The economic burden of prostate cancer

Prostate high dose-rate brachytherapy as monotherapy for low and intermediate-risk prostate cancer: Efficacy results from a randomized phase II clinical trial of one fraction of 19 Gy or two fractions of 13.5 Gy: A 9-year update

BACKGROUND AND PURPOSE

High dose-rate (HDR) brachytherapy as a monotherapy is an accepted treatment for localized prostate cancer, but the optimal dose and fractionation schedule remain unknown. We report on the efficacy of a randomized Phase II trial comparing HDR monotherapy delivered as 27 Gy in 2 fractions vs. 19 Gy in 1 fraction with a median follow-up of 9 years.

MATERIALS AND METHODS

Enrolled patients had low or intermediate-risk disease, <60 cc prostate volume and no androgen deprivation use. Patients were randomized to 27 Gy in 2 fractions delivered one week apart vs a single fraction of 19 Gy.

RESULTS

170 patients were randomized: median age 65 years, median follow-up 107 months and median baseline PSA 6.35 ng/ml. NCCN risk categories comprised low (19 %), favourable (51 %), and unfavourable intermediate risk (30 %). The median PSA at 8 years was 0.08 ng/ml in the 2-fraction arm vs. 0.89 ng/ml in the single-fraction arm. The cumulative incidence of local failure at 8 years was 11.2 % in the 2-fraction arm vs. 35.9 % in the single-fraction arm (p < 0.001). The incidence of distant failure at 8 years was 3.8 % in the 2-fraction arm and 2.5 % in the single-fraction arm (p = 0.6).

CONCLUSIONS

HDR monotherapy delivered in two fractions of 13.5 Gy demonstrated a persistent cancer control rate at 8 years and was well-tolerated. Single-fraction monotherapy yielded poor oncologic control and is not recommended. These findings contribute to the ongoing discourse on optimal HDR monotherapy strategies for low and intermediate-risk prostate cancer.

Systematic Review on the Cost Effectiveness of Prostate Cancer Screening in Europe

BACKGROUND AND OBJECTIVE

In Europe, prostate cancer (PCa) is the most common cancer in men. Screening may therefore be crucial to lower health care costs, morbidity, and mortality. This systematic review aimed to provide a contemporary overview of the costs and benefits of PCa screening programmes.

METHODS

A peer-reviewed literature search was conducted, using the PICO method. A detailed search strategy was developed in four databases based on the following key search terms: "PCa", "screening", and "cost effectiveness". Any type of economic evaluation was included. The search strategy was restricted to European countries, but no restrictions were set on the year of publication.

KEY FINDINGS AND LIMITATIONS

A total of 7484 studies were identified initially. Of these, 19 studies described the cost effectiveness of PCa screening in Europe. Among the studies using an initially healthy study population, most focussed on risk- and/or age- and/or magnetic resonance imaging (MRI)-based screening in addition to prostate-specific antigen (PSA) testing and compared this with no screening. Incremental cost ratios (ICERs) varied from €5872 per quality-adjusted life year (QALY) to €372 948/QALY, with a median of €56 487/QALY. Risk-based screening followed by MRI testing seemed to be a more cost-effective strategy than no screening.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This systematic review indicates that screening programmes incorporating a risk-based approach and MRI have the potential to be cost effective.

PATIENT SUMMARY

In this review, we looked at the cost effectiveness of prostate cancer screening in Europe. We found that a risk-based approach and incorporation of magnetic resonance imaging has the potential to be cost effective. However, there remains a knowledge gap regarding cost effectiveness of prostate cancer screening. Therefore, determinants of cost effectiveness require further investigation.

A cost-benefit analysis of mass prostate cancer screening

BACKGROUND

Prostate cancer (PCa) causes a substantial health and financial burden worldwide, underscoring the need for efficient mass screening approaches. This study attempts to evaluate the Net Cost-Benefit Index (NCBI) of PCa screening in Iran to offer insights for informed decision-making and resource allocation.

METHOD

The Net Cost-Benefit Index (NCBI) was calculated for four age groups (40 years and above) using a decision-analysis model. Two screening strategies, prostate-specific antigen (PSA) solely and PSA with Digital Rectal Examination (DRE), were evaluated from the health system perspective. A retrospective assessment of 1402 prostate cancer (PCa) patients' profiles were conducted, and direct medical and non-medical costs were calculated based on the 2021 official tariff rates, patient records, and interviews. The monetary value of mass screening was determined through Willingness to Pay (WTP) assessments, which served as a measure for the benefit aspect.

RESULT

The combined PSA and DRE strategy of screening is cost-effective, yields up to $3 saving in costs per case and emerges as the dominant strategy over PSA alone. Screening for men aged 70 and above does not meet economic justification, indicated by a negative Net Cost-Benefit Index (NCBI). The 40-49 age group exhibits the highest net benefit, $13.81 based on basic information and $13.54 based on comprehensive information. Sensitivity analysis strongly supports the cost-effectiveness of the combined screening approach.

CONCLUSION

This study advocates prostate cancer screening with PSA and DRE, is economically justified for men aged 40-69. The results of the study recommend that policymakers prioritize resource allocation for PCa screening programs based on age and budget constraints. Men's willingness to pay, especially for the 40-49 age group which had the highest net benefit, leverages their financial participation in screening services. Additionally, screening services for other age groups, such as 50-54 or 55-59, can be provided either for free or at a reduced cost.

Primary cancer prevention for cancers with no known infectious etiology: Time for a new paradigm

Vaccines developed for hepatitis B and human papilloma virus infections have been very successful in reducing the burden of cancer due to these infections. In the past decade, our understanding of the immunology of cancer has greatly improved and important progress has been made in the use of immunotherapy for several cancers. However, for the majority of cancers, an infectious etiology is either unknown or does not exist. Prostate cancer, for which no infectious etiology is known, is the most common cancer in men in the United States. Here we discuss the rationale for developing a preventive vaccine for prostate cancer, discuss a possible approach for further work in this area and a means of testing the effectiveness of a prostate cancer prevention vaccine in a clinical trial.

