Prostate cancer screening in the randomized Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial: mortality results after 13 years of follow-up

Assessment of a Polygenic Risk Score in Screening for Prostate Cancer

BACKGROUND

The incidence of prostate cancer is increasing. Screening with an assay of prostate-specific antigen (PSA) has a high rate for false positive results. Genomewide association studies have identified common germline variants in persons with prostate cancer, which can be used to calculate a polygenic risk score associated with risk of prostate cancer.

METHODS

We recruited persons 55 to 69 years of age from primary care centers in the United Kingdom. Using germline DNA extracted from saliva, we derived polygenic risk scores from 130 variants known to be associated with an increased risk of prostate cancer. Participants with a polygenic risk score in the 90th percentile or higher were invited to undergo prostate cancer screening with multiparametric magnetic resonance imaging (MRI) and transperineal biopsy, irrespective of PSA level.

RESULTS

Among 40,292 persons invited to participate, 8953 (22.2%) expressed interest in participating and 6393 had their polygenic risk score calculated; 745 (11.7%) had a polygenic risk score in the 90th percentile or higher and were invited to undergo screening. Of these 745 participants, 468 (62.8%) underwent MRI and prostate biopsy; prostate cancer was detected in 187 participants (40.0%). The median age at diagnosis was 64 years (range, 57 to 73). Of the 187 participants with cancer, 103 (55.1%) had prostate cancer classified as intermediate or higher risk according to the 2024 National Comprehensive Cancer Network (NCCN) criteria, so treatment was indicated; cancer would not have been detected in 74 (71.8%) of these participants according to the prostate cancer diagnostic pathway currently used in the United Kingdom (high PSA level and positive MRI results). In addition, 40 of the participants with cancer (21.4%) had disease classified as unfavorable intermediate risk or as high or very high risk according to NCCN criteria.

CONCLUSIONS

In a prostate cancer screening program involving participants in the top decile of risk as determined by a polygenic risk score, the percentage found to have clinically significant disease was higher than the percentage that would have been identified with the use of PSA or MRI. (Funded by the European Research Council Seventh Framework Program and others; BARCODE1 ClinicalTrials.gov number, NCT03857477.).

Novel AI applications in systematic review: GPT-4 assisted data extraction, analysis, review of bias

OBJECTIVE

To assess custom GPT-4 performance in extracting and evaluating data from medical literature to assist in the systematic review (SR) process.

DESIGN

A proof-of-concept comparative study was conducted to assess the accuracy and precision of custom GPT-4 models against human-performed reviews of randomised controlled trials (RCTs).

SETTING

Four custom GPT-4 models were developed, each specialising in one of the following areas: (1) extraction of study characteristics, (2) extraction of outcomes, (3) extraction of bias assessment domains and (4) evaluation of risk of bias using results from the third GPT-4 model. Model outputs were compared against data from four SRs conducted by human authors. The evaluation focused on accuracy in data extraction, precision in replicating outcomes and agreement levels in risk of bias assessments.

PARTICIPANTS

Among four SRs chosen, 43 studies were retrieved for data extraction evaluation. Additionally, 17 RCTs were selected for comparison of risk of bias assessments, where both human comparator SRs and an analogous SR provided assessments for comparison.

INTERVENTION

Custom GPT-4 models were deployed to extract data and evaluate risk of bias from selected studies, and their outputs were compared to those generated by human reviewers.

MAIN OUTCOME MEASURES

Concordance rates between GPT-4 outputs and human-performed SRs in data extraction, effect size comparability and inter/intra-rater agreement in risk of bias assessments.

RESULTS

When comparing the automatically extracted data to the first table of study characteristics from the published review, GPT-4 showed 88.6% concordance with the original review, with <5% discrepancies due to inaccuracies or omissions. It exceeded human accuracy in 2.5% of instances. Study outcomes were extracted and pooling of results showed comparable effect sizes to comparator SRs. A review of bias assessment using GPT-4 showed fair-moderate but significant intra-rater agreement (ICC=0.518, p<0.001) and inter-rater agreements between human comparator SR (weighted kappa=0.237) and the analogous SR (weighted kappa=0.296). In contrast, there was a poor agreement between the two human-performed SRs (weighted kappa=0.094).

CONCLUSION

Customized GPT-4 models perform well in extracting precise data from medical literature with potential for utilization in review of bias. While the evaluated tasks are simpler than the broader range of SR methodologies, they provide an important initial assessment of GPT-4's capabilities.

Prostate Cancer: genetics in practice now and in the future

Prostate Cancer (PrCa) is one of the most common cancers worldwide and causes a significant healthcare burden. Recent predictions estimate the incidence of new cases of PrCa will double from 1.4 million in 2020 to 2.9 million by 2040.The known risk factors for PrCa are increasing age, family history, ancestry and genetics. PrCa is one of the most heritable of the more common cancers. The heritability of PrCa is due to both rare moderate to high-risk monogenic variants and more common variants known as single nucleotide polymorphisms (SNPs) which can be used to calculate a polygenic risk score (PRS) for PrCa, while there is some of the genetic risk as yet unexplained. In recent years more PrCa risk-associated SNPs have been identified, increasing over time with the inclusion of more persons of diverse ancestry in studies. The identification of germline variants known to be associated with increased PrCa risk and disease aggressiveness has led to targeted treatments for certain pathogenic variant carriers.This is a mini review of how the genetics of PrCa can impact on screening and early detection of the disease and the treatment and management of the disease when diagnosed.

Prostate cancer screening in the Middle East and North Africa: a cross-sectional study on current practices

BACKGROUND

Prostate cancer is a substantial health concern in the Middle East and North Africa region, with many cases diagnosed at advanced stages, a high mortality to incidence ratio, and low prostate cancer awareness. This study aimed to evaluate prostate cancer screening practices in the region to inform effective early detection and management strategies.

METHODS

A cross-sectional survey was conducted from July 1, 2023, to November 8, 2024, among physicians from 19 countries in the Middle East and North Africa region. The study used a validated questionnaire to assess prostate cancer screening practices, barriers, and educational needs.

RESULTS

The survey had a response rate of 96.8% and 1163 participants. Of these participants, 34.7% routinely performed prostate cancer screenings, with 61.1% using prostate-specific antigen tests. The primary barrier was lack of patient awareness (51.2%). In addition, 65.3% of participants had no formal training. To improve screening rates, participants suggested better patient education (63.5%), increased training for health-care professionals (41.9%), and improved access to screening equipment (38.9%).

CONCLUSION

This study revealed that prostate cancer screening rates were low, with barriers including a lack of patient awareness and formal training among physicians. Addressing these issues through culturally tailored education programs may improve early detection rates and ultimately reduce the burden of prostate cancer in the Middle East and North Africa region.

Prostate Cancer Early Detection in the European Union and UK

BACKGROUND AND OBJECTIVE

While prostate cancer (PCa) incidence and mortality rates continue to rise, early detection of PCa remains highly controversial, and the research landscape is rapidly evolving. Existing systematic reviews (SRs) and meta-analyses (MAs) provide valuable insights, but often focus on single aspects of early detection, hindering a comprehensive understanding of the topic. We aim to fill this gap by providing a comprehensive SR of contemporary SRs covering different aspects of early detection of PCa in the European Union (EU) and the UK.

METHODS

On June 1, 2023, we searched four databases (Medline ALL via Ovid, Embase, Web of Science, and Cochrane Central Register of Controlled Trials) and Google Scholar. To avoid repetition of previous studies, only SRs (qualitative, quantitative, and/or MAs) were considered eligible. In the data, common themes were identified to present the evidence systematically.

KEY FINDINGS AND LIMITATIONS

We identified 1358 citations, resulting in 26 SRs eligible for inclusion. Six themes were identified: (1) invitation: men at general risk should be invited at >50 yr of age, and testing should be discontinued at >70 yr or with <10 yr of life expectancy; (2) decision-making: most health authorities discourage population-based screening and instead recommend a shared decision-making (SDM) approach, but implementation of SDM in clinical practice varies widely; decision aids help men make more informed and value-consistent screening decisions and decrease men's intention to attempt screening, but these do not affect screening uptake; (3) acceptance: facilitators for men considering screening include social prompting by partners and clinician recommendations, while barriers include a lack of knowledge, low-risk perception, and masculinity attributes; (4) screening test and algorithm: prostate-specific antigen-based screening reduces PCa-specific mortality and metastatic disease in men aged 55-69 yr at randomisation if screened at least twice; (5) harms and benefits: these benefits come at the cost of unnecessary biopsies, overdiagnosis, and subsequent overtreatment; and (6) future of screening: risk-adapted screening including (prebiopsy) risk calculators, magnetic resonance imaging, and blood- and urine-based biomarkers could reduce these harms. To enable a comprehensive overview, we focused on SRs. These do not include the most recent prospective studies, which were therefore incorporated in the discussion.

CONCLUSIONS AND CLINICAL IMPLICATIONS

By identifying consistent and conflicting evidence, this review highlights the evidence-based foundations that can be built upon, as well as areas requiring further research and improvement to reduce the burden of PCa in the EU and UK.

PATIENT SUMMARY

This review of 26 reviews covers various aspects of prostate cancer screening such as invitation, decision-making, screening tests, harms, and benefits. This review provides insights into existing evidence, highlighting the areas of consensus and discrepancies, to guide future research and improve prostate cancer screening strategies in Europe.

Impact of patients' age and comorbidities on prostate cancer overdiagnosis in clinical practice

INTRODUCTION

Overdiagnosis in PSA-based prostate cancer (PCa) screening is primarily studied in younger, healthier populations from clinical trials. This study aimed to evaluate the probability of overdiagnosis in PCa screening within a clinical practice context, focusing on its relationship with PSA levels, Gleason scores, and subsequent clinical procedures.

METHODS

We conducted a retrospective cohort analysis of 1,070 asymptomatic men over 40 years old diagnosed with PCa between 2004 and 2022, following a positive PSA test. The patients were followed until December 31, 2022, with a median follow-up time of 5.7 years (IQR 3.2-8.6). The primary outcome was the probability of overdiagnosis, assessed through life expectancy and the Charlson Comorbidity Index, considering lead times of 5, 10, and 15 years.

RESULTS

We found that patients with PSA levels >10 ng/dL and/or Gleason scores ≥8 were generally older and had more comorbidities than those with PSA levels 4-10 ng/dL and/or Gleason scores ≤7. The probability of overdiagnosis was significantly higher in patients with PSA levels >10 ng/dL (41.4%, IQR 21.5-73.9) and Gleason scores ≥8 (42.6%, IQR 14.9-38.9), compared to those with PSA levels 4-10 ng/dL (20.1%, IQR 12.8-30.4) and Gleason scores ≤7 (26.6%, IQR 23.6-68.6). Notably, 71.7% of patients did not receive pharmacological treatment. Patients with higher PSA levels also experienced greater radiation exposure from diagnostic imaging (median 19.9 mSv vs. 14.7 mSv, p = 0.004).

