Randomized trial results did not resolve controversies surrounding prostate cancer screening

The expression of vascular endothelial growth factor-C correlates with lymphatic microvessel density and lymph node metastasis in prostate carcinoma: An immunohistochemical study

Aim:

To evaluate the expression of two different lymphatic vascular density (LVD) markers (D2-40 and LYVE-1) and a lymphangiogenic cytokine (Vascular Endothelial Growth Factor-C, [VEGF-C]) in prostate carcinoma and to investigate their relationship with the lymph node status.

Settings and Design:

Archival material study of 92 non-consecutive radical prostatectomy specimens.

Materials and Methods:

The mean LVD was assessed immunohistochemically in 24 prostate carcinoma specimens from patients with clinically localized disease, who were found to have nodal metastasis (pN1), and was compared with 68 pN0 cases. Furthermore, the mean LVD, VEGF-C expression, and lymphatic invasion were examined in relation to lymph node involvement.

Results:

Peritumoral (but not intratumoral) mean LVD assessed by D2-40 was higher in pN1 tumors (P = 0.015). LYVE-1 expression was limited and not associated with lymph node status. The VEGF-C expression was higher in the N1 cases and also correlated with the increased mean LVD in both the peri- and intratumoral compartments. Lymphatic invasion was strongly associated with nodal metastasis and higher VEGF-C expression.

Conclusions:

Our results indicate that increased peritumoral (but not intratumoral) LVD in the tumor specimen is associated with lymph node metastasis. Increased expression of VEGF-C is associated with higher LVD (in both intratumoral and peritumoral compartments) and with positive lymph node status, indicating a possible dual role in both lymphangiogenesis and lymphatic vessel invasion.

Prostate cancer deaths and incident cases among American Indian/Alaska Native men, 1999-2009

OBJECTIVES

We linked databases to improve identification of American Indians/Alaska Natives (AI/ANs) in determining prostate cancer death and incidence rates.

METHODS

We linked prostate cancer mortality and incidence data with Indian Health Service (IHS) patient records; analyses focused on residents of IHS Contract Health Service Delivery Area (CHSDA) counties. We calculated age-adjusted incidence and death rates for AI/AN and White men for 1999 to 2009; men of Hispanic origin were excluded.

RESULTS

Prostate cancer death rates were higher for AI/AN men than for White men. Death rates declined for White men (-3.0% per year) but not for AI/AN men. AI/AN men had lower prostate cancer incidence rates than White men. Incidence rates declined among Whites (-2.2% per year) and AI/ANs (-1.9% per year).

CONCLUSIONS

AI/AN men had higher prostate cancer death rates and lower prostate cancer incidence rates than White men. Disparities in accessing health care could contribute to mortality differences, and incidence differences could be related to lower prostate-specific antigen testing rates among AI/AN men.

Time for a strategic research response to anal cancer

Anal cancer was until recently regarded as a rare cancer of little consequence. The articles in this special edition of Sexual Health clearly demonstrate that anal cancer is increasing in incidence and, in some populations, it has become an urgent public health priority. In this summary paper, we will review the data presented in this issue and elsewhere on the magnitude of the issue, the means of prevention and treatment, and suggest a way forward.

A systems-based modelling approach using transurethral resection of the prostate (TURP) specimens yielded incremental prognostic significance to Gleason when predicting long-term outcome in men with localized prostate cancer

OBJECTIVE

To develop a systems-based model for predicting prostate cancer-specific survival (PCSS) using a conservatively managed cohort with clinically localized prostate cancer and long-term follow-up.

PATIENTS AND METHODS

Transurethral prostate (TURP) specimens in tissue microarray format and medical records from a 758 patient cohort were obtained. Slides were stained with haematoxylin and eosin (H&E), imaged and digitally outlined for invasive tumour. Additional sections were analysed with two multiplex quantitative immunofluorescence (IF) assays for cytokeratin-18 (epithelial cells), 4'-6-diamidino-2-phenylindole(nuclei), p63/high-molecular-weight keratin (basal cells), androgen receptor (AR) and α-methyl CoA-racemase, Ki67, phosphorylated AKT (pAKT)and CD34. Images were acquired with spectral imaging software. H&E and IF images were evaluated with image analysis algorithms; feature data were integrated with clinical variables to construct prognostic models for outcome.

RESULTS

Using a training set of 256 patients with 24% events, one clinical variable (Gleason score) and two tissue-specific characteristics (H&E morphometry and tumour-specific pAKT levels) were identified (concordance index [CoI] 0.79, sensitivity 76%, specificity 86%, hazard ratio [HR] 6.6) for predicting PCSS. Validation on an independent cohort of 269 patients with 29% events yielded a CoI of 0.76, sensitivity 59%, specificity 80% and HR of 3.6. Both H&E and IF features were selected in a multivariate setting and added incremental prognostic value to the Gleason score alone (CoI 0.77 to CoI 0.79). Furthermore, global Ki67 expression and AR levels in Gleason grade 3 tumours were both univariately associated with outcome; however, neither was selected in the final model.

CONCLUSION

A previously validated prostate needle-biopsy systems modelling approach that integrates clinical data with reproducible methods to assess H&E morphometry and biomarker expression, provided incremental benefit to the TURP Gleason score for predicting PCSS. Ki67 and AR, known to be associated with outcome in the prostate needle biopsy, were not associated with PCSS in multivariate models using TURP specimens.

Screening for prostate cancer: systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To examine the evidence on the benefits and harms of screening for prostate cancer.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Electronic databases including Medline, Embase, CENTRAL, abstract proceedings, and reference lists up to July 2010. Review methods Included studies were randomised controlled trials comparing screening by prostate specific antigen with or without digital rectal examination versus no screening. Data abstraction and assessment of methodological quality with the GRADE approach was assessed by two independent reviewers and verified by the primary investigator. Mantel-Haenszel and inverse variance estimates were calculated and pooled under a random effects model expressing data as relative risks and 95% confidence intervals.

RESULTS

Six randomised controlled trials with a total of 387 286 participants that met inclusion criteria were analysed. Screening was associated with an increased probability of receiving a diagnosis of prostate cancer (relative risk 1.46, 95% confidence interval 1.21 to 1.77; P<0.001) and stage I prostate cancer (1.95, 1.22 to 3.13; P=0.005). There was no significant effect of screening on death from prostate cancer (0.88, 0.71 to 1.09; P=0.25) or overall mortality (0.99, 0.97 to 1.01; P=0.44). All trials had one or more substantial methodological limitations. None provided data on the effects of screening on participants' quality of life. Little information was provided about potential harms associated with screening.

CONCLUSIONS

The existing evidence from randomised controlled trials does not support the routine use of screening for prostate cancer with prostate specific antigen with or without digital rectal examination.