared prostate specific antigen and prostate volume by multivariate regression analysis across body mass index and waist circumference after adjusting for age and/or prostate volume.

RESULTS

Increasing body mass index or waist circumference was associated with decreasing prostate specific antigen (with or without prostate volume adjustment) and increasing prostate volume (p for trend <0.01). When we stratified prostate volume by quartile, age was not associated with prostate specific antigen except in quartile 4 (p for trend by quartile 0.402, 0.639, 0.056 and <0.01). Mean prostate specific antigen of the group with a body mass index less than 23 in prostate volume quartile 4 was approximately 3 times that of the group with a body mass index greater than 30 in prostate volume quartile 1 (1.42 vs 0.55).

CONCLUSIONS

Obesity had a negative association with prostate specific antigen regardless of prostate volume, and a positive association with prostate volume. Age was not associated with prostate specific antigen after prostate volume adjustment. Obese men, especially those with a small prostate volume, may have lower baseline prostate specific antigen and, thus, be at higher risk for having prostate cancer undetected in a prostate specific antigen screening test.

Quantification of phase I/II metabolizing enzyme gene expression and polycyclic aromatic hydrocarbon-DNA adduct levels in human prostate

BACKGROUND

Studies of migrant populations suggest that dietary and/or environmental factors play a crucial role in the etiology of prostatic adenocarcinoma (CaP). The human prostate consists of the peripheral zone (PZ), transition zone (TZ), and central zone (CZ); CaP occurs most often in the PZ.

METHODS

To investigate the notion that an underlying differential expression of phase I/II genes, and/or the presence of polycyclic aromatic hydrocarbon (PAH)-DNA adducts might explain the elevated PZ susceptibility, we examined prostate tissues (matched tissue sets consisting of PZ and TZ) from men undergoing radical retropubic prostatectomy for CaP (n = 26) or cystoprostatectomy (n = 1). Quantitative gene expression analysis was employed for cytochrome P450 (CYP) isoforms CYP1A1, CYP1B1, and CYP1A2, as well as N-acetyltransferase 1 and 2 (NAT1 and NAT2) and catechol-O-methyl transferase (COMT).

RESULTS

CYP1B1, NAT1, and COMT were expressed in all tissue sets; levels of CYP1B1 and NAT1 were consistently higher in the PZ compared to TZ. Immunohistochemistry confirmed the presence of CYP1B1 (nuclear-associated and primarily in basal epithelial cells) and NAT1. Normal tissue from 23 of these aforementioned 27 matched tissue sets was analyzed for PAH-DNA adduct levels using antiserum elicited against DNA modified with r7,t8-dihydroxy-t-9,10-oxy-7,8,9,10-tetrahydro-benzo[a]pyrene (BPDE). PAH-DNA adduct levels were highest in glandular epithelial cells, but a comparison of PZ and TZ showed no significant differences.

CONCLUSION

Although expression of activating and/or detoxifying enzymes may be higher in the PZ, PAH-DNA adduct levels appear to be similar in both zones. Therefore, factors other than PAH-DNA adducts may be responsible for promotion of tumor formation in the human prostate.

Cancer screenings, diagnostic technology evolution, and cancer control

Screening should allow for the anticipation of cancer diagnosis at an earlier stage, when curative treatment is possible. Screening for cervical, large bowel, and breast cancer were shown to be effective in reducing mortality. The wide acceptance of the screening concept led to the wide diffusion also of screening of uncertain benefit against prostate cancer and skin melanoma. Diagnostic technologies are continuously evolving, and new tests are proposed to improve existing screenings or as screening tests for additional cancer sites (e.g., lung cancer). Cancer screening, however, is a complex and costly intervention that does not result only in benefits but also may cause harm. A major emerging problem of screening is overdiagnosis, or the detection of cases that would have not progressed to the symptomatic phase in the absence of screening. Thus, both experimental and observational evaluation studies are needed to reduce harm caused by screenings and to select effective interventions among many proposed innovations. Finally, the research of markers to assess the aggressive nature of screen-detected lesions is of great importance to improve screenings ' harm/benefit ratio.