CONCLUSIONS

These findings underscore the high likelihood of overdiagnosis in older patients with elevated PSA levels and significant comorbidities, highlighting the need for careful consideration of patient comorbidities before PSA testing.

Physical activity, metabolites, and breast cancer associations

BACKGROUND

The effects of usual physical activity on physiology and disease prevention are not fully understood. We examined the associations between physical activity, metabolites, and breast cancer risk.

METHODS

Physical activity levels were assessed using doubly labeled water, accelerometers, and 24-hour recalls in the Interactive Diet and Activity Tracking in AARP (IDATA) Study (N = 707 participants, ages 50-74 years, 51% women), with 1 to 6 assessments over 12 months and 2 blood sample collections. Partial Spearman correlations were used to estimate associations between physical activity and 843 serum metabolites, corrected for multiple testing. Conditional logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of metabolites with postmenopausal breast cancer in a nested case-control study (621 cases, 621 controls); all statistical tests were 2-sided.

RESULTS

Physical activity was associated with 164 metabolites spanning numerous pathways, including amino acid and fatty acid metabolism. Twelve of these metabolites were also associated with breast cancer risk, 10 of which supported a protective role of physical activity. Notably, higher physical activity was associated with lower 16alpha-hydroxy dehydroepiandrosterone 3-sulfate (sulfated steroid) and adipoylcarnitine (fatty acid), both of which were associated with increased breast cancer risk (OR per 1 standard deviation [SD] = 1.34, 95% CI = 1.16 to 1.55 and 1.26, 1.11 to 1.42, respectively). Higher physical activity energy expenditure was also associated with lower sphingomyelin (d18:1/20:1, d18:2/20:0), which was associated with a reduced breast cancer risk (OR = 0.82, 95% CI = 0.73 to 0.93).

CONCLUSION

Physical activity is associated with a broad range of metabolites, many of which are consistent with a protective effect against breast cancer. Our findings highlight potential metabolic pathways for cancer prevention.

What does cancer screening have to do with tomato growing?

Cancer screening is considered to be a major strategy for combatting cancer. The United States Preventive Services Task Force (USPSTF) recommends screening for five cancers, but the strength of evidence about the effectiveness of screening is limited. To gain insights into the efficacy of early detection requires prospective, blinded, placebo-controlled clinical trials with decades of follow-up and inclusion of millions of participants. Recently, Bretthauer et al. estimated lifetime gained with cancer screening tests by using a meta-analysis of 18 large randomized clinical trials which included more than two million subjects. They asked if cancer screening tests are saving lives and how much life is extended due to commonly used cancer screening tests. Colorectal cancer screening with sigmoidoscopy prolonged lifetime by 110 days, while fecal testing and mammography screening did not prolong life. A modest extension of 37 days was noted for prostate cancer screening with prostate-specific antigen testing and 107 days with lung cancer screening using computed tomography, but these estimates were not statistically significant. The authors concluded that current cancer screening strategies do not significantly prolong life. Based on these data, and the known biological behavior of some cancers, we hypothesized that the current strategies of treating cancer, after detection, could be modified to avoid the side effects of screening, which is a major determinant of the patient's overall survival.

A cross-sectional study of the association between depression and serum prostate-specific antigen (PSA) among U.S. males: national health and nutrition examination survey (NHANES), 2005-2010

BACKGROUND

The association between depression and serum total prostate-specific antigen (PSA) concentrations remains unclear. To explore whether there is a relationship between depression and PSA in American males without prostate cancer (PCa), according to the National Health and Nutrition Examination Survey (NHANES) database.

METHODS

Three biennial cycles of survey data from 2005 to 2010 were used in our study. Multivariate adjusted regression analysis, stratified analysis, trend testing, smooth curve fitting and multiple imputation (MI) were our main research methods. Depression was assessed by the Patient Health Questionnaire-9 (PHQ-9).

RESULTS

The study included a total of 4185 participants. After adjusting all covariates, whether depression was used as a continuous [β = -0.038; 95% confidence interval (CI): -0.059, -0.017; P < 0.001] or categorical variable (P for trend = 0.001), especially in the mild [β = -0.239; 95% CI: -0.473, -0.006; P = 0.044)] and moderate [β = -0.499; 95% CI: -0.907, -0.092; P = 0.016)] depression groups, it was associated with a decrease in serum PSA concentrations. Smoothing curve fitting found the presence of a linear relationship, with PSA reduced by 0.038 ng/ml or 0.026 ng/ml (log-2 transformed total PSA) for each additional unit of depression score. Similar results were obtained for complete data after MI or data categorized by depressive symptoms.

CONCLUSIONS

Depression score is inversely correlated with serum total PSA concentrations among American men, and there is an interaction between depression and myocardial infarction.

CLINICAL TRIAL NUMBER

Not applicable.

Perspectives of clinicians and screening candidates on shared decision-making in prostate cancer screening with the prostate-specific antigen (PSA) test: a qualitative study (PROSHADE study)

OBJECTIVE

The objective of this study is to analyse the perspectives of screening candidates and healthcare professionals on shared decision-making (SDM) in prostate cancer (PCa) screening using the prostate-specific antigen (PSA) test.

DESIGN

Descriptive qualitative study (May-December 2022): six face-to-face focus groups and four semistructured interviews were conducted, transcribed verbatim and thematically analysed using ATLAS.ti software.

SETTING

Data were obtained as part of the project PROSHADE (Decision Aid for Promoting Shared Decision Making in Opportunistic Screening for Prostate Cancer) to develop a tool for SDM in PCa screening with PSA testing in Spain.

PARTICIPANTS

A total of 27 screening candidates (three groups of men: 40-50 years old; 51-60 years old and 61-80 years old), 25 primary care professionals (one group of eight nurses and two groups of physicians: one with more and one with less than 10 years of experience), and four urologists. Focus groups for patients and healthcare professionals were conducted separately.

MAIN OUTCOME MEASURES

Participants' perceptions of shared decision-making related to PSA opportunistic screening, including their understanding, preferences, and attitudes.

RESULTS

Three themes were generated: (1) perceptions of SDM, (2) perceptions of PSA testing and (3) perceptions of SDM regarding PCa screening. Theme 1: screening candidates valued SDM when it included clear information and empowered them. There was consensus with primary care health professionals on this point, although their knowledge and implementation of SDM varied. Theme 2: candidates were divided on PSA testing; some trusted it for early detection, while others expressed scepticism due to concerns about false positives and invasive procedures, reflecting gaps in accessible information. Theme 3: professionals across primary and specialised care stressed the need for standardised SDM protocols. Primary care physicians were particularly concerned that PSA decisions align with scientific evidence and urologists recognised SDM as valuable in PSA testing only if it was adequately explained to each patient. Barriers to implementing SDM included insufficient coordination across care levels, lack of consensus-driven protocols and limited clinical time.

CONCLUSIONS

While patients expect comprehensive information, primarily based on practice to achieve empowerment, healthcare professionals face obstacles such as limited time and insufficient coordination between primary care and urology. All stakeholders agree on the importance of evidence-based tools to reinforce effective SDM and enhance collaboration across urologists and primary care in the context of PSA testing.

Oncological outcomes after radical prostatectomy of localized prostate cancer: stratified by magnetic resonance imaging and risk classification

Background

We investigated whether combining T2-weighted magnetic resonance imaging (MRI) findings and clinical risk categories improves upon established prognostic indicators of oncological outcomes in prostate cancer.

Methods

Patients who underwent radical prostatectomy, but not preoperative hormone therapy, radiotherapy, or chemotherapy, for localized prostate cancer at Seoul National University Bundang Hospital from October 2007 to April 2016 were included. MRIs were classified according to the Prostate Imaging-Reporting and Data System (PI-RADS). Patients were divided into the following five groups: 1, no focal suspicious lesion; 2, organ-confined suspicious lesion PI-RADS ≤3; 3, organ-confined suspicious lesion PI-RADS 4 or 5; 4, suspicious lesion with extraprostatic extension (EPE), no seminal vesicle invasion (SVI); 5, suspicious lesion with EPE and SVI. Risk classified according to the National Comprehensive Cancer Network (NCCN) and MRI findings were combined to analyze survival curves for biochemical recurrence (BCR)-free and metastasis-free survival. The area under a time-dependent receiver operating characteristic was analyzed for event prediction after 5 years.

Results

We analyzed 1,290 patients. In multivariate Cox regression models, PI-RADS ≥4 (hazard ratio [HR] 2.33, P < 0.001), EPE (HR 1.46, P = 0.027), SVI (HR 5.03, P < 0.001) and NCCN high-risk (HR 2.33, 95% CI 1.66-3.26, P < 0.001) were associated with BCR. For metastasis, EPE (HR 2.33, P = 0.047), SVI (HR 13.08, P < 0.001) and NCCN high-risk (HR 2.78, P = 0.026) were independent risk factors. Depending on MRI group, BCR-free survival significantly decreased in NCCN intermediate-risk (P = 0.001) and high-risk (P < 0.001) groups, and metastasis-free survival decreased in the intermediate-risk group (P = 0.39) and significantly decreased in the high-risk (P < 0.001) group. Adding MRI group to NCCN risk classification significantly improved the predictive accuracy for BCR in comparison with NCCN risk classification alone (P = 0.042), but not for metastasis (P = 0.012).

Conclusion

Combining prostate MRI with NCCN risk classification improves the prediction value of BCR following radical prostatectomy for localized prostate cancer.

Prostate cancer incidence rates, trends, and treatment related to prostate-specific antigen screening recommendations in the United States

BACKGROUND

Changes in US prostate-specific antigen (PSA) screening guidelines have impacted prostate cancer (PCa) incidence rates and trends. This study shows corresponding changes in PCa incidence rates and describes treatment patterns by tumor stage, age, and race/ethnicity.

METHODS

Analyses were based on 777,152 cases diagnosed in 17 population-based tumor registries in the SEER Program of the US National Cancer Institute, 2007-2021. Rates were age adjusted and trends assessed using annual percent change and joinpoint regression.