Lower baseline testosterone level is related to earlier development of castration resistance in metastatic prostate cancer: a multi-center cohort study

Purpose

In the era of concurrent combination therapy in metastatic hormone sensitive prostate cancer, the impact of the testosterone level before initiating androgen deprivation therapy on treatment outcome is still uncertain. We aimed to investigate its effect on time-to-castration-resistance in a metastatic hormone sensitive prostate cancer cohort.

Methods

This is a multi-center retrospective study of 5 databases from China, Japan, Austria and Spain including 258 metastatic hormone sensitive prostate cancer patients with androgen deprivation therapy initiated between 2002 and 2021. Baseline testosterone was divided into high and low groups using 12 nmol/L as cutoff level. Primary outcome was time-to-castration-resistance. Secondary outcomes were survival functions. Kaplan-Meier method was employed to evaluate the correlation between baseline testosterone and time-to-castration-resistance. Subgroup analysis was performed to elucidate the effect of upfront combination-therapy and metastatic volume.

Results

Median age was 72 years. Median follow-up time was 31 months. Median pre-treatment prostate-specific-antigen level was 161 ng/mL. Majority of case were graded as International-Society-of-Urological-Pathology grade 5 (63.6%). 57.8% patients had high volume disease and 69.0% received upfront combination treatment. 44.6% of the cohort developed castration-resistance. The low testosterone group demonstrated shorter mean-time-to-castration-resistance (19.0 vs 22.4 months, p=0.031). The variance was more significant in patients without combination therapy (13.2 vs 26.3 months, p=0.015). Cancer-specific and overall survival were inferior in the low baseline testosterone level group without receiving combination therapy (p=0.001).

Conclusions

Lower pre-treatment testosterone level is correlated to shorter time-to-castration resistance and worse survival in metastatic prostate cancer patients without upfront combination therapy. Those with low baseline testosterone should be encouraged to adopt combination therapy to delay progression.

Factor associated with willingness to pay for prevention of cancer: a study of prostate cancer screening

INTRODUCTION

This study investigates Iranian men's willingness to pay (WTP) for prostate cancer (PCa) screening and influencing factor, along with the impact of information.

METHOD

We assessed preferences for prostate cancer screening in 771 Iranian men aged 40 and above using an internet-based questionnaire survey. Participants received basic and complementary information, and their willingness to pay was determined through a payment card approach. A Wilcoxon test assessed the impact of information. We also analyzed prostate cancer screening demand and employed Heckman's two-step model to evaluate factors influencing the willingness to pay. Additionally, reasons for unwillingness to pay were explored.

RESULTS

Willingness to pay significantly decreased with complementary information relative to basic information (16.3$ vs 17.8$). Heckman model, using WTP based on basic information shows age, education, and monthly household expenditure positively influenced the decision to pay. In contrast, health status, expectations of remaining life and prostate problems history positively affect amount of WTP for PCa screening, and insurance coverage has a negative impact on it. Majority of respondents (91%) supported PCa screening, with 82% expressing a willingness to pay. Common reasons for not paying include seeing screening as a public good (43%), financial constraints (35%), and having insurance (20%). The screening demand is price-sensitive.

CONCLUSION

The basic mindset of Iranian men exaggerates the risk of prostate cancer. Reduced willingness to pay after receiving information reassures the reliability of their financial expectation. Taking into account the factors that influence PCa screening is essential for accurate planning and the successful implementation of this program.

Financial burden of prostate cancer in the Iranian population: a cost of illness and financial risk protection analysis

BACKGROUND

Prostate cancer is the second most common cancer in males worldwide and the third most common among Iran's male population. However, there is a lack of evidence regarding its direct and indirect costs in low and middle-income countries. This study intends to bridge the gap using a cost of illness approach, assessing the costs of prostate cancer from the perspectives of patients, society, and the insurance system.

METHODS

Two hundred ninety seven patients were included in the study. Data for a 2-month period were obtained from patients registered at two hospitals (Tabriz, Tehran) in Iran in 2017. We applied a prevalence-based, bottom-up approach to assess the costs of the illness. We used the World Health Organization methods to measure the prevalence and investigate the determinants of catastrophic and impoverishing health expenditures.

RESULTS

We determined the total costs of the disease for the patients to be IRR 68 million (PPP $ 5,244.44). Total costs of the disease from the perspective of the society amounted to IRR 700,000 million (PPP $ 54 million). Insurance companies expended IRR 20 million (PPP $ 1,558.80) per patient. Our findings show that 31% of the patients incurred catastrophic health expenditure due to the disease. Five point forty-four percent (5.44%) of the patients were impoverished due to the costs of this cancer.

CONCLUSION

We found an alarmingly high prevalence of catastrophic health expenditures among prostate cancer patients. In addition, prostate cancer puts a substantial burden on both the patients and society.

Characterization of allosteric modulators that disrupt androgen receptor co-activator protein-protein interactions to alter transactivation-Drug leads for metastatic castration resistant prostate cancer

Three series of compounds were prioritized from a high content screening campaign that identified molecules that blocked dihydrotestosterone (DHT) induced formation of Androgen Receptor (AR) protein-protein interactions (PPIs) with the Transcriptional Intermediary Factor 2 (TIF2) coactivator and also disrupted preformed AR-TIF2 PPI complexes; the hydrobenzo-oxazepins (S1), thiadiazol-5-piperidine-carboxamides (S2), and phenyl-methyl-indoles (S3). Compounds from these series inhibited AR PPIs with TIF2 and SRC-1, another p160 coactivator, in mammalian 2-hybrid assays and blocked transcriptional activation in reporter assays driven by full length AR or AR-V7 splice variants. Compounds inhibited the growth of five prostate cancer cell lines, with many exhibiting differential cytotoxicity towards AR positive cell lines. Representative compounds from the 3 series substantially reduced both endogenous and DHT-enhanced expression and secretion of the prostate specific antigen (PSA) cancer biomarker in the C4-2 castration resistant prostate cancer (CRPC) cell line. The comparatively weak activities of series compounds in the H3-DHT and/or TIF2 box 3 LXXLL-peptide binding assays to the recombinant ligand binding domain of AR suggest that direct antagonism at the orthosteric ligand binding site or AF-2 surface respectively are unlikely mechanisms of action. Cellular enhanced thermal stability assays (CETSA) indicated that compounds engaged AR and reduced the maximum efficacy and right shifted the EC50 of DHT-enhanced AR thermal stabilization consistent with the effects of negative allosteric modulators. Molecular docking of potent representative hits from each series to AR structures suggest that S1-1 and S2-6 engage a novel binding pocket (BP-1) adjacent to the orthosteric ligand binding site, while S3-11 occupies the AR binding function 3 (BF-3) allosteric pocket. Hit binding poses indicate spaces and residues adjacent to the BP-1 and BF-3 pockets that will be exploited in future medicinal chemistry optimization studies. Small molecule allosteric modulators that prevent/disrupt AR PPIs with coactivators like TIF2 to alter transcriptional activation in the presence of orthosteric agonists might evade the resistance mechanisms to existing prostate cancer drugs and provide novel starting points for medicinal chemistry lead optimization and future development into therapies for metastatic CRPC.