National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines for Use of Tumor Markers in Testicular, Prostate, Colorectal, Breast, and Ovarian Cancers

Background: Updated National Academy of Clinical Biochemistry (NACB) Laboratory Medicine Practice Guidelines for the use of tumor markers in the clinic have been developed.

Methods: Published reports relevant to use of tumor markers for 5 cancer sites—testicular, prostate, colorectal, breast, and ovarian—were critically reviewed.

Results: For testicular cancer, α-fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase are recommended for diagnosis/case finding, staging, prognosis determination, recurrence detection, and therapy monitoring. α-Fetoprotein is also recommended for differential diagnosis of nonseminomatous and seminomatous germ cell tumors. Prostate-specific antigen (PSA) is not recommended for prostate cancer screening, but may be used for detecting disease recurrence and monitoring therapy. Free PSA measurement data are useful for distinguishing malignant from benign prostatic disease when total PSA is &lt;10 μg/L. In colorectal cancer, carcinoembryonic antigen is recommended (with some caveats) for prognosis determination, postoperative surveillance, and therapy monitoring in advanced disease. Fecal occult blood testing may be used for screening asymptomatic adults 50 years or older. For breast cancer, estrogen and progesterone receptors are mandatory for predicting response to hormone therapy, human epidermal growth factor receptor-2 measurement is mandatory for predicting response to trastuzumab, and urokinase plasminogen activator/plasminogen activator inhibitor 1 may be used for determining prognosis in lymph node–negative patients. CA15-3/BR27–29 or carcinoembryonic antigen may be used for therapy monitoring in advanced disease. CA125 is recommended (with transvaginal ultrasound) for early detection of ovarian cancer in women at high risk for this disease. CA125 is also recommended for differential diagnosis of suspicious pelvic masses in postmenopausal women, as well as for detection of recurrence, monitoring of therapy, and determination of prognosis in women with ovarian cancer.

Conclusions: Implementation of these recommendations should encourage optimal use of tumor markers.

Screening, treatment, and prostate cancer mortality in the Seattle area and Connecticut: fifteen-year follow-up

BACKGROUND

Prior to introduction of the prostate-specific antigen (PSA) test, the Seattle-Puget Sound and Connecticut Surveillance, Epidemiology and End Results (SEER) areas had similar prostate cancer mortality rates. Early in the PSA era (1987-1990), men in the Seattle area were screened and treated more intensively for prostate cancer than men in Connecticut.

OBJECTIVE

We previously reported more intensive screening and treatment early in the PSA era did not lower prostate cancer mortality through 11 years and now extend follow-up to 15 years.

DESIGN

Natural experiment comparing two fixed population-based cohorts.

SUBJECTS

Male Medicare beneficiaries ages 65-79 from the Seattle (N = 94,900) and Connecticut (N = 120,621) SEER areas, followed from 1987-2001.

MEASUREMENTS

Rates of prostate cancer screening; treatment with radical prostatectomy, external beam radiotherapy, and androgen deprivation therapy; and prostate cancer-specific mortality.

MAIN RESULTS

The 15-year cumulative incidences of radical prostatectomy and radiotherapy through 2001 were 2.84% and 6.02%, respectively, for Seattle cohort members, compared to 0.56% and 5.07% for Connecticut cohort members (odds ratio 5.20, 95% confidence interval 3.22 to 8.42 for surgery and odds ratio 1.24, 95% confidence interval 0.98 to 1.58 for radiation). The cumulative incidence of androgen deprivation therapy from 1991-2001 was 4.78% for Seattle compared to 6.13% for Connecticut (odds ratio 0.77, 95% confidence interval 0.67 to 0.87). The adjusted rate ratio of prostate cancer mortality through 2001 was 1.02 (95% C.I. 0.96 to 1.09) in Seattle versus Connecticut.

CONCLUSION

Among men aged 65 or older, more intensive prostate cancer screening early in the PSA era and more intensive treatment particularly with radical prostatectomy over 15 years of follow-up were not associated with lower prostate cancer-specific mortality.