RESULTS

PCa age-adjusted incidence rates (per 100,000) fell from 165.8 in 2007 to 101 in 2014 (APC=-6.51, p<0.05) and then rose to 121.2 in 2021 (APC=1.87, p< 0.05). The significant fall and rise in rates appeared in ages 55-69 and ≥70, all racial/ethnic groups (except in Hispanics during 2014-2021), and in local/regional stage. PCa incidence rates by tumor stage, age, and race/ethnicity were presented and discussed. A few PCa cases were identified through autopsy or death certificate among the racial/ethnic groups (0.68 %-1.37 %). Unstaged cases identified through sources other than autopsy or death certificate significantly varied by race/ethnicity, ranging from 4.13 % for non-Hispanic (NH) Whites to 9.5 % for Hispanic (Chi-square p <.0001). In 2017-2021, surgery occurred in 33 % of cases (primarily in local/regional cases, inversely associated with age), radiation in 30 % of cases (increasing with age in local/regional stage cases and decreasing with age in distant stage cases), and chemotherapy in 2 % of cases (<1 % in local/regional stage cases and 9 %-38 % for age groups in distant stage cases). Several racial/ethnic differences in treatment exist, such as NH Blacks (vs. NH Whites) with local/regional disease were significantly less likely to receive surgery and more likely to receive radiation.

CONCLUSIONS

Understanding trends and patterns of PCa rates and treatment among patients by tumor stage, age, and race/ethnicity can guide public health planning in relation to screening and treatment.

Liquid-Biopsy Glycan Score Biomarker Accurately Indicates and Stratifies Primary and Metastatic Prostate Cancers

Prostate cancer (PCa) is the most commonly diagnosed cancer in males. Early PCa usually shows no clinical symptoms and its primary diagnosis is currently guided by liquid-biopsy testing of serum prostate-specific antigen (PSA). This testing suffers from high false-positive and false-negative rates. Identifying new biomarkers for precise liquid-biopsy detection of PCa is, thus, an acute clinical request. Here, by using an advanced dual-functional aptamer assay, we quantified the extent of glycosylation of PSA circulating in cancer patients' serum, linked it to cancer-related breakage of PSA complexes with serum-circulating proteins, and proved its facility for stratification of primary and metastatic PCa. PSA's "Glycan Score" 100% accurately informed about PCa status in a 30-patient cohort, while serum PSA's concentration correctly classified only 53% of PCa patients and did not inform about their PCa status. The Glycan Score liquid-biopsy test thus has a huge potential for accurate diagnosis and staging of PCa, enabling mass-screening program progress and advanced PCa treatment monitoring.

Multidimensional Healthcare Access Barriers to Prostate-Specific Antigen Testing: A Nation-Wide Panel Study in the United States From 2006 to 2020

BACKGROUND

Rising metastatic prostate cancer incidence has renewed debate regarding benefits of prostate-specific antigen (PSA) screening. Identifying barriers to accessing screening for individuals at high risk of lethal prostate cancer may slow this rise. We examined associations of access barriers with receipt of PSA testing, stratified by sociodemographic factors.

METHODS

We pooled data from male respondents to Behavior Risk Factor Surveillance Systems (BRFSS) surveys from 2006 to 2020. Questions related to affordability (insurance, cost of visits) and accommodation (regular primary care provider (PCP), physician recommending a PSA test) were considered as individual-level barriers. For availability, we linked provider density from the 2012 Area Health Resource File and estimated driving times to closest health facility within Micropolitan and Metropolitan Statistical Area (MMSA) using Google Earth Engine. These measures were used to compute a spatial accessibility index. We fit survey-weighted, covariate-adjusted logistic regression models to estimate associations of barriers with receipt of PSA within the past 2 years and examined effect modification by sociodemographic factors.

RESULTS

There were 185,643 participants, of whom 73% were White, 11% were Black, 4% were Asian, and 11% were Hispanic. Physician recommendation was the strongest predictor of having a PSA test (aOR: 14.5, 95% CI: 13.6, 15.6). Not having a regular PCP (aOR: 0.29, 95% CI: 0.27, 0.31), insurance (aOR: 0.64, 95% CI: 0.58, 0.71), and prohibitive cost of care (aOR: 0.82, 95% CI: 0.75, 0.90) were associated with lower PSA testing. Access barriers were stronger predictors of PSA testing for Asian and White participants compared to other groups (Phet < 0.004 for insurance and regular PCP) and for those with college education compared to those without (Phet < 0.05 for insurance, perceived unaffordability).

DISCUSSION

Physician recommendation was the strongest predictor of receipt of PSA testing, regardless of sociodemographic grouping. Future studies should consider access barriers jointly and across sociodemographic strata.

The Influence of Disparities on Prostate Cancer at Diagnosis in the Charlotte Metropolitan Area

INTRODUCTION

Prostate cancer (PCa) is the most diagnosed noncutaneous malignancy and second leading-cause of cancer death in men, yet screening is decreasing. As PCa screening has become controversial, socioeconomic disparities in PCa diagnosis and outcomes widen. This study was designed to determine the current disparities influencing PCa diagnosis in Charlotte, NC.

METHODS

The Levine Cancer Institute database was queried for patients with PCa, living in metropolitan Charlotte. Socioeconomic status (SES) was determined by the Area Deprivation Index (ADI); higher ADI indicated lower SES. Patients were compared by their National Comprehensive Cancer Network risk stratification. Artificial intelligence predictive models were trained and heatmaps were created, demonstrating the geographic and socioeconomic disparities in late-stage PCa.

RESULTS

Of the 802 patients assessed, 202 (25.2%) with high-risk PCa at diagnosis were compared with 198 (24.7%) with low-risk PCa. High-risk PCa patients were older (69.8 ± 9.0 vs. 64.0 ± 7.9 years; p < 0.001) with lower SES (ADI block: 98.4 ± 20.9 vs. 92.1 ± 19.8; p = 0.004) and more commonly African-American (White: 66.2% vs. 78.3%, African-American: 31.3% vs. 20.7%; p = 0.009). On regression, ADI block was an independent predictor (odds ratio [OR] = 1.013, 95% confidence interval [CI] 1.002-1.024; p = 0.024) of high-risk PCa at diagnosis, whereas race was not (OR = 1.312, 95% CI 0.782-2.201; p = 0.848). A separate regression demonstrated higher ADI (OR = 1.016, 95% CI 1.004-1.027; p = 0.006) and older age (OR = 1.083, 95% CI 1.054-1.114; p < 0.001) were independent predictors for high-risk PCa. Findings, depicted in heatmaps, demonstrated the geographic locations where men with PCa were predicted to have high-risk disease based on their age and SES.

CONCLUSIONS

Socioeconomic status was more closely associated with high-risk PCa at diagnosis than race. Although, of any variable, age was most predictive. The heatmaps identified areas that would benefit from increased awareness, education, and screening to facilitate an earlier PCa diagnosis.

PSA screening for prostate cancer in the United States: 30 years of controversy

In 1994, the United States approved the Prostate-Specific Antigen (PSA) test as a screening tool for prostate cancer. It did so despite the test's inherent weakness: not being prostate cancer specific. Subsequent randomized trials yielded conflicting results as to its benefits. Medical guideline organizations are concerned that PSA screening results in the diagnosis and treatment of clinically indolent prostate cancer. Nevertheless, PSA screening is prevalent in North America and Europe with PSA screening increasing in other regions. We provide a critical review of the major factors that led to the prevalence of PSA screening in the United States despite the debate about its benefits. Public advocacy in favor of the test and failure of the medical community to appreciate its inherent weakness led to widespread adoption. These factors persist today. Other countries need to carefully analyze the utility of the PSA test before adopting it.

Premature mortality trends in 183 countries by cancer type, sex, WHO region, and World Bank income level in 2000-19: a retrospective, cross-sectional, population-based study

BACKGROUND

Cancer is a leading cause of mortality worldwide. By 2040, over 30 million new cancers are predicted, with the greatest cancer burden in low-income countries. In 2015, the UN passed the Sustainable Development Goal 3.4 (SDG 3.4) to tackle the rising burden of non-communicable diseases, which calls for a reduction by a third in premature mortality from non-communicable diseases, including cancer, by 2030. However, there is a paucity of data on premature mortality rates by cancer type. In this study, we examine annual rates of change for cancer-specific premature mortality and classify whether countries are on track to reach SDG 3.4 targets.

METHODS

This is a retrospective, cross-sectional, population-based study investigating premature mortality trends from 2000-19 using the WHO Global Health Estimates data. All cancers combined and thirteen individual cancers in 183 countries were examined by WHO region, World Bank income level, and sex. The risk of premature mortality was calculated for ages 30-69 years, independent of other competing causes of death, using standard life table methods. The primary objective was to compute average annual rate of change in premature mortality from 2000 to 2019. Secondary objectives assessed whether this annual rate of change would be sufficient to reach SDG 3.4. targets for premature mortality by 2030.

FINDINGS

This study was conducted using data retrieved for the years 2000-19. Premature mortality rates decreased in 138 (75%) of 183 countries across all World Bank income levels and WHO regions, however only eight (4%) countries are likely to meet the SDG 3.4 targets for all cancers combined. Cancers where early detection strategies exist, such as breast and colorectal cancer, have higher declining premature mortality rates in high-income countries (breast cancer 48 [89%] of 54 and colorectal cancer 45 [83%]) than in low-income countries (seven [24%] of 29 and four [14%]). Cancers with primary prevention programmes, such as cervical cancer, have more countries with declining premature mortality rates (high-income countries 50 [93%] of 54 and low-income countries 26 [90%] of 29). Sex-related disparities in premature mortality rates vary across WHO regions, World Bank income groups, and by cancer type.

INTERPRETATION

There is a greater reduction in premature mortality for all cancers combined and for individual cancer types in high-income countries compared with lower-middle-income and low-income countries. However, most countries will not reach the SDG 3.4 target. Cancers with early detection strategies in place, such as breast and colorectal cancers, are performing poorly in premature mortality compared with cancers with primary prevention measures, such as cervical cancer. Investments toward prevention, early detection, and treatment can potentially accelerate declines in premature mortality.

FUNDING

WHO.

Prostate-Specific Antigen Screening and Prostate Cancer Mortality: An Emulation of Target Trials in US Medicare

PURPOSE

No consensus about the effectiveness of prostate-specific antigen (PSA) screening exists among clinical guidelines, especially for the elderly. Randomized trials of PSA screening have yielded different results, partly because of variations in adherence, and it is unlikely that new trials will be conducted. Our objective was to estimate the effect of annual PSA screening on prostate cancer (PC) mortality in Medicare beneficiaries age 67-84 years.