Modified Citrus Pectin Treatment in Non-Metastatic Biochemically Relapsed Prostate Cancer: Long-Term Results of a Prospective Phase II Study

The optimal therapy for patients with non-metastatic biochemically relapsed prostate cancer (BRPC-M0) after local therapy is elusive. Thus, the evaluation of new non-toxic compounds in BRPC-M0 patients is warranted. PectaSol®-Modified citrus pectin (P-MCP) is a food supplement categorized as GRAS (Generally Recognized As Safe) by the FDA. It is a competitive inhibitor of the galectin-3 protein, which is involved in cancer pathogenesis. In an early report of the present phase 2 study, P-MCP treatment for 6 months led to prostate-specific antigen doubling time (PSADT) improvement in 75% of patients with BRPC-M0. Herein, we report the second long-term treatment phase of an additional 12 months of P-MCP therapy (4.8 g × 3/day orally) in patients without disease progression after the initial 6 months of therapy. Of the 46 patients that entered the second treatment phase, 7 patients withdrew consent and decided to continue therapy out of pocket, and 39 initiated the second treatment phase. After a total of 18 months of P-MCP treatment, 85% (n = 33) had a durable long-term response, with 62% (n = 24) showing decreased/stable PSA, 90% (n = 35) PSADT improvement, and all with negative scans. No patient had grade 3/4 toxicity. In conclusion, P-MCP may have long-term durable efficacy and is safe in BRPC-M0.

Risk of urinary tract cancers following arsenic exposure and tobacco smoking: a review

Bladder cancer, prostate cancer, and kidney cancer, due to their high morbidity and mortality rates, result in significant economic and health care costs. Arsenic exposure affects the drinking water of millions of people worldwide. Long-term exposure to arsenic, even in low concentrations, increases the risk of developing various cancers. Smoking is also one of the leading causes of bladder, prostate and kidney cancers. Accordingly, this research reviews the relationship between arsenic exposure and smoking with three kinds of urinary tract cancers (bladder cancer, prostate cancer, and kidney cancer) due to their widespread concern for their negative impact on public health globally. In this review, we have gathered the most current information from scientific databases [PubMed, Scopus, Google Scholar, ISI web of science] regarding the relationship between arsenic exposure and tobacco smoking with the risk of bladder, prostate, and kidney cancer. In several studies, a significant relationship was determined between the incidence and mortality rate of the above-mentioned cancers in humans with arsenic exposure and tobacco smoking. The decrease or cessation of smoking and consumption of arsenic-free water significantly declined the incidence of bladder, prostate, and kidney cancers.

Guidelines for genetic testing in prostate cancer: a scoping review

BACKGROUND

Genetic testing, to identify pathogenic or likely pathogenic variants in prostate cancer, is valuable in guiding treatment decisions for men with prostate cancer and to inform cancer prevention and early detection options for their immediate blood relatives. There are various guidelines and consensus statements for genetic testing in prostate cancer. Our aim is to review genetic testing recommendations across current guidelines and consensus statements and the level of evidence supporting those recommendations.

METHODS

A scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA-ScR) guidelines. Electronic database searches and manual searches of grey literature, including websites of key organisations were conducted. Using the Population, Concept, Context (PCC) framework, this scoping review included: men with prostate cancer or men at high risk of prostate cancer and their biological families; existing guidelines and consensus statements with supporting evidence for genetic testing of men with prostate cancer from any geographical location worldwide.

RESULTS

Of the 660 citations identified, 23 guidelines and consensus statements met the inclusion criteria for the scoping review. Based on different levels of evidence about who should be tested and how, a diverse range of recommendations were identified. There was general consensus among the guidelines and consensus statements that men with metastatic disease be offered genetic testing; however, there was less consensus in relation to genetic testing in localised prostate cancer. While there was some consensus in relation to which genes to test, recommendations varied regarding who to test, testing methods and implementation.

CONCLUSION

While genetic testing in prostate cancer is routinely recommended and numerous guidelines exist, there is still considerable lack of consensus regarding who should be tested and how they should be tested. Further evidence is needed to inform value-based genetic testing strategies for implementation in practice.

ACR Appropriateness Criteria® Pretreatment Detection, Surveillance, and Staging of Prostate Cancer: 2022 Update

Prostate cancer is second leading cause of death from malignancy after lung cancer in American men. The primary goal during pretreatment evaluation of prostate cancer is disease detection, localization, establishing disease extent (both local and distant), and evaluating aggressiveness, which are the driving factors of patient outcomes such as recurrence and survival. Prostate cancer is typically diagnosed after the recognizing elevated serum prostate-specific antigen level or abnormal digital rectal examination. Tissue diagnosis is obtained by transrectal ultrasound-guided biopsy or MRI-targeted biopsy, commonly with multiparametric MRI without or with intravenous contrast, which has recently been established as standard of care for detecting, localizing, and assessing local extent of prostate cancer. Although bone scintigraphy and CT are still typically used to detect bone and nodal metastases in patients with intermediate- or high-risk prostate cancer, novel advanced imaging modalities including prostatespecific membrane antigen PET/CT and whole-body MRI are being more frequently utilized for this purpose with improved detection rates. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Targeting P21-Activated Kinase-1 for Metastatic Prostate Cancer

