Audit and its impact in the management of early prostatic cancer

Reporting and Handling of Indeterminate Bone Scan Results in the Staging of Prostate Cancer: A Systematic Review

Bone scintigraphy is key in imaging skeletal metastases in newly diagnosed prostate cancer. Unfortunately, a notable proportion of scans are not readily classified as positive or negative but deemed indeterminate. The extent of reporting of indeterminate bone scans and how such scans are handled in clinical trials are not known. A systematic review was conducted using electronic databases up to October 2016. The main outcome of interest was the reporting of indeterminate bone scans, analyses of how such scans were managed, and exploratory analyses of the association of study characteristics and the reporting of indeterminate bone scan results. Seventy-four eligible clinical trials were identified. The trials were mostly retrospective (85%), observational (95%), large trials (median 195 patients) from five continents published over four decades. The majority of studies had university affiliation (72%), and an author with imaging background (685). Forty-five studies (61%) reported an indeterminate option for the bone scan and 23 studies reported the proportion of indeterminate scans (median 11.4%). Most trials (44/45, 98%) reported how to handle indeterminate scans. Most trials (n = 39) used add-on supplementary imaging, follow-up bone scans, or both. Exploratory analyses showed a significant association of reporting of indeterminate results and number of patients in the study (p = 0.024) but failed to reach statistical significance with other variables tested. Indeterminate bone scan for staging of prostate cancer was insufficiently reported in clinical trials. In the case of indeterminate scans, most studies provided adequate measures to obtain the final status of the patients.

Patterns of referral, management and survival of patients diagnosed with prostate cancer in Scotland during 1988 and 1993: results of a national, retrospective population-based audit

OBJECTIVES

To examine patterns of referral, management and survival of men with prostate cancer, and to document changes over time.

PATIENTS AND METHODS

All men registered with prostate cancer in 1988 and 1993 were identified from the Scottish Cancer Registry. Data were abstracted according to standard definitions from the available medical records of 930 men in 1988 and 1355 in 1993.

RESULTS

There was limited evidence of multidisciplinary care, with only 8% of patients in 1988 being managed by both a urologist and a clinical oncologist within a year of diagnosis, increasing to 13% in 1993. Only a small proportion of patients were managed by clinical oncologists during the first year of care (14% in 1988 and 20% in 1993). Documentation of thorough staging information was poor, with a T stage being recorded in <30% of cases in both years. Documentation of metastatic status increased from 53% to 63% between 1988 and 1993, paralleling an increase in the use of bone scans. The proportion of cases with pathological grading obtained at diagnosis increased from 63% in 1988 to 68% by 1993. The use of PSA testing and core biopsies increased between the years while the use of transurethral prostatectomy decreased. More patients received radical radiotherapy within a year of diagnosis in 1993 than 1988, increasing from 6% to 9%, and more radical prostatectomies were also undertaken (0.2% to 2.3%). Nonetheless, most patients (81% in 1993) with no documented evidence of metastases received no active intervention (radical radiotherapy, radical prostatectomy, or 'watchful waiting'). The survival at 5 years increased nonsignificantly from 34% for the 1988 cohort to 38% for the 1993 cohort.

CONCLUSION

This audit reveals considerable inconsistency in the management of men with prostate cancer in Scotland. Against a background of controversy about numerous aspects of the management of this disease, the need for a multidisciplinary approach, comprehensive staging and appropriate documentation is highlighted.

Are neuroendocrine cells of practical value as an independent prognostic parameter in prostate cancer?

OBJECTIVE

To assess whether the presence of neuroendocrine (NE) cells is of value as an independent indicator of poor prognosis in patients with prostate carcinoma.

PATIENTS AND METHODS

A series of 160 consecutive patients with prostate carcinoma was studied retrospectively. In 120 there was sufficient tissue for review and to perform immunoperoxidase stains for neuron specific enolase (NSE) and chromogranin A (CGA). All patients had a potential follow-up of at least 5 years.

RESULTS

Five-year survival was poorer for patients with a high tumour grade and stage at presentation compared to those with a lower grade and stage. NE cells were more common in higher grade and stage disease, but 5-year survival did not differ significantly between patients with NE cell positive and negative tumours.

CONCLUSION

NE cells are of no practical value as an independent prognostic indicator in patients with prostatic adenocarcinoma.

Expectant management of early stage prostatic cancer: Swedish experience

To learn about the natural history of untreated early stage prostatic cancer (stage T0-2NXM0) progression-free, disease specific, overall survival and the need for palliative care were evaluated in a population-based and regionally well defined cohort from Sweden. Complete followup, with a mean observation of 12.5 years, was achieved in 223 consecutively diagnosed, eligible patients (98%) of all ages. Patients with progression were hormonally treated (orchiectomy or estrogens) if they had symptoms. After a mean of 12.5 years only 23 patients (10%) had died of prostate cancer and 125 of 148 deaths (84%) were of other causes. The 10-year disease specific survival rate was 85% (95% confidence interval 79 to 91%) and was equally high (89%) in a subgroup of 58 patients who met current indications for radical prostatectomy. The progression-free 10-year survival rate was 55% (95% confidence interval 46 to 63%) but in 49 of 77 patients local growth provided the only evidence of progression and endocrine treatment was generally successful in these cases. Following an initial increase, the rate of disease progression and death from prostate cancer decreased during the last years of followup. The low disease specific mortality rate, especially in patients with highly and moderately differentiated tumors, means that any local or systemic therapy intended for patients with early prostatic cancer must be evaluated in clinical trials with untreated controls for comparison. One such trial is in progress in Sweden and Finland evaluating deferred treatment and radical prostatectomy. As of the beginning of December 1993, 330 patients were included in the study.