METHODS

This is a large-scale, population-based, observational study of two screening strategies: annual PSA screening and no screening. We used data from 537,599 US Medicare (2001-2008) beneficiaries age 67-84 years who had a good life expectancy, no previous PC, and no PSA test in the 2 years before baseline. We estimated the 8-year PC mortality and incidence, treatments for PC, and treatment complications of PSA screening.

RESULTS

In men age 67-74 years, the estimated difference in 8-year risk of PC death between PSA screening and no screening was -2.3 (95% CI, -4.1 to -1.1) deaths per 1,000 men (a negative risk difference favors screening). Treatment complications were more frequent under PSA screening than under no screening. In men age 75-84 years, risk difference estimates were closer to zero.

CONCLUSION

Our estimates suggest that under conventional statistical criteria, annual PSA screening for 8 years is highly compatible with reductions of PC mortality from four to one fewer PC deaths per 1,000 screened men age 67-74 years. As with any study using real-world data, the estimates could be affected by residual confounding.

Determinants of receipt of prostate cancer screening among men living with HIV enrolled in an urban HIV Clinic in the United States over the period of 2000-2020

BACKGROUND

Prostate cancer is projected to account for the greatest proportion of cancer-related burden among men with HIV. However, incidence is reportedly lower than in men without HIV, potentially due to differences in screening. Factors influencing receipt of screening in men with HIV are unknown. We described receipt of prostate-specific antigen (PSA) testing and assessed factors for association with receipt of PSA test.

METHODS

Demographics, measures of HIV and related care, and non-HIV care were assessed for association with receipt of first PSA test in men ≥40 years old each calendar year in 2000-2020 using univariable and multivariable Poisson regression. Models were additionally stratified by calendar period to identify changes in determinants of PSA test as prostate cancer screening guidelines changed.

RESULTS

Men (n = 2,063) 72% Non-Hispanic Black, median age of 47 (IQR: 41, 53), contributed median of 4.7 years (IQR: 2.3, 10.0) of follow-up. Receipt of antiretroviral therapy (aIRR = 1.33; 95% CI: 1.14, 1.55), engagement in HIV care (aIRR = 2.09; 95% CI: 1.66, 2.62), history of testosterone-replacement therapy (aIRR = 1.34; 95% CI: 1.19, 1.50), urologist evaluation (aIRR = 1.66; 95% CI: 1.35, 2.05), and receipt of PSA test in preceding two years (no elevated PSA aIRR = 2.37; 95% CI: 2.16, 2.61; elevated PSA aIRR = 4.35; 95% CI: 3.24, 5.84) were associated with PSA testing in men aged 50 or older. Associations varied across calendar time.

CONCLUSION

Findings suggest men with greater interaction with healthcare are more likely to receive PSA test. Measures of control of HIV did not appear to influence the decision to screen.

Prostate cancer-derived extracellular vesicles metabolic biomarkers: Emerging roles for diagnosis and prognosis

Prostate cancer (PCa) is a global health concern, ranking as the most common cancer among men in Western countries. Traditional diagnostic methods are invasive with adverse effects on patients. Due to the heterogeneous nature of PCa and their multifocality, tissue biopsies often yield false-negative results. To address these challenges, researchers are exploring innovative approaches, particularly in the realms of proteomics and metabolomics, to identify more reliable biomarkers and improve PCa diagnosis. Liquid biopsy (LB) has emerged as a promising non-invasive strategy for PCa early detection, biopsy selection, active surveillance for low-risk cases, and post-treatment and progression monitoring. Extracellular vesicles (EVs) are lipid-bilayer nanovesicles released by all cell types and play an important role in intercellular communication. EVs have garnered attention as a valuable biomarker resource in LB for PCa-specific biomarkers, enhancing diagnosis, prognostication, and treatment guidance. Metabolomics provides insight into the body's metabolic response to both internal and external stimuli, offering quantitative measurements of biochemical alterations. It excels at detecting non-genetic influences, aiding in the discovery of more accurate cancer biomarkers for early detection and disease progression monitoring. This review delves into the potential of EVs as a resource for LB in PCa across various clinical applications. It also explores cancer-related metabolic biomarkers, both within and outside EVs in PCa, and summarises previous metabolomic findings in PCa diagnosis and risk assessment. Finally, the article addresses the challenges and future directions in the evolving field of EV-based metabolomic analysis, offering a comprehensive overview of its potential in advancing PCa management.

Optimising Extracellular Vesicle Metabolomic Methodology for Prostate Cancer Biomarker Discovery

Conventional diagnostic tools for prostate cancer (PCa), such as prostate-specific antigen (PSA), transrectal ultrasound (TRUS), digital rectal examination (DRE), and tissue biopsy face, limitations in individual risk stratification due to invasiveness or reliability issues. Liquid biopsy is a less invasive and more accurate alternative. Metabolomic analysis of extracellular vesicles (EVs) holds a promise for detecting non-genetic alterations and biomarkers in PCa diagnosis and risk assessment. The current research gap in PCa lies in the lack of accurate biomarkers for early diagnosis and real-time monitoring of cancer progression or metastasis. Establishing a suitable approach for observing dynamic EV metabolic alterations that often occur earlier than being detectable by other omics technologies makes metabolomics valuable for early diagnosis and monitoring of PCa. Using four distinct metabolite extraction approaches, the metabolite cargo of PC3-derived large extracellular vesicles (lEVs) was evaluated using a combination of methanol, cell shearing using microbeads, and size exclusion filtration, as well as two fractionation chemistries (pHILIC and C18 chromatography) that are also examined. The unfiltered methanol-microbeads approach (MB-UF), followed by pHILIC LC-MS/MS for EV metabolite extraction and analysis, is effective. Identified metabolites such as L-glutamic acid, pyruvic acid, lactic acid, and methylmalonic acid have important links to PCa and are discussed. Our study, for the first time, has comprehensively evaluated the extraction and separation methods with a view to downstream sample integrity across omics platforms, and it presents an optimised protocol for EV metabolomics in PCa biomarker discovery.

Access to Prostate-Specific Antigen Testing and Mortality Among Men With Prostate Cancer

Importance

Prostate-specific antigen (PSA) screening for prostate cancer is controversial but may be associated with benefit for certain high-risk groups.

Objectives

To evaluate associations of county-level PSA screening prevalence with prostate cancer outcomes, as well as variation by sociodemographic and clinical factors.

Design, Setting, and Participants

This cohort study used data from cancer registries based in 8 US states on Hispanic, non-Hispanic Black, and non-Hispanic White men aged 40 to 99 years who received a diagnosis of prostate cancer between January 1, 2000, and December 31, 2015. Participants were followed up until death or censored after 10 years or December 31, 2018, whichever end point came first. Data were analyzed between September 2023 and January 2024.

Exposure

County-level PSA screening prevalence was estimated using the Behavior Risk Factor Surveillance System survey data from 2004, 2006, 2008, 2010, and 2012 and weighted by population characteristics.

Main Outcomes and Measures

Multivariable logistic, Cox proportional hazards regression, and competing risks models were fit to estimate adjusted odds ratios (AOR) and adjusted hazard ratios (AHR) for associations of county-level PSA screening prevalence at diagnosis with advanced stage (regional or distant), as well as all-cause and prostate cancer-specific survival.

Results

Of 814 987 men with prostate cancer, the mean (SD) age was 67.3 (9.8) years, 7.8% were Hispanic, 12.2% were non-Hispanic Black, and 80.0% were non-Hispanic White; 17.0% had advanced disease. There were 247 570 deaths over 5 716 703 person-years of follow-up. Men in the highest compared with lowest quintile of county-level PSA screening prevalence at diagnosis had lower odds of advanced vs localized stage (AOR, 0.86; 95% CI, 0.85-0.88), lower all-cause mortality (AHR, 0.86; 95% CI, 0.85-0.87), and lower prostate cancer-specific mortality (AHR, 0.83; 95% CI, 0.81-0.85). Inverse associations between PSA screening prevalence and advanced cancer were strongest among men of Hispanic ethnicity vs other ethnicities (AOR, 0.82; 95% CI, 0.78-0.87), older vs younger men (aged ≥70 years: AOR, 0.77; 95% CI, 0.75-0.79), and those in the Northeast vs other US Census regions (AOR, 0.81; 95% CI, 0.79-0.84). Inverse associations with all-cause mortality were strongest among men of Hispanic ethnicity vs other ethnicities (AHR, 0.82; 95% CI, 0.78-0.85), younger vs older men (AHR, 0.81; 95% CI, 0.77-0.85), those with advanced vs localized disease (AHR, 0.80; 95% CI, 0.78-0.82), and those in the West vs other US Census regions (AHR, 0.89; 95% CI, 0.87-0.90).

Conclusions and Relevance

This population-based cohort study of men with prostate cancer suggests that higher county-level prevalence of PSA screening was associated with lower odds of advanced disease, all-cause mortality, and prostate cancer-specific mortality. Associations varied by age, race and ethnicity, and US Census region.

Prostate cancer screening in Switzerland: a literature review and consensus statement from the Swiss Society of Urology

Over a decade ago, the United States Preventive Services Taskforce (USPSTF) recommended against prostate-specific antigen (PSA)-based screening for prostate cancer in all men, which considerably influenced prostate cancer screening policies worldwide after that. Consequently, the world has seen increasing numbers of advanced stages and prostate cancer deaths, which later led the USPSTF to withdraw its initial statement. Meanwhile, the European Union has elaborated a directive to address the problem of implementing prostate cancer screening in "Europe's Beating Cancer Plan". In Switzerland, concerned urologists formed an open Swiss Prostate Cancer Screening Group to improve the early detection of prostate cancer. On the 20th of September 2023, during the annual general assembly of the Swiss Society of Urology (SGU/SSU) in Lausanne, members positively voted for a stepwise approach to evaluate the feasibility of implementing organised prostate cancer screening programs in Switzerland. The following article will summarise the events and scientific advances in the last decade during which evidence and promising additional modalities to complement PSA-based prostate cancer screening have emerged. It also aims to provide an overview of contemporary strategies and their potential harms and benefits.

Variation in harms and benefits of prostate-specific antigen screening for prostate cancer by socio-clinical risk factors: A rapid review

Objective

To analyse the latest evidence on the relative harms and benefits of screening and diagnostic pathways with close examination of (i) men aged 50 years or older, (ii) men whose ethnicity places them at higher risk and (iii) men with a family history.

Methods

We conducted a literature search using PubMed and Cochrane Central Register of Controlled Trials (CENTRAL) databases and other sources, from January 1990 to 25 January 2023. Two independent reviewers selected for randomised controlled trials (RCTs) and cohort studies which met our inclusion criteria.