Metastatic prostate cancer (mPCa) has limited therapeutic options and a high mortality rate. The p21-activated kinase (PAK) family of proteins is important in cell survival, proliferation, and motility in physiology, and pathologies such as infectious, inflammatory, vascular, and neurological diseases as well as cancers. Group-I PAKs (PAK1, PAK2, and PAK3) are involved in the regulation of actin dynamics and thus are integral for cell morphology, adhesion to the extracellular matrix, and cell motility. They also play prominent roles in cell survival and proliferation. These properties make group-I PAKs a potentially important target for cancer therapy. In contrast to normal prostate and prostatic epithelial cells, group-I PAKs are highly expressed in mPCA and PCa tissue. Importantly, the expression of group-I PAKs is proportional to the Gleason score of the patients. While several compounds have been identified that target group-I PAKs and these are active in cells and mice, and while some inhibitors have entered human trials, as of yet, none have been FDA-approved. Probable reasons for this lack of translation include issues related to selectivity, specificity, stability, and efficacy resulting in side effects and/or lack of efficacy. In the current review, we describe the pathophysiology and current treatment guidelines of PCa, present group-I PAKs as a potential druggable target to treat mPCa patients, and discuss the various ATP-competitive and allosteric inhibitors of PAKs. We also discuss the development and testing of a nanotechnology-based therapeutic formulation of group-I PAK inhibitors and its significant potential advantages as a novel, selective, stable, and efficacious mPCa therapeutic over other PCa therapeutics in the pipeline.

Health Care Costs Attributable to Prostate Cancer in British Columbia, Canada: A Population-Based Cohort Study

We aimed to estimate the total health care costs attributable to prostate cancer (PCa) during care phases by age, cancer stage, tumor grade, and primary treatment in the first year in British Columbia (BC), Canada. Using linked administrative health data, we followed a cohort of men aged ≥ 50 years at diagnosis with PCa between 2010 and 2017 (Cohort 1) from the diagnosis date until the date of death, the last date of observation, or 31 December 2019. Patients who died from PCa after 1 January 2010, were selected for Cohort 2. PCa attributable costs were estimated by comparing costs in patients to matched controls. Cohort 1 (n = 22,672) had a mean age of 69.9 years (SD = 8.9) and a median follow-up time of 5.2 years. Cohort 2 included 6942 patients. Mean PCa attributable costs were the highest during the first year after diagnosis ($14,307.9 [95% CI: $13,970.0, $14,645.8]) and the year before death ($9959.7 [$8738.8, $11,181.0]). Primary treatment with radiation therapy had significantly higher costs each year after diagnosis than a radical prostatectomy or other surgeries in advanced-stage PCa. Androgen deprivation therapy (and/or chemotherapy) had the highest cost for high-grade and early-stage cancer during the three years after diagnosis. No treatment group had the lowest cost. Updated cost estimates could inform economic evaluations and decision-making.

The impact of life expectancy on cost-effectiveness of treatment options for clinically localized prostate cancer

BACKGROUND

Life expectancy (LE) impacts effectiveness and morbidity of prostate cancer (CaP) treatment, but its impact on cost-effectiveness is unknown. We sought to evaluate the impact of LE on the cost-effectiveness of radical prostatectomy (RP), radiation therapy (RT), and active surveillance (AS) for clinically localized disease.

METHODS

We created a Markov model to calculate incremental cost-effectiveness ratios (ICERs) for RP, RT, and AS over a 20-year time horizon from a Medicare payer perspective for low- and intermediate-risk CaP. Mortality outcomes varied by tumor risk and PCCI score, a validated proxy for LE. We performed 1,000 Monte Carlo simulations with 1-way sensitivity analyses of PCCI within each tumor risk subgroup to compare cost/quality-adjusted life years (QALYs) between treatments.

RESULTS

AS dominated RP and RT for low- and intermediate-risk disease in men with LE ≤10 years (PCCI ≥7 and ≥9, respectively). However, AS failed to dominate RP and RT for men with longer LE. For men with low-risk cancer and LE>10 years (PCCI 0-6), AS had the greatest effectiveness, but failed to dominate due to higher cost relative to RP. For men with intermediate-risk cancer with LE>10 years, AS failed to dominate due to higher cost relative to RP (PCCI 0-8) and lower effectiveness relative to RT (PCCI 0-3). The range of QALYs between RP, RT, and AS varied <13% (range: 0%-12.9%) while costs varied up to 521% (range 0.5%-521%) across PCCI scores.

CONCLUSIONS

LE strongly modulates the cost of CaP treatments. This results in AS dominating RP and RT in men with LE ≤10 years. However, in men with longer LE, AS fails to dominate primarily due to its high cumulative costs, underscoring the need for risk-adjusted AS protocols.

Emerging Developments in ETS-Positive Prostate Cancer Therapy

Prostate cancer is a global health concern, which has a low survival rate in its advanced stages. Even though second-generation androgen receptor-axis inhibitors serve as the mainstay treatment options, utmost of the metastatic cases progress into castration-resistant prostate cancer after their initial treatment response with poor prognostic outcomes. Hence, there is a dire need to develop effective inhibitors that aim the causal oncogenes tangled in the prostate cancer initiation and progression. Molecular-targeted therapy against E-26 transformation-specific (ETS) transcription factors, particularly ETS-related gene, has gained wide attention as a potential treatment strategy. ETS rearrangements with the male hormone responsive transmembrane protease serine 2 promoter defines a significant number of prostate cancer cases and is responsible for cancer initiation and progression. Notably, inhibition of ETS activity has shown to reduce tumorigenesis, thus highlighting its potential as a clinical therapeutic target. In this review, we recapitulate the various targeted drug approaches, including small molecules, peptidomimetics, nucleic acids, and many others, aimed to suppress ETS activity. Several inhibitors have demonstrated ERG antagonist activity in prostate cancer, but further investigations into their molecular mechanisms and impacts on nontumor ETS-containing tissues is warranted.