Prostate cancer

In developed countries, prostate cancer is the second most frequently diagnosed cancer, and the third most common cause of death from cancer in men. Apart from age and ethnic origin, a positive family history is probably the strongest known risk factor. Clinically, prostate cancer is diagnosed as local or advanced, and treatments range from surveillance to radical local treatment or androgen-deprivation treatment. Androgen deprivation reduces symptoms in about 70-80% of patients with advanced prostate cancer, but most tumours relapse within 2 years to an incurable androgen-independent state. The recorded incidence of prostate cancer has substantially increased in the past two decades, probably because of the introduction of screening with prostate-specific antigen, the use of improved biopsy techniques for diagnosis, and increased public awareness. Trends in mortality from the disease are less clearcut. Mortality changes are not of the same magnitude as the changes in incidence, and in some countries mortality has been stable or even decreased. The disparity between reported incidence and mortality rates leads to the probable conclusion that only a small proportion of diagnosed low-risk prostate cancers will progress to life-threatening disease during the lifetime of the patient.

Prostate-specific antigen and prostate cancer: prediction, detection and monitoring

Testing for prostate-specific antigen (PSA) has profoundly affected the diagnosis and treatment of prostate cancer. PSA testing has enabled physicians to detect prostate tumours while they are still small, low-grade and localized. This very ability has, however, created controversy over whether we are now diagnosing and treating insignificant cancers. PSA testing has also transformed the monitoring of treatment response and detection of disease recurrence. Much current research is directed at establishing the most appropriate uses of PSA testing and at developing methods to improve on the conventional PSA test.

PSA and other tissue kallikreins for prostate cancer detection

Prostate cancer is the most common neoplasia of middle-aged men. Prostate specific antigen (PSA) is the first FDA-approved tumour marker for early detection of cancer and it is now in widespread clinical use. The discovery of different PSA molecular forms in serum (free PSA, PSA complexed with various protease inhibitors) in the early 1990s renewed clinical research to enhance the specificity of PSA. Also, the use of a homologous prostate-localised antigen, human glandular kallikrein 2 (KLK2) may further reduce the number of unnecessary prostate biopsies. More recently, promising data is emerging regarding molecular forms of free PSA (proPSA, BPSA, 'intact' PSA) and other members of the expanded human kallikrein family. These new findings may add substantial clinical information for early detection of prostate cancer.

Prostate cancer mortality in relation to screening by prostate-specific antigen testing and digital rectal examination: a population-based study in middle-aged men

BACKGROUND

Although prostate cancer screening by measurement of serum prostate-specific antigen (PSA) and digital rectal examination (DRE) is common in clinical practice, the impact of such screening on prostate cancer-specific mortality remains uncertain.

METHODS

Data from a population-based case-control study in King County, Washington, among men aged 50-64 years (706 cases, 645 controls) were used to examine the relationships between PSA and DRE screening and fatal prostate cancer and other-cause mortality. Incident cases were diagnosed in 1993-1996, identified via the Seattle-Puget Sound SEER cancer registry and followed for vital status through 1 June 2007. Controls were ascertained by random digit dialing and frequency age-matched to cases. The screening variable used in this analysis was self-reported receipt of one or more PSA and/or DRE tests performed as part of a routine checkup in the five-year period before diagnosis or reference date.

RESULTS

A smaller proportion of men with fatal prostate cancer had one or more PSA and/or DRE screening tests compared to controls, resulting in an adjusted odds ratios (OR) of 0.38 (95% CI 0.19-0.77). There was no association, however, between PSA and/or DRE screening and other-cause mortality (OR = 1.02; 95% CI 0.51-2.02).

CONCLUSIONS

Results of this study suggest a reduction in prostate cancer-specific mortality associated with PSA and/or DRE screening in middle-aged men. Findings should be interpreted cautiously, however, as results are based on observational data. Further, the study was not able to separate the relative efficacy of PSA versus DRE screening.

Is the organised screening of prostate cancer reasonable?