Results

Twenty-eight articles were selected, from six trials, including the Göteborg trial-reported separately from European Randomised Study of Screening for Prostate Cancer (ERSPC). Prostate-specific antigen (PSA)-based screening led to the increased detection of low-grade cancer and reduction of advanced/metastatic disease but had contradictory effects on prostate cancer (PCa)-specific mortality (no difference or reduced), possibly due to issues of contamination or compliance. Screening men from a relatively young age (50-55) reduced risk of PCa-specific mortality in a subanalysis of an 18-year follow-up study and in a 17-year cohort study from the main Göteborg trial. Moreover, one Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial analysis reported a trend of reduced risk of PCa-specific mortality for men with a family history who were screened. [Correction added on 05 March 2024, after first online publication: "Cancer Screening Trial" has been added to the preceding sentence.] However, we did not find relevant studies for ethnicity.

Conclusion

Under current UK practice, the choice to conduct a PSA test relies on a shared decision-making approach guided by known risk factors. However, we found there was a lack of strong evidence on the harms and benefits of PSA screening by socio-clinical risk factors and suggest further research is required to understand the long-term impact of screening on high-risk populations in the current diagnostic setting.

Prediagnostic Prostate-specific Antigen Testing and Clinical Characteristics in Men with Lethal Prostate Cancer

Background and objective

Prostate cancer (PC) is the fifth leading cause of cancer-related mortality in men worldwide. Opportunistic testing with prostate-specific antigen (PSA) has limited impact on PC mortality. Our objective was to assess prediagnostic PSA testing patterns and clinical characteristics at diagnosis in men with lethal PC.

Methods

We conducted a population-based observational study of all men dying from PC in Stockholm County, Sweden, from 2015 to 2019. Data were retrieved from the National Prostate Cancer Register and the Stockholm PSA and Biopsy Register. If the first PSA was registered within 1 yr before diagnosis, men were categorised as PSA naïve. If an elevated PSA level was registered >1 yr before diagnosis without leading to prostate biopsy or repeating PSA within 1 yr, men were categorised as having delayed diagnosis. If a normal PSA level was registered within 5 yr before diagnosis, followed by an elevated PSA level that resulted in PC diagnosis within 1 yr, men were categorised as PSA tested. Clinical characteristics at diagnosis were stratified with D'Amico risk group classification.

Key findings and limitations

Among 1473 men dying from PC, PSA test history was available for 995. Of these men, 60% (n = 592) were PSA naïve, 25% (n = 250) received delayed diagnosis, and 15% (n = 153) were PSA tested. After examining all 1473 men, 25% (n = 350) were diagnosed with low- or intermediate-risk cancer, 48% (n = 687) with high-risk cancer, and 27% (n = 385) with metastatic disease. Limitations include the retrospective design.

Conclusions and clinical implications

Many men with lethal PC lacked PSA testing before diagnosis or had been tested without subsequent follow-up. Nearly half of the study population was diagnosed with high-risk cancer and almost one-third with metastatic disease. These findings suggest further evaluation of the current opportunistic PSA testing approach.

Patient summary

Data from a population-based observational study of men dying from prostate cancer showed that many of them did not undergo either prostate-specific antigen (PSA) testing before diagnosis or subsequent follow-up if tested. These findings implicate deficiencies in the current opportunistic PSA testing approach.

Mortality reduction and cumulative excess incidence (CEI) in the prostate-specific antigen (PSA) screening era

The extent to which PSA screening is related to prostate cancer mortality reduction in the United States (US) is controversial. US Surveillance, Epidemiology, and End Results Program (SEER) data from 1980 to 2016 were examined to assess the relationship between prostate cancer mortality and cumulative excess incidence (CEI) in the PSA screening era and to clarify the impact of race on this relationship. CEI was considered as a surrogate for the intensity of prostate cancer screening with PSA testing and subsequent biopsy as appropriate. Data from 163,982,733 person-years diagnosed with 544,058 prostate cancers (9 registries, 9% of US population) were examined. Strong inverse linear relationships were noted between CEI and prostate cancer mortality, and 317,356 prostate cancer deaths were avoided. Eight regions of the US demonstrated prostate cancer mortality reduction of 46.0-63.7%. On a per population basis, the lives of more black men than white men were saved in three of four registries with sufficient black populations for comparison. Factor(s) independent of CEI (potential effects of treatment advances) explained 14.6% of the mortality benefit (p-value = 0.3357) while there was a significant main effect of CEI (effect = -0.0064; CI: [-0.0088, -0.0040]; p-value < 0.0001). Therefore, there is a strong relationship between CEI and prostate cancer mortality reduction that was not related to factors independent of screening utilization. Minority populations have experienced large mortality reductions in the context of PSA mass utilization.

Benefits and harms of prostate specific antigen testing according to Australian guidelines

Guidelines for prostate specific antigen (PSA) testing in Australia recommend that men at average risk of prostate cancer who have been informed of the benefits and harms, and who decide to undergo regular testing, should be offered testing every 2 years from 50 to 69 years. This study aimed to estimate the benefits and harms of regular testing in this context. We constructed Policy1-Prostate, a discrete event microsimulation platform of the natural history of prostate cancer and prostate cancer survival, and PSA testing patterns and subsequent management in Australia. The model was calibrated to pre-PSA (before 1985) prostate cancer incidence and mortality and validated against incidence and mortality trends from 1985 to 2011 and international trials. The model predictions were concordant with trials and Australian observed incidence and mortality data from 1985 to 2011. Out of 1000 men who choose to test according to the guidelines, 36 [21-41] men will die from prostate cancer and 126 [119-133] men will be diagnosed with prostate cancer, compared with 50 [47-54] and 94 [90-98] men who do not test, respectively. During the 20 years of active PSA testing, 32.3% [25.6%-38.8%] of all PSA-test detected cancers are overdiagnosed cases that is, 30 [21-42] out of 94 [83-107] PSA-test detected cancers. Australian men choosing to test with PSA every two years from 50 to 69 will reduce their risk of ever dying from prostate cancer and incur a risk of overdiagnosis: for every man who avoids dying from prostate cancer, two will be overdiagnosed with prostate cancer between 50 and 69 years of age. Australian men, with health professionals, can use these results to inform decision-making about PSA testing.

Quality of Life Longitudinal Evaluation in Prostate Cancer Patients from Radiotherapy Start to 5 Years after IMRT-IGRT

PURPOSE

The purpose of this study is to study the evolution of quality of life (QoL) in the first 5 years following Intensity-modulated radiation therapy (IMRT) for prostate cancer (PCa) and to determine possible associations with clinical/treatment data.

MATERIAL AND METHODS

Patients were enrolled in a prospective multicentre observational trial in 2010-2014 and treated with conventional (74-80 Gy, 1.8-2 Gy/fr) or moderately hypofractionated IMRT (65-75.2 Gy, 2.2-2.7 Gy/fr). QoL was evaluated by means of EORTC QLQ-C30 at baseline, at radiation therapy (RT) end, and every 6 months up to 5 years after IMRT end. Fourteen QoL dimensions were investigated separately. The longitudinal evaluation of QoL was analysed by means of Analysis of variances (ANOVA) for multiple measures.

RESULTS

A total of 391 patients with complete sets of questionnaires across 5 years were available. The longitudinal analysis showed a trend toward the significant worsening of QoL at RT end for global health, physical and role functioning, fatigue, appetite loss, diarrhoea, and pain. QoL worsening was recovered within 6 months from RT end, with the only exception being physical functioning. Based on ANOVA, the most impaired time point was RT end. QoL dimension analysis at this time indicated that acute Grade ≥ 2 gastrointestinal (GI) toxicity significantly impacted global health, physical and role functioning, fatigue, appetite loss, diarrhoea, and pain. Acute Grade ≥ 2 genitourinary (GU) toxicity resulted in lower role functioning and higher pain. Prophylactic lymph-nodal irradiation (WPRT) resulted in significantly lower QoL for global health, fatigue, appetite loss, and diarrhoea; lower pain with the use of neoadjuvant/concomitant hormonal therapy; and lower fatigue with the use of an anti-androgen.

CONCLUSIONS

In this prospective, longitudinal, observational study, high radiation IMRT doses delivered for PCa led to a temporary worsening of QoL, which tended to be completely resolved at six months. Such transient worsening was mostly associated with acute GI/GU toxicity, WPRT, and higher prescription doses.

Incorporating Genetic Risk Into Prostate Cancer Care: Implications for Early Detection and Precision Oncology

The availability and cost of germline and somatic genetic testing have dramatically improved over the past two decades, enabling precision medicine approaches in oncology, with significant implications for prostate cancer (PCa) care. Roughly 12% of individuals with advanced disease are carriers of rare pathogenic germline variants that predispose to particularly aggressive and earlier-onset disease. Several of these variants are already established as clinically actionable by modern precision oncology therapeutics, while others may come to aid the selection of active surveillance, definitive local therapies, and systemic therapies. Concurrently, the number of common variants (ie, incorporated into polygenic risk scores) associated with PCa risk has continued to grow, but with several important considerations both at the intersection of race and ancestry and for early detection of aggressive disease. Family history has historically been used as a proxy for this inherited genetic risk of PCa, but recently emerging evidence examining this relation has shifted our understanding of how best to leverage this tool in PCa care. This review seeks to clarify and contextualize the existing and emerging precision oncology paradigms that use inherited genetic risk in PCa care, for both early detection and localized disease management.

Racial Disparities in Prostate Cancer Screening: The Role of Shared Decision Making

INTRODUCTION

The 2018 U.S. Preventive Services Task Force recommendations endorsed shared decision making for men aged 55-69 years, encouraging consideration of patient race/ethnicity for prostate-specific antigen screening. This study aimed to assess whether a proxy shared decision-making variable modified the impact of race/ethnicity on the likelihood of prostate-specific antigen screening.

METHODS

A cross-sectional analysis of men aged between 55 and 69 years, who responded to the prostate-specific antigen screening portions of the 2020 U.S.-based Behavioral Risk Factor Surveillance System survey, was performed between September and December 2022. Complex sample multivariable logistic regression models with an interaction term combining race and estimated shared decision making were used to test whether shared decision making modified the impact of race/ethnicity on screening.