Urinary extracellular vesicles miRNA-A new era of prostate cancer biomarkers

Prostate cancer is the second most common male cancer worldwide showing the highest rates of incidence in Western Europe. Although the measurement of serum prostate-specific antigen levels is the current gold standard in PCa diagnosis, PSA-based screening is not considered a reliable diagnosis and prognosis tool due to its lower sensitivity and poor predictive score which lead to a 22%-43% overdiagnosis, unnecessary biopsies, and over-treatment. These major limitations along with the heterogeneous nature of the disease have made PCa a very unappreciative subject for diagnostics, resulting in poor patient management; thus, it urges to identify and validate new reliable PCa biomarkers that can provide accurate information in regard to disease diagnosis and prognosis. Researchers have explored the analysis of microRNAs (miRNAs), messenger RNAs (mRNAs), small proteins, genomic rearrangements, and gene expression in body fluids and non-solid tissues in search of lesser invasive yet efficient PCa biomarkers. Although the presence of miRNAs in body fluids like blood, urine, and saliva initially sparked great interest among the scientific community; their potential use as liquid biopsy biomarkers in PCa is still at a very nascent stage with respect to other well-established diagnostics and prognosis tools. Up to date, numerous studies have been conducted in search of PCa miRNA-based biomarkers in whole blood or blood serum; however, only a few studies have investigated their presence in urine samples of which less than two tens involve the detection of miRNAs in extracellular vesicles isolated from urine. In addition, there exists some discrepancy around the identification of miRNAs in PCa urine samples due to the diversity of the urine fractions that can be targeted for analysis such as urine circulating cells, cell-free fractions, and exosomes. In this review, we aim to discuss research output from the most recent studies involving the analysis of urinary EVs for the identification of miRNA-based PCa-specific biomarkers.

Analysis of the financial impact and efficiency of the One Stop Prostate Clinic: A same day prostate cancer diagnostic clinic in the Australian public health system

Background

Access to prostate cancer diagnostic clinics are challenging for rural men in Western Australia due to remoteness and long travel distances. The One Stop Prostate Clinic (OSPC) provided same day assessment and diagnosis for prostate cancer in a public tertiary hospital to reduce access barriers for rural men. The objective of this study was to determine the financial and resource utilisation impact of the OSPC compared to a usual care pathway (UCP).

Design and methods

Study design: Cost minimisation analysis of the OSPC model (assuming 100% new referrals) compared with a UCP, including impact on the Patient Assisted Transport Scheme (PATS) for rural men. An estimate of total cost comparison of OSPC and UCP pathways of outpatient and diagnostic costs was calculated based on journey mapping of attendance and follow up.

Methods

Prospective data collection between August 2011 and November 2017 of referral, attendance and follow up outcomes. Journey mapping to identify time from referral to diagnosis, number of outpatient appointment (OPA) and travel savings.

Results

A total of 1000 men attended - 466 (47%) rural and 534 (53%) metro. Mean time from referral to diagnosis was 57 days (rural) versus 63 (metro; p = 0.034)). The OSPC saved 543 travel episodes (distance of 1.5M km) and 658 OPA's. Total episode of care costs for the OSPC (100% new) pathway estimated as $2237.34, compared to $2847.00 for a UCP, generating savings of $609.66 per attendance ($609,658.22 overall).

Conclusion

The OSPC was more cost effective and efficient in comparison to a UCP.

Comparing costs and health care resource utilization between nmHSPC and mHSPC patients: a retrospective claims analysis

BACKGROUND: Prostate cancer is common among men in the United States, and hormone sensitive-prostate cancer (HSPC) is the predominant etiology. However, there is a paucity of evidence documenting the financial impact of metastatic disease within this etiology. OBJECTIVE: To estimate the differences in health care resource utilization (HCRU) and costs for patients with nonmetastatic HSPC (nmHSPC) and metastatic HSPC (mHSPC) and their payers. METHODS: We conducted a retrospective cohort analysis using claims data from the IBM MarketScan databases from January 2016 to December 2019. HSPC was defined as having at least 1 inpatient services or 2 outpatient services claims with a prostate cancer diagnosis and a claim for androgen deprivation therapy use within 6 months of the initial diagnostic claim. Metastatic patients had a secondary diagnosis code of metastasis with their initial diagnostic claim. We compared mean 12-month HCRU, patient out-of-pocket (OOP), and payer costs between patients with nmHSPC and mHSPC using multivariable linear regression. RESULTS: 4,329 patients met the study inclusion criteria, 600 of which had mHSPC. Patients with mHSPC had more outpatient prescription fills (10.91 additional fills; 95% CI = 8.09-13.99) and outpatient services visits (10.61 additional visits; 95% CI = 8.38-13.04) but similar other HCRU. The overall 12-month costs of patients with mHSPC were significantly greater than patients with nmHSPC for patient OOP ($1,244; 95% CI = $1,004-$1,513) and payers ($113,725; 95% CI = $91,494-$141,127). CONCLUSIONS: Compared with patients with nmHSPC, individuals with mHSPC incur greater HCRU and significant personal and overall financial burden. DISCLOSURES: This study had no outside funding support. The authors have nothing to disclose.

Prostate cancer treatment costs increase more rapidly than for any other cancer—how to reverse the trend?

According to GLOBOCAN, about 1.41 million new prostate cancer (PCa) cases were registered in the year 2020 globally. The corresponding socio-economic burden is enormous. Anti-cancer mRNA-based therapy is a promising approach, the principle of which is currently applied for anti-COVID-19 vaccination, undergoing a detailed investigation in populations considering its short- and long-term effectiveness and potential side effects. Pragmatically considered, it will take years or even decades to make mRNA therapy working for any type of cancers, and if possible, for individual malignancy sub-types which are many specifically for the PCa. Actually, the costs of treating PCa are increasing more rapidly than those of any other cancer. The trend has to be reversed now, not in a couple of years. In general, two main components are making currently applied reactive (management of clinically manifested disease) PCa treatment particularly expensive. On one hand, it is rapidly increasing incidence of the disease and metastatic PCa as its subtype. To this end, rapidly increasing PCa incidence rates in young and middle-aged male sub-populations should be taken into account as a long-term contributor to the metastatic disease potentially developed later on in life. On the other hand, patient stratification to differentiate between non-metastatic PCa (no need for an extensive and costly treatment) and particularly aggressive cancer subtypes requiring personalised treatment algorithms is challenging. Considering current statistics, it becomes obvious that reactive medicine got at its limit in PCa management. Multi-professional expertise is unavoidable to create and implement anti-PCa programmes in the population. In our strategic paper, we exemplify challenging PCa management by providing detailed expert recommendations for primary (health risk assessment), secondary (prediction and prevention of metastatic disease in PCa) and tertiary (making palliative care to the management of chronic disease) care in the framework of predictive, preventive and personalised medicine.