A prosztatarák Magyarországon is jelentős népegészségügyi probléma, ezért a halálozás mérséklése céljából szűrővizsgálata indokolt lenne. Szűrővizsgálati módszerek, úgymint a prosztataspecifikus antigén (PSA) kimutatása és a rectalis digitális vizsgálat rendelkezésre állnak, ám érzékenységük, fajlagosságuk, pozitív jósló értékük kívánnivalókat hagy maguk után. Nem randomizált vizsgálatokból származó bizonyítékok a szűrés lehetséges haszna mellett szólnak, azonban randomizált, ellenőrzött vizsgálatok még nem szolgáltattak meggyőző bizonyítékot. A szűrővizsgálat – a fajlagosság korlátozott volta miatt – túldiagnosztizálás és túlkezelés révén jelentős kárt is okozhat. A szerzők népegészségügyi szempontból megalapozott álláspontja szerint a szűrővizsgálati módszerek alkalomszerű felhasználása a szakorvosi diagnosztika keretében nem ütközik akadályba, azonban népegészségügyi lakosságszűrés nem kezdhető el mindaddig, amíg a folyamatban lévő randomizált, ellenőrzött vizsgálatok meg nem hozzák a várt bizonyítékokat.

Prostate-specific antigen in clinical practice

Currently, in the United States (US), most prostate cancers are diagnosed through screening with digital rectal examination (DRE) and measurement of serum prostate-specific antigen (PSA). The serum PSA level correlates directly with prostate cancer risk and aggressiveness, as well as the outcomes after treatment. PSA testing is also useful in monitoring patients for tumor recurrence after treatment. PSA testing has limited specificity for prostate cancer detection, and its appropriate clinical application has been the topic of debate. Accordingly, several variations on the PSA measurement have emerged as useful adjuncts for prostate cancer screening. These take into consideration additional factors, such as the proportion of different PSA isoforms (free PSA, complexed PSA, pro-PSA and B PSA), the prostate volume (PSA density), and the rate of change in PSA levels over time (PSA velocity or PSA doubling time). Widespread PSA screening is associated with a 75% reduction in the proportion of men who present with metastatic disease since 1985-89 in the US and a 32.5% reduction in the age-adjusted prostate cancer mortality rate through 2003. The history and evidence underlying each of these parameters are reviewed in the following article.

Cancer mortality trends in the Umbria region of Italy 1978-2004: a joinpoint regression analysis

BACKGROUND

The aim of the present paper was to analyse cancer mortality in the Umbria region, from 1978 to 2004. Mortality trends depend on a number of factors including exposures, health system interventions, and possibly artefact (e.g. classification change, variations of data completeness). Descriptive data on mortality only allow for generation of hypotheses to explain observed trends. Some clues on the respective role of possible mortality determinants may be found comparing mortality with incidence and survival data.

METHODS

Mortality data for the periods 1978-1993 and 1994-2004 were supplied by the National Institute of Statistics (ISTAT) and the Regional Causes of Death Registry (ReNCaM) respectively. Sex and site-specific mortality time trends were analysed by the "joinpoint regression" method.

RESULTS

For all sites combined, in both sexes, the standardised rate was first increasing before the end of the eighties and decreasing thereafter. Gastric cancer mortality showed a different trend by gender; that is the rate constantly decreased over the period among females while, for males, it was first increasing up to 1985 and decreasing thereafter. Liver cancer trend showed a pattern similar to gastric cancer. Large bowel cancer showed a gender specific trend, that is it was increasing among males and stable among females. Also lung cancer mortality varied by gender: it started to decline after 1989 among males but was steadily increasing over the study period among women. A decreasing trend for female breast cancer mortality began in 1994. Prostate cancer mortality trend is the only one showing two significant joinpoints: mortality decreased up to 1990, then it increased up to 1998 and, finally, was decreasing.

CONCLUSION

Overall cancer mortality was decreasing in both sexes in Umbria and this favourable trend will probably continue and further improve since population screening against breast, cervix, and large bowel cancers were recently introduced. Besides gastric cancer, tobacco-related cancers and prostate cancer mainly contributed to mortality reduction in males, whereas breast cancer mainly contributed to declining mortality in females.