RESULTS

Of a weighted sample of 26.8 million men eligible for prostate-specific antigen screening, 25.7% (6.9 million) reported for prostate-specific antigen screening. In adjusted analysis, estimated shared decision making was a significant predictor of prostate-specific antigen screening (AOR=2.65, 95% CI=2.36, 2.98, p<0.001). The interaction between race/ethnicity and estimated shared decision making on the receipt of prostate-specific antigen screening was significant (pint=0.001). Among those who did not report estimated shared decision making, both non-Hispanic Black (OR=0.77, 95% CI=0.61, 0.97, p=0.026) and Hispanic (OR=0.51, 95% CI=0.39, 0.68, p<0.001) men were significantly less likely to undergo prostate-specific antigen screening than non-Hispanic White men. On the contrary, among respondents who reported estimated shared decision making, no race-based differences in prostate-specific antigen screening were found.

CONCLUSIONS

Although much disparities research focuses on race-based differences in prostate-specific antigen screening, research on strategies to mitigate these disparities is needed. Shared decision making might attenuate the impact of race/ethnic disparities on the likelihood of prostate-specific antigen screening.

Development and validation of open-source deep neural networks for comprehensive chest x-ray reading: a retrospective, multicentre study

BACKGROUND

Artificial intelligence (AI) systems for automated chest x-ray interpretation hold promise for standardising reporting and reducing delays in health systems with shortages of trained radiologists. Yet, there are few freely accessible AI systems trained on large datasets for practitioners to use with their own data with a view to accelerating clinical deployment of AI systems in radiology. We aimed to contribute an AI system for comprehensive chest x-ray abnormality detection.

METHODS

In this retrospective cohort study, we developed open-source neural networks, X-Raydar and X-Raydar-NLP, for classifying common chest x-ray findings from images and their free-text reports. Our networks were developed using data from six UK hospitals from three National Health Service (NHS) Trusts (University Hospitals Coventry and Warwickshire NHS Trust, University Hospitals Birmingham NHS Foundation Trust, and University Hospitals Leicester NHS Trust) collectively contributing 2 513 546 chest x-ray studies taken from a 13-year period (2006-19), which yielded 1 940 508 usable free-text radiological reports written by the contemporary assessing radiologist (collectively referred to as the "historic reporters") and 1 896 034 frontal images. Chest x-rays were labelled using a taxonomy of 37 findings by a custom-trained natural language processing (NLP) algorithm, X-Raydar-NLP, from the original free-text reports. X-Raydar-NLP was trained on 23 230 manually annotated reports and tested on 4551 reports from all hospitals. 1 694 921 labelled images from the training set and 89 238 from the validation set were then used to train a multi-label image classifier. Our algorithms were evaluated on three retrospective datasets: a set of exams sampled randomly from the full NHS dataset reported during clinical practice and annotated using NLP (n=103 328); a consensus set sampled from all six hospitals annotated by three expert radiologists (two independent annotators for each image and a third consultant to facilitate disagreement resolution) under research conditions (n=1427); and an independent dataset, MIMIC-CXR, consisting of NLP-annotated exams (n=252 374).

FINDINGS

X-Raydar achieved a mean AUC of 0·919 (SD 0·039) on the auto-labelled set, 0·864 (0·102) on the consensus set, and 0·842 (0·074) on the MIMIC-CXR test, demonstrating similar performance to the historic clinical radiologist reporters, as assessed on the consensus set, for multiple clinically important findings, including pneumothorax, parenchymal opacification, and parenchymal mass or nodules. On the consensus set, X-Raydar outperformed historical reporter balanced accuracy with significance on 27 of 37 findings, was non-inferior on nine, and inferior on one finding, resulting in an average improvement of 13·3% (SD 13·1) to 0·763 (0·110), including a mean 5·6% (13·2) improvement in critical findings to 0·826 (0·119).

INTERPRETATION

Our study shows that automated classification of chest x-rays under a comprehensive taxonomy can achieve performance levels similar to those of historical reporters and exhibit robust generalisation to external data. The open-sourced neural networks can serve as foundation models for further research and are freely available to the research community.

FUNDING

Wellcome Trust.

Clinical stage and grade migration of localized prostate cancer at diagnosis during the past decade

OBJECTIVES

Early 2010s data suggest a reverse stage and grade migration towards more aggressive prostate cancer (PCa) at diagnosis, accelerated by the 2012 US Preventive Services Task Force recommendation against PSA screening. Using the National Cancer Database, we investigated the impact of the 2018 USPSTF recommendation and the COVID-19 outbreak on this shift. We hypothesized that the COVID-19 outbreak would further contribute to a stage and grade migration towards more aggressive disease.

MATERIAL AND METHODS

We identified men with localized PCa diagnosed between 2010 and 2020. We analyzed the shift in the proportion of PCa stratified according to D'Amico risk classification. We used multivariable logistic regression models to assess the association between year of diagnosis and dichotomous variables related to clinical stage and grade of PCa. Predicted probabilities with 95% CI were computed through marginal effect analyses.

RESULTS

We identified 910,898 men with localized PCa. The proportion of low-risk PCa almost halved from 34.9% in 2010 to 17.7% in 2020 (P < 0.001). Compared to 2010, we found in each year increased odds of: PSA≥10 ng/dL starting from 2012 (aOR2012 1.05; 95% CI, 1.02-1.08); cT3-T4 starting from 2015 (aOR2015 1.10; 95% CI, 1.03-1.17); ISUP GG 3-5 starting from 2011 (aOR2011 1.06; 95% CI, 1.03-1.08); and consequently, D'Amico intermediate/high-risk class starting from 2011 (aOR2011 1.03; 95% CI, 1.01-1.05). Fluctuations in the probabilities of PSA≥10 ng/dL and cT3-T4 at diagnosis were observed over time (all P < 0.001). The probability of PSA≥10 ng/dL peaked at 29.0% (95% CI, 28.0%-29.0%) in 2018, while the probability of cT3-T4 peaked at 3.7% (95% CI, 3.6%-3.8%) in 2020. All other outcome variables demonstrated a consistent upward shift (all P < 0.001), with the highest probabilities in 2020 for ISUP GG 3-5 (42.3%, 95% CI, 41.9%-42.6%) and D'Amico intermediate/high-risk (81.3%, 95% CI, 81.0%-81.6%).

CONCLUSIONS

Our study confirms an enduring shift towards a higher proportion of aggressive PCa at diagnosis, likely influenced by the COVID-19 pandemic. The impact of the 2018 USPSTF PCa screening recommendation on the proportion of aggressive PCa seems restricted and likely affected by the pandemic outbreak. Future investigations should evaluate the long-term effects of the 2018 USPSTF recommendations in the postpandemic setting.

Estimated Lifetime Gained With Cancer Screening Tests: A Meta-Analysis of Randomized Clinical Trials

Importance

Cancer screening tests are promoted to save life by increasing longevity, but it is unknown whether people will live longer with commonly used cancer screening tests.

Objective

To estimate lifetime gained with cancer screening.

Data Sources

A systematic review and meta-analysis was conducted of randomized clinical trials with more than 9 years of follow-up reporting all-cause mortality and estimated lifetime gained for 6 commonly used cancer screening tests, comparing screening with no screening. The analysis included the general population. MEDLINE and the Cochrane library databases were searched, and the last search was performed October 12, 2022.

Study Selection

Mammography screening for breast cancer; colonoscopy, sigmoidoscopy, or fecal occult blood testing (FOBT) for colorectal cancer; computed tomography screening for lung cancer in smokers and former smokers; or prostate-specific antigen testing for prostate cancer.

Data Extraction and Synthesis

Searches and selection criteria followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Data were independently extracted by a single observer, and pooled analysis of clinical trials was used for analyses.

Main Outcomes and Measures

Life-years gained by screening was calculated as the difference in observed lifetime in the screening vs the no screening groups and computed absolute lifetime gained in days with 95% CIs for each screening test from meta-analyses or single randomized clinical trials.

Results

In total, 2 111 958 individuals enrolled in randomized clinical trials comparing screening with no screening using 6 different tests were eligible. Median follow-up was 10 years for computed tomography, prostate-specific antigen testing, and colonoscopy; 13 years for mammography; and 15 years for sigmoidoscopy and FOBT. The only screening test with a significant lifetime gain was sigmoidoscopy (110 days; 95% CI, 0-274 days). There was no significant difference following mammography (0 days: 95% CI, -190 to 237 days), prostate cancer screening (37 days; 95% CI, -37 to 73 days), colonoscopy (37 days; 95% CI, -146 to 146 days), FOBT screening every year or every other year (0 days; 95% CI, -70.7 to 70.7 days), and lung cancer screening (107 days; 95% CI, -286 days to 430 days).

Conclusions and Relevance

The findings of this meta-analysis suggest that current evidence does not substantiate the claim that common cancer screening tests save lives by extending lifetime, except possibly for colorectal cancer screening with sigmoidoscopy.

Disparities Associated with Shared Decision-making in Prostate Cancer Screening

BACKGROUND

Prostate cancer screening guidelines recommend shared decision-making (SDM) regarding prostate-specific antigen (PSA) testing. However, it is unclear who undergoes SDM and whether any disparities exist.

OBJECTIVE

To examine sociodemographic differences in participation of SDM and its association with PSA testing in prostate cancer screening.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cross-sectional study was conducted among men aged 45-75 yr undergoing PSA screening, using the 2018 National Health Interview Survey database. The evaluated sociodemographic features included age, race, marital status, sexual orientation, smoking status, working status, financial difficulty, US geographic regions, and cancer history. Questions regarding self-reported PSA testing and whether respondents discussed its advantages and disadvantages with their healthcare provider were analyzed.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Our primary outcome was to evaluate the possible associations between various sociodemographic factors and undergoing PSA screening and SDM. We used multivariable logistic regression analyses to detect potential associations.

RESULTS AND LIMITATIONS

A total of 59596 men were identified, of whom 5605 answered the question regarding PSA testing, with 2288 (40.6%) undergoing PSA testing. Of these men, 39.5% (n = 2226) discussed the advantages and 25.6% (n = 1434) discussed the disadvantages of PSA testing. On a multivariable analysis, older (odds ratio [OR] 1.092; 95% confidence interval [CI] 1.081-1.103, p < 0.001) and married (OR 1.488; 95% CI 1.287-1.720, p < 0.001) men were more likely to undergo PSA testing. Although Black men were more likely to discuss PSA advantages (OR 1.421; 95% CI 1.150-1.756, p = 0.001) and disadvantages (OR 1.554; 95% CI 1.240-1.947, p < 0.001) than White men, this did not correlate with higher rates of PSA screening (OR 1.086; 95% CI 0.865-1.364, p = 0.477). The lack of important clinical data remains a limitation.

CONCLUSIONS

Overall, SDM rates were low. Older and married men had an increased likelihood of SDM and PSA testing. Despite higher rates of SDM, Black men had similar rates of PSA testing to White men.