Exploring the Role of Testosterone Replacement Therapy in Benign Prostatic Hyperplasia and Prostate Cancer: A Review of Safety

Increased risk of prostate diseases triggered by testosterone replacement therapy (TRT) remains a worldwide concern. That said, we reviewed the safety of TRT in the spheres of benign prostatic hyperplasia (BPH) and prostate cancer (PCa), exploring clinical findings in this regard. Compelling evidence based on meta-analyses of randomized and observational studies indicates safety for TRT in patients suffering from prostate disorders such as BPH and PCa, at the same time improving lower tract urinary symptoms. Thus, the harmful relationship geared toward androgens and BPH seems to be overestimated as TRT has sufficient safety and, if properly prescribed, may counteract several metabolic problems. Even after PCa treatment, the benefits of TRT could outweigh the risk of recurrence, but further long-term randomized clinical trials are needed to elucidate unresolved questions.

Combined Transfer Learning and Test-Time Augmentation Improves Convolutional Neural Network-Based Semantic Segmentation of Prostate Cancer from Multi-Parametric MR Images

PURPOSE

Multiparametric MRI (mp-MRI) is a widely used tool for diagnosing and staging prostate cancer. The purpose of this study was to evaluate whether transfer learning, unsupervised pre-training and test-time augmentation significantly improved the performance of a convolutional neural network (CNN) for pixel-by-pixel prediction of cancer vs. non-cancer using mp-MRI datasets.

METHODS

154 subjects undergoing mp-MRI were prospectively recruited, 16 of whom subsequently underwent radical prostatectomy. Logistic regression, random forest and CNN models were trained on mp-MRI data using histopathology as the gold standard. Transfer learning, unsupervised pre-training and test-time augmentation were used to boost CNN performance. Models were evaluated using Dice score and area under the receiver operating curve (AUROC) with leave-one-subject-out cross validation. Permutation feature importance testing was performed to evaluate the relative value of each MR contrast to CNN model performance. Statistical significance (p<0.05) was determined using the paired Wilcoxon signed rank test with Benjamini-Hochberg correction for multiple comparisons.

RESULTS

Baseline CNN outperformed logistic regression and random forest models. Transfer learning and unsupervised pre-training did not significantly improve CNN performance over baseline; however, test-time augmentation resulted in significantly higher Dice scores over both baseline CNN and CNN plus either of transfer learning or unsupervised pre-training. The best performing model was CNN with transfer learning and test-time augmentation (Dice score of 0.59 and AUROC of 0.93). The most important contrast was apparent diffusion coefficient (ADC), followed by Ktrans and T2, although each contributed significantly to classifier performance.

CONCLUSIONS

The addition of transfer learning and test-time augmentation resulted in significant improvement in CNN segmentation performance in a small set of prostate cancer mp-MRI data. Results suggest that these techniques may be more broadly useful for the optimization of deep learning algorithms applied to the problem of semantic segmentation in biomedical image datasets. However, further work is needed to improve the generalizability of the specific model presented herein.

Excessive waitlists and delays to treatment with low-dose-rate brachytherapy predict an increased risk of recurrence and metastases in intermediate-risk prostatic carcinoma

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Resource constraints have led to prolonged wait-times for prostate brachytherapy.

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Increased wait times predict a significant increase in recurrence and metastases.

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Better resource planning is needed to reduce management delays & improve outcomes.

Purpose

It has previously been shown that increased wait times for prostatectomy are associated with poorer outcomes in intermediate-risk prostatic carcinoma (PCa). However, the impact of wait times on PCa outcomes following low-dose-rate brachytherapy (LDR-BT) are unknown.

Methods and Materials

We retrospectively reviewed 466 intermediate-risk PCa patients that underwent LDR-BT at a single comprehensive cancer center between 2003 and 2016. Wait times were defined as the time from biopsy to LDR-BT. The association of wait times with outcomes was evaluated using Cox and Fine-Gray regression in both univariate and multivariate models.

Results

Median (interquartile range) follow-up and wait time for all patients were 8.1 (6.3–10.4) years and 5.1 (3.9–6.9) months, respectively. Among NCCN unfavourable intermediate-risk (UIR) patients (n = 170; 36%), increased wait times predicted both a greater cumulative incidence of recurrence [MHR = 1.01/month of wait time (95% CI: 1.00–1.03); P = 0.044] and metastases [MHR = 1.04/month of wait time (95% CI: 1.02–1.06); P < 0.001] in multivariate modeling. In NCCN favourable intermediate-risk (FIR) patients, there was no significant association between wait time and recurrence or metastases risk. Among all intermediate-risk patients, wait time was associated with an increase in the incidence of metastases [MHR = 1.03/month of wait time (95% CI: 1.02–1.05); P < 0.001], but not recurrence in multivariate models. There was no association between wait time and overall survival in the UIR, FIR, or all intermediate-risk cohorts.

Conclusions

Resource constraints within this center’s public healthcare system have contributed to waitlists exceeding 5-months in length. This study finds that patients with UIR PCa experience a 1% increase in the risk of recurrence and 4% increase in the risk of metastases with each additional month of delay in definitive disease management. Preventing such extended management delays in LDR-BT may improve disease-related outcomes in patients with PCa.

Comparing the frequency of CD33+ pSTAT3+ myeloid-derived suppressor cells and IL-17+ lymphocytes in patients with prostate cancer and benign prostatic hyperplasia

Prostate cancer (PCa) is one of the most epidemic types of cancer in men. The tumor microenvironment (TME) of PCa is involved in the emergence of immunosuppressive factors such as myeloid-derived suppressor cells (MDSC), which regulate the immune system by several mechanisms, including interleukin (IL)-10 production. On the other hand, IL-17⁺ helper T cells (Th17) induce MDSCs and chronic inflammation in TME by producing IL-17. This study demonstrated that the frequency of CD33⁺ pSTAT3⁺ MDSC and IL-17⁺ lymphocyte as well as IL-10 messenger RNA (mRNA) expression were significantly higher in the PCa patients than in the benign prostatic hyperplasia (BPH) group. Moreover, there was no significant relationship between the frequency of CD33⁺ pSTAT3⁺ MDSC, and IL-17⁺ lymphocyte with Gleason scores in the PCa group. We suggested that the higher frequency of CD33⁺ pSTAT3⁺ MDSC and IL-17⁺ lymphocyte and the more frequent expression of IL-10 mRNA in PCa patients may play roles in tumor progression from BPH to PCa.