PATIENT SUMMARY

We evaluated sociodemographic differences in shared decision-making (SDM) in prostate cancer screening using a large national database. We found that SDM had varying results in different sociodemographic groups.

Cell-free DNA approaches for cancer early detection and interception

Rapid advancements in the area of early cancer detection have brought us closer to achieving the goals of finding cancer early enough to treat or cure it, while avoiding harms of overdiagnosis. We evaluate progress in the development of early cancer detection tests in the context of the current principles for cancer screening. We review cell-free DNA (cfDNA)-based approaches using mutations, methylation, or fragmentomes for early cancer detection. Lastly, we discuss the challenges in demonstrating clinical utility of these tests before integration into routine clinical care.

Lipidomics and pancreatic cancer risk in two prospective studies

Pancreatic ductal carcinoma (PDAC) is highly fatal with limited understanding of mechanisms underlying its carcinogenesis. We comprehensively investigated whether lipidomic measures were associated with PDAC in two prospective studies. We measured 904 lipid species and 252 fatty acids across 15 lipid classes in pre-diagnostic serum (up to 24 years) in a PDAC nested-case control study within the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO, NCT00002540) with 332 matched case-control sets including 272 having serial blood samples and Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study (ATBC, NCT00342992) with 374 matched case-control sets. Controls were matched to cases by cohort, age, sex, race, and date at blood draw. We used conditional logistic regression to calculate odds ratios (OR) and 95% confidence intervals (CI) per one-standard deviation increase in log-lipid concentrations within each cohort, and combined ORs using fixed-effects meta-analyses. Forty-three lipid species were associated with PDAC (false discovery rate, FDR ≤ 0.10), including lysophosphatidylcholines (LPC, n = 2), phosphatidylethanolamines (PE, n = 17), triacylglycerols (n = 13), phosphatidylcholines (PC, n = 3), diacylglycerols (n = 4), monoacylglycerols (MAG, n = 2), cholesteryl esters (CE, n = 1), and sphingomyelins (n = 1). LPC(18:2) and PE(O-16:0/18:2) showed significant inverse associations with PDAC at the Bonferroni threshold (P value < 5.5 × 10-5). The fatty acids LPC[18:2], LPC[16:0], PC[15:0], MAG[18:1] and CE[22:0] were significantly associated with PDAC (FDR < 0.10). Similar associations were observed in both cohorts. There was no significant association for the differences between PLCO serial lipidomic measures or heterogeneity by follow-up time overall. Results support that the pre-diagnostic serum lipidome, including 43 lipid species from 8 lipid classes and 5 fatty acids, is associated with PDAC.

LncRNA Osilr9 coordinates promoter DNA demethylation and the intrachromosomal loop structure required for maintaining stem cell pluripotency

Nuclear reprogramming of somatic cells into a pluripotent status has the potential to create patient-specific induced pluripotent stem cells for regenerative medicine. Currently, however, the epigenetic mechanisms underlying this pluripotent reprogramming are poorly understood. To delineate this epigenetic regulatory network, we utilized a chromatin RNA in situ reverse transcription sequencing (CRIST-seq) approach to identify long noncoding RNAs (lncRNAs) embedded in the 3-dimensional intrachromosomal architecture of stem cell core factor genes. By combining CRIST-seq and RNA sequencing, we identified Oct4-Sox2 interacting lncRNA 9 (Osilr9) as a pluripotency-associated lncRNA. Osilr9 expression was associated with the status of stem cell pluripotency in reprogramming. Using short hairpin RNA (shRNA) knockdown, we showed that this lncRNA was required for the optimal maintenance of stem cell pluripotency. Overexpression of Osilr9 induced robust activation of endogenous stem cell core factor genes in fibroblasts. Osilr9 participated in the formation of the intrachromosomal looping required for the maintenance of pluripotency. After binding to the Oct4 promoter, Osilr9 recruited the DNA demethylase ten-eleven translocation 1, leading to promoter demethylation. These data demonstrate that Osilr9 is a critical chromatin epigenetic modulator that coordinates the promoter activity of core stem cell factor genes, highlighting the critical role of pluripotency-associated lncRNAs in stem cell pluripotency and reprogramming.

Unknown Causes of Death in Cancer Patients

OBJECTIVES

Deaths from an unknown cause are difficult to adjudicate and oncologic studies of comparative effectiveness often demonstrate inconsistencies in incorporating these deaths and competing events (eg, heart disease and stroke) in their analyses. In this study, we identify cancer patients most at risk for death of an unknown cause.

METHODS

This retrospective, population-based study used cancer registry data from the Surveillance, Epidemiology, and End Results database (1992-2015). The absolute rate of unknown causes of death (COD) cases stratified by sex, marital status, race, treatment, and cancer site were calculated and a multivariable logistic regression model was applied to obtain adjusted odds ratios with 95% CIs.

RESULTS

Out of 7,154,779 cancer patients across 22 cancer subtypes extracted from Surveillance, Epidemiology, and End Results, 3,448,927 died during follow-up and 276,068 (7.4%) of these deaths were from unknown causes. Patients with an unknown COD had a shorter mean survival time compared with patients with known COD (36.3 vs 65.7 mo, P < 0.001). The contribution of unknown COD to total mortality was highest in patients with more indolent cancers (eg, prostate [12.7%], thyroid [12.3%], breast [10.7%]) and longer follow-up (eg, >5 to 10 y). One, 3, and 5-year cancer-specific survival (CSS) calculations including unknown COD were significantly decreased compared with CSS estimates excluding cancer patients with unknown COD.

CONCLUSION

Of the patients, 7.4% died of unknown causes during follow-up and the proportion of death was higher with longer follow-up and among more indolent cancers. The attribution of high percentages of unknown COD to cancer or non-cancer causes could impact population-based cancer registry studies or clinical trial outcomes with respect to measures involving CSS and mortality.

Regional disparities of prostate cancer mortality in Ecuador: an examination of trends and correlates from 2004 to 2019

BACKGROUND

Prostate cancer is the leading cause of cancer death in Ecuadorian men. However, there is a lack of information regarding the evolution of prostate cancer mortality rates in Ecuador and its regions in the last few decades.

OBJECTIVE

The aim of this study was to report prostate cancer mortality rates in Ecuador and its geographical areas and observe the evolution of these rates between 2004 and 2019.

METHODS

An observational ecological study was conducted, analysing data for prostate cancer deaths from 2004 to 2019 in Ecuador. Age standardized mortality rates (ASMR) were calculated per 100,000 men using the world standard population with the direct method proposed by SEGI. Joinpoint regression analysis was performed to examine mortality trends. We used a Cluster Map to explore relationships among regions between 2015 and 2019.

RESULTS

Ecuador reported 13,419 deaths by prostate cancer between 2004 and 2019, with the Coastal region accounting for 49.8% of the total deaths. The mean age at death was 79 years (± 10 years), 91.7% were elderly (more than 65 years old) and had primary education (53%). Deaths by prostate cancer were more frequently reported among mestizos (81.4%). There were no significant variations in these percentages in Ecuador and its regions during the study period. Carchi province had the highest mortality rate in 2005 and 2019 (> 13 deaths per 100,000). Heterogeneity in the evolution of mortality rates was reported among the provinces of Ecuador. Azuay decreased in the first few years, and then increased from 2010 to 2019, whereas Guayas and Pichincha decreased throughout the whole period.

CONCLUSION

Although prostate cancer mortality rates in Ecuador have remained stable over the past few decades, there are significant disparities among the different regions. These findings suggest the need for the development of national and provincial registration measures, integrated healthcare actions, and targeted interventions to reduce the burden of prostate cancer in the Ecuadorian population.

Analysis of Body Mass Index in Early and Middle Adulthood and Estimated Risk of Gastrointestinal Cancer

Importance

In a population with significantly increasing rates of individuals with overweight or obesity, understanding the association of obesity with long-term disease risk, such as cancer, is necessary to improve public health.

Objective

To investigate the association between body mass index (BMI) and gastrointestinal (GI) cancer risk (colorectal cancer [CRC] and noncolorectal GI cancer) in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial.

Design, Setting, and Participants

This retrospective cohort study was a secondary analysis of data from the PLCO Cancer Screening Trial. Participants aged 55 to 74 years were enrolled and randomized to the intervention (screening group) or control group at 10 screening centers between November 8, 1993, and July 2, 2001. The initial analysis of PLCO Cancer Screening Trial data occurred after 13 years of follow-up or December 31, 2009, whichever came first. Participants were reconsented in 2011 and either continued follow-up or refused additional follow-up. For those who reconsented, follow-up for incident cancers continued until December 31, 2014, or death, whichever occurred first. Data analysis for this secondary analysis was performed from April 2022 through November 2022.

Exposures

Body mass index and aspirin use, defined as the frequency of use of aspirin or aspirin-containing substances in the last 12 months.

Main Outcomes and Measures

The primary outcomes were the diagnoses of CRC and noncolorectal GI cancer. The association between BMI and cancer (CRC and noncolorectal GI cancer) was assessed using Cox proportional hazards regression modeling. The association between cancer risk and change in BMI was further analyzed at different ages, and an exploratory analysis was performed to evaluate GI cancer risk among aspirin users.

Results

This analysis included 135 161 participants (median [range] age, 62 [55-78] years; 67 643 [50.0%] female). Overweight BMI in early adulthood (hazard ratio [HR], 1.23; 95% CI, 1.10-1.37) and overweight BMI in middle adulthood (HR, 1.23; 95% CI, 1.13-1.34) and later adulthood (HR, 1.21; 95% CI, 1.10-1.32) as well as obese BMI in middle adulthood (HR, 1.55; 95% CI, 1.38-1.75) and later adulthood (HR, 1.39; 95% CI, 1.25-1.54) were associated with increased risk of CRC. Similar results were observed for the association with overall GI and non-CRC GI risk and BMI in middle and later adulthood. Maintaining overweight or obese BMI or increasing BMI to overweight or obese in later adulthood was also associated with increased CRC risk. Aspirin use 3 or more times per week did not significantly modify this association.

Conclusions and Relevance

In this secondary analysis of the PLCO Cancer Screening Trial, overweight and obese BMI in early and middle adulthood was associated with an elevated risk of CRC and noncolorectal GI cancers. The results of the current study prompt further exploration into the mechanistic role of obese BMI in carcinogenesis.

Screening for prostate cancer: evidence, ongoing trials, policies and knowledge gaps

Long-term screening with serum prostate-specific antigen (PSA) and systematic prostate biopsies can reduce prostate cancer mortality but leads to unacceptable overdiagnosis. Over the past decade, diagnostic methods have improved and the indolent nature of low-grade prostate cancer has been established. These advances now enable more selective detection of potentially lethal prostate cancer. This non-systematic review summarises relevant diagnostic advances, previous and ongoing screening trials, healthcare policies and important remaining knowledge gaps. Evidence synthesis and conclusions: The strong association between low serum PSA values and minimal long-term risk of prostate cancer death allows for adjusting screening intervals. Use of risk calculators, biomarkers and MRI to select men with a raised PSA value for biopsy and lesion-targeting rather than systematic prostate biopsies reduce the detection of low-grade cancer and thereby overdiagnosis. These improvements recently led the European Union to recommend its member states to evaluate the feasibility and effectiveness of organised screening programmes for prostate cancer. Nonetheless, important knowledge gaps remain such as the performance of modern diagnostic methods in long-term screening programmes and their impact on mortality. The knowledge gaps are currently being addressed in three large randomised screening trials. Population-based pilot programmes will contribute critical practical experience.

Quantification of overdiagnosis in randomised trials of cancer screening: an overview and re-analysis of systematic reviews

The degree of overdiagnosis in common cancer screening trials is uncertain due to inadequate design of trials, varying definition and methods used to estimate overdiagnosis. Therefore, we aimed to quantify the risk of overdiagnosis for the most widely implemented cancer screening programmes and assess the implications of design limitations and biases in cancer screening trials on the estimates of overdiagnosis by conducting an overview and re-analysis of systematic reviews of cancer screening. We searched PubMed and the Cochrane Library from their inception dates to November 29, 2021. Eligible studies included systematic reviews of randomised trials comparing cancer screening interventions to no screening, which reported cancer incidence for both trial arms. We extracted data on study characteristics, cancer incidence and assessed the risk of bias using the Cochrane Collaboration's risk of bias tool. We included 19 trials described in 30 articles for review, reporting results for the following types of screening: mammography for breast cancer, chest X-ray or low-dose CT for lung cancer, alpha-foetoprotein and ultrasound for liver cancer, digital rectal examination, prostate-specific antigen, and transrectal ultrasound for prostate cancer, and CA-125 test and/or ultrasound for ovarian cancer. No trials on screening for melanoma were eligible. Only one trial (5%) had low risk in all bias domains, leading to a post-hoc meta-analysis, excluding trials with high risk of bias in critical domains, finding the extent of overdiagnosis ranged from 17% to 38% across cancer screening programmes. We conclude that there is a significant risk of overdiagnosis in the included randomised trials on cancer screening. We found that trials were generally not designed to estimate overdiagnosis and many trials had high risk of biases that may draw the estimates of overdiagnosis towards the null. In effect, the true extent of overdiagnosis due to cancer screening is likely underestimated.

Knowledge and Attitudes towards Prostate Cancer and Screening among Males in Limpopo Province, South Africa

Inadequate knowledge and poor attitudes about prostate cancer (PC) negatively affect early screening practices among males. The PC mortality rate is increasing due to late reporting, screening, and treatment. This study explored the awareness, attitudes, and PC screening behaviours among males in the Limpopo, Thulamela municipality. This descriptive cross-sectional study involved 245 males that were randomly selected. A structured questionnaire was used to collect data. Fisher's exact tests and logistic regression analysis were used to examine the association between sociodemographic variables, awareness, and attitudes towards PC. Our findings revealed that 64.1% demonstrated inadequate awareness about PC. The overall score (84.9%) showed a positive attitude towards PC. However, 87.4% had a negative attitude towards the effectiveness of treatment for PC. The majority (96.7%) of respondents had never undergone a PSA test, although 53.1% were willing to undergo a PSA test. There was a significant positive correlation between awareness of prostate cancer and attitudes toward prostate cancer (r = 0.280, p < 0.001). Health status predicted awareness about PC, while age and health status predicted attitudes towards PC among men. Rural community-based programmes and heightened awareness campaigns are needed to conscientize men about the risk factors, symptoms, diagnosis, and treatment of PC in rural areas of Limpopo.

Instrumental variable estimation of complier causal treatment effect with interval-censored data

Assessing causal treatment effect on a time-to-event outcome is of key interest in many scientific investigations. Instrumental variable (IV) is a useful tool to mitigate the impact of endogenous treatment selection to attain unbiased estimation of causal treatment effect. Existing development of IV methodology, however, has not attended to outcomes subject to interval censoring, which are ubiquitously present in studies with intermittent follow-up but are challenging to handle in terms of both theory and computation. In this work, we fill in this important gap by studying a general class of causal semiparametric transformation models with interval-censored data. We propose a nonparametric maximum likelihood estimator of the complier causal treatment effect. Moreover, we design a reliable and computationally stable expectation-maximization (EM) algorithm, which has a tractable objective function in the maximization step via the use of Poisson latent variables. The asymptotic properties of the proposed estimators, including the consistency, asymptotic normality, and semiparametric efficiency, are established with empirical process techniques. We conduct extensive simulation studies and an application to a colorectal cancer screening data set, showing satisfactory finite-sample performance of the proposed method as well as its prominent advantages over naive methods.

Using "Age and Total-PSA" as the Main Indicators: The Results of Taizhou Integrated Prostate Screening (No 2)

The aim of the study was to analyze population-based prostate cancer (PCa) screening and the incidence of PCa among males ≥50 years of age residing in the Luqiao district of Taizhou, China. From October to December 2020, male residents ≥50 years of age were screened for serum total prostate-specific antigen (total-PSA). If t-PSA re-test levels persisted above 4 μg/L, subjects underwent further noninvasive examinations, including digital rectal examination or multiparameter magnetic resonance imaging (mpMRI) of the prostate. Subjects underwent prostate biopsy of pathological tissue based on t-PSA and mpMRI results. A total of 3524 (49.1%) residents participated in this PCa screening study. In total, 285 (8.1%) subjects exhibited t-PSA levels ≥4.0 μg/L and 112 (3.2%) underwent noninvasive examinations. Forty-two (1.2%) residents underwent prostate biopsy, of which 16 (0.45%) were diagnosed with PCa. Of those diagnosed with PCa, three (19%) had localized PCa (cT1-cT2N0M0), six (37%) had locally advanced PCa (cT3a- cT4N0-1M0), and seven (44%) had advanced metastatic PCa (M1). Unfortunately, 3477 (48.5%) residents did not participate in the study, mainly due to lack of awareness of PCa based on feedback from local health centers. Age and t-PSA were used as primary screening indicators and, when further combined with mpMRI and prostate biopsy, confirmed the diagnosis of PCa among participating residents. Although this was a relatively economical and convenient screening method, education and knowledge should be further enhanced to increase the participation rate in PCa screening programs.

Investigating the racial gap in prostate cancer screening with prostate-specific antigen among younger men from 2012 to 2020

BACKGROUND

The United States Preventive Services Task Force recommended against prostate-specific antigen (PSA) screening in 2012, which was modified in 2018 into shared decision making for men aged 55-70 years with a life expectancy over 10 years. We studied the trends in PSA screening in younger Black and White men with the implementation of the 2012 and 2018 guidelines.

METHODS

Younger Black and White men (aged 40-54 years) were identified using the Behavioral Risk Factor Surveillance System database biennially from 2012 to 2020. Our primary outcome was PSA screening within 2 years of the survey. An adjusted logistic regression model with 2-way interaction assessment between race and survey year was used to investigate the temporal trend of PSA screening in younger Black and White men.

RESULTS

A total of 142 892 men were included. We saw steadily decreasing odds of PSA screening among both younger Black and White men in 2014, 2016, 2018, and 2020 compared with 2012 (for younger Black men: odds ratio [OR]2014 = 0.77, 95% confidence interval [CI] = 0.62 to 0.96, OR2016 = 0.51, 95% CI = 0.41 to 0.63, OR2018 = 0.33, 95%CI = 0.27 to 0.42, OR2020 = 0.25, 95% CI = 0.18 to 0.32; and for younger White men: OR2014 = 0.81, 95% CI = 0.76 to 0.87, OR2016 = 0.66, 95% CI = 0.61 to 0.71, OR2018 = 0.41, 95%CI = 0.37 to 0.44, OR2020 = 0.36, 95% CI = 0.33 to 0.39). Younger Black men showed a brisker decrease in PSA screening in 2016, 2018, and 2020 compared with younger White men (all P < .05).

CONCLUSIONS

PSA screening among younger men steadily decreased over the past decade since the 2012 United States Preventive Services Task Force guidelines, demonstrating a narrowing racial gap. How such an observed trend translates to long-term clinical outcomes for younger Black men remains to be seen.

Underlying Features of Prostate Cancer-Statistics, Risk Factors, and Emerging Methods for Its Diagnosis

Prostate cancer (PCa) is the most frequently occurring type of malignant tumor and a leading cause of oncological death in men. PCa is very heterogeneous in terms of grade, phenotypes, and genetics, displaying complex features. This tumor often has indolent growth, not compromising the patient's quality of life, while its more aggressive forms can manifest rapid growth with progression to adjacent organs and spread to lymph nodes and bones. Nevertheless, the overtreatment of PCa patients leads to important physical, mental, and economic burdens, which can be avoided with careful monitoring. Early detection, even in the cases of locally advanced and metastatic tumors, provides a higher chance of cure, and patients can thus go through less aggressive treatments with fewer side effects. Furthermore, it is important to offer knowledge about how modifiable risk factors can be an effective method for reducing cancer risk. Innovations in PCa diagnostics and therapy are still required to overcome some of the limitations of the current screening techniques, in terms of specificity and sensitivity. In this context, this review provides a brief overview of PCa statistics, reporting its incidence and mortality rates worldwide, risk factors, and emerging screening strategies.

A Novel Blood Proteomic Signature for Prostate Cancer

Prostate cancer is the most common malignant tumour in men. Improved testing for diagnosis, risk prediction, and response to treatment would improve care. Here, we identified a proteomic signature of prostate cancer in peripheral blood using data-independent acquisition mass spectrometry combined with machine learning. A highly predictive signature was derived, which was associated with relevant pathways, including the coagulation, complement, and clotting cascades, as well as plasma lipoprotein particle remodeling. We further validated the identified biomarkers against a second cohort, identifying a panel of five key markers (GP5, SERPINA5, ECM1, IGHG1, and THBS1) which retained most of the diagnostic power of the overall dataset, achieving an AUC of 0.91. Taken together, this study provides a proteomic signature complementary to PSA for the diagnosis of patients with localised prostate cancer, with the further potential for assessing risk of future development of prostate cancer. Data are available via ProteomeXchange with identifier PXD025484.