The aftereffects of the UK national lockdown – could the reduction in urgent referrals, diagnostic and surgical capacities result in increased cancer morbidity and mortality?

Background:

The COVID-19 pandemic has cause major disruption to daily life in the United Kingdom in 2020. The national lockdown and mobilization of healthcare resources to areas with increased demand has resulted in a historical shift in referral, diagnostic and surgical capabilities in most healthboards. This regional, retrospective study aimed to shed light on the potential consequences of the UK national lockdown, the resultant decrease in referrals and diagnostic capacity on surgical services and patients during the recovery phase.

Methods:

Urgent referrals for suspected (USC) prostate cancer ( N =1430) from primary care in the north-east of Scotland and the number of diagnostic prostate biopsies performed in the region were reviewed to assess trends between January 2018 and December 2020. The data was anonymized and charted to highlight the differences between the period of national lockdown and other times.

Results:

The number of USC referrals for prostate cancer dropped significantly between March 2020 and June 2020 (a mean of 25 per month from 45 per month in the same period in 2018 and 2019). The number of diagnostic procedures also decreased significantly, with 74 fewer biopsies having been performed during the lockdown period compared with the same period in 2019.

Conclusions:

The shifts in USC referrals and diagnostics during the lockdown period have led to a backlog which may put patients at risk of cancer stage migration, leading to increased morbidity and mortality. This study indicates that reestablishment of surgical services should take priority during the recovery phase. Level of evidence: 3

Treatment-Related Healthcare Costs of Metastatic Castration-Resistant Prostate Cancer in Germany: A Claims Data Study

PURPOSE

Treatments for patients with metastatic castration-resistant prostate cancer (mCRPC) have expanded rapidly. They include the chemotherapies docetaxel and cabazitaxel, hormonal drugs abiraterone and enzalutamide, and best supportive care (BSC). Cabazitaxel has proven to be the last life-prolonging option, associated with a significant risk of serious adverse events. Given the lack of real-world evidence, we aimed to compare healthcare resource utilization (HRU) and costs in patients with mCRPC treated with cabazitaxel, docetaxel, abiraterone, enzalutamide, and BSC.

METHODS

We used 2014-2017 claims data from a large German statutory health insurance fund, the Techniker Krankenkasse, to identify patients with mCRPC. Patient allocation to individual therapy regimens was based on clinical knowledge and included therapy cycles, duration of therapy, and continuous treatment. The study period lasted from the first claim until death, the end of data availability, a drug switch, or discontinuation of therapy, whichever came first. Multivariate regression models were used to compare monthly all-cause and mCRPC-related HRU and costs across cohorts by adjusting for baseline covariates (including age and comorbidities).

RESULTS

The 3944 identified patients with mCRPC initiated treatment with cabazitaxel (n = 240), docetaxel (n = 539), abiraterone (n = 486), enzalutamide (n = 351), or BSC (n = 2328). In most domains, HRU was highest in the cabazitaxel cohort and lowest in the BSC group. Accordingly, the highest all-cause and mCRPC-related costs per month, respectively, were observed in patients receiving cabazitaxel (€7631/€6343), followed by abiraterone (€5226/€4579), enzalutamide (€5079/€4416), docetaxel (€2392/€1580), and BSC (€959/€438). Cost variations were mostly attributable to drugs, inpatient treatment, and sick leave payments.

CONCLUSION

mCRPC treatment imposes a high economic burden on statutory health insurance. Cabazitaxel is associated with substantially higher expenses, resulting from higher drug costs and a greater need for inpatient treatment. As mCRPC continues to be incurable, decision makers and clinician leaders should carefully evaluate public access to innovative agents and optimal treatment strategies.

Geospatial analysis, web-based mapping and determinants of prostate cancer incidence in Georgia counties: evidence from the 2012-2016 SEER data

Background

Prostate cancer (CaP) cases are high in the United States. According to the American Cancer Society, there are an estimated number of 174,650 CaP new cases in 2019. The estimated number of deaths from CaP in 2019 is 31,620, making CaP the second leading cause of cancer deaths among American men with lung cancer been the first. Our goal is to estimate and map prostate cancer relative risk, with the ultimate goal of identifying counties at higher risk where interventions and further research can be targeted.

Methods

The 2012–2016 Surveillance, Epidemiology, and End Results (SEER) Program data was used in this study. Analyses were conducted on 159 Georgia counties. The outcome variable is incident prostate cancer. We employed a Bayesian geospatial model to investigate both measured and unmeasured spatial risk factors for prostate cancer. We visualised the risk of prostate cancer by mapping the predicted relative risk and exceedance probabilities. We finally developed interactive web-based maps to guide optimal policy formulation and intervention strategies.

Results

Number of persons above age 65 years and below poverty, higher median family income, number of foreign born and unemployed were risk factors independently associated with prostate cancer risk in the non-spatial model. Except for the number of foreign born, all these risk factors were also significant in the spatial model with the same direction of effects. Substantial geographical variations in prostate cancer incidence were found in the study. The predicted mean relative risk was 1.20 with a range of 0.53 to 2.92. Individuals residing in Towns, Clay, Union, Putnam, Quitman, and Greene counties were at increased risk of prostate cancer incidence while those residing in Chattahoochee were at the lowest risk of prostate cancer incidence.

Conclusion

Our results can be used as an effective tool in the identification of counties that require targeted interventions and further research by program managers and policy makers as part of an overall strategy in reducing the prostate cancer burden in Georgia State and the United States as a whole.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08254-0.

The cost of metastatic prostate cancer using time-driven activity-based costing

OBJECTIVE

To estimate the cost of metastatic prostate cancer (mPC) treatment using the time-driven activity-based costing (TDABC) method from the perspective of a philanthropic hospital in the Brazilian public health system (PHS) and to identify determinants of costs.

METHODS

We used data from patients who received docetaxel chemotherapy in the Brazilian PHS from September 2012 to May 2017. Direct medical costs were estimated with the TDABC microcosting method, taking into account the multiple departments and services the patients interacted with during their oncological treatment.

RESULTS

The median overall survival of the forty-three patient sample was 1.8 years (95% CI 1.45-2.30), and the total cost of the sample was BRL 917.005 (USD 250,878). The median monthly cost per patient was BRL 20.201 (USD 5,526). The end-of-life cost per patient using the TDABC method was BRL 5.151 (USD 1,409). Patients who had received previous treatment at the center registered the lowest cost for hospitalizations and exams, suggesting an opportunity to better manage healthcare resources.

CONCLUSIONS

This is the first study on the economic burden of mPC in the Brazilian PHS using the TDABC costing evaluation method. Accurate cost information obtained with the TDABC can be helpful in guiding disease management to guarantee better use of ever-scarcer resources.

Physical activity assessment among men undergoing genetic counseling for inherited prostate cancer: a teachable moment for improved survivorship

BACKGROUND

Genetic counseling (GC) presents an opportunity to address modifiable cancer risk factors, such as obesity, which is impacted by non-adherence to physical activity (PA) guidelines. Adherence to PA guidelines has not been assessed among men undergoing GC for prostate cancer (PCA). We conducted a targeted analysis of men undergoing PCA GC to assess adherence to PA recommendations.

METHODS

Using a cross-sectional design, a total of 158 men from the Genetic Evaluation of Men (GEM) study at two academic cancer centers with a diagnosis or at risk for PCA completed a structured lifestyle survey, including questions about the number of days and intensity of PA over the past year. One-sample t tests assessed adherence of participants to PA recommendations. Chi-square analyses compared differences in PA adherence by PCA status, aggressiveness, family history, and body mass index. Logistic regression analyses identified predictors of PA adherence.

RESULTS

High proportions of GEM participants were overweight (44.9%) or obese (38.0%, p = 0.002). Men with PCA engaged in less moderate (p = 0.019) and vigorous (p = 0.005) aerobic activity than men without PCA. Higher education was predictive of adherence to light (p = 0.008), moderate (p = 0.019), and vigorous (p = 0.002) intensity PA. Older age (p = 0.015) and higher education (p = 0.001) were predictive of adherence to strength-based recommendations.

CONCLUSIONS

High proportions of men receiving PCA GC were overweight/obese and lacked adherence to PA recommendations. GC represents a teachable moment to address PA to reduce cancer risk and promote cancer survivorship.

Au-Ag assembled on silica nanoprobes for visual semiquantitative detection of prostate-specific antigen

Background

Blood prostate-specific antigen (PSA) levels are widely used as diagnostic biomarkers for prostate cancer. Lateral-flow immunoassay (LFIA)-based PSA detection can overcome the limitations associated with other methods. LFIAbased PSA detection in clinical samples enables prognosis and early diagnosis owing to the use of high-performance signal reporters.

Results

Here, a semiquantitative LFIA platform for PSA detection in blood was developed using Au–Ag nanoparticles (NPs) assembled on silica NPs (SiO2@Au–Ag NPs) that served as signal reporters. Synthesized SiO2@Au–Ag NPs exhibited a high absorbance at a wide wavelength range (400–800 nm), with a high scattering on nitrocellulose membrane test strips. In LFIA, the color intensity of the test line on the test strip differed depending on the PSA concentration (0.30–10.00 ng/mL), and bands for the test line on the test strip could be used as a standard. When clinical samples were assessed using this LFIA, a visual test line with particular color intensity observed on the test strip enabled the early diagnosis and prognosis of patients with prostate cancer based on PSA detection. In addition, the relative standard deviation of reproducibility was 1.41%, indicating high reproducibility, and the signal reporter showed good stability for 10 days.

Conclusion

These characteristics of the signal reporter demonstrated the reliability of the LFIA platform for PSA detection, suggesting potential applications in clinical sample analysis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12951-021-00817-4.

Accuracy of Urologic Conditions Portrayed on Grey's Anatomy

Despite the common prevalence of urologic diseases, studies have demonstrated that the general public often has little knowledge or insight into the field of urology or the role of an urologist. In this study, we investigated the context, frequency, and accuracy of urologic conditions on the television series Grey's Anatomy. We reviewed episodes from the first 15 seasons. Episodes with urologic references were then screened and the urologic conditions, outcomes, and treatments were recorded. We identified a total of only 21 urologic events across 15 seasons and 342 episodes of Grey's Anatomy. A total of 52% (11/21) of the conditions were related to external male genitalia. The portrayal of these conditions and the associated treatments were considered to be medically accurate within reason 62% (13/21) of the time. There is significant room for improvement to increase the portrayal of common urologic conditions and malignancies to improve the public's awareness and perception of our specialty.

Detecting and grading prostate cancer in radical prostatectomy specimens through deep learning techniques

OBJECTIVES

This study aims to evaluate the ability of deep learning algorithms to detect and grade prostate cancer (PCa) in radical prostatectomy specimens.

METHODS

We selected 12 whole-slide images of radical prostatectomy specimens. These images were divided into patches, and then, analyzed and annotated. The annotated areas were categorized as follows: stroma, normal glands, and Gleason patterns 3, 4, and 5. Two analyses were performed: i) a categorical image classification method that labels each image as benign or as Gleason 3, Gleason 4, or Gleason 5, and ii) a scanning method in which distinct areas representative of benign and different Gleason patterns are delineated and labeled separately by a pathologist. The Inception v3 Convolutional Neural Network architecture was used in categorical model training, and a Mask Region-based Convolutional Neural Network was used to train the scanning method. After training, we selected three new whole-slide images that were not used during the training to evaluate the model as our test dataset. The analysis results of the images using deep learning algorithms were compared with those obtained by the pathologists.

RESULTS

In the categorical classification method, the trained model obtained a validation accuracy of 94.1% during training; however, the concordance with our expert uropathologists in the test dataset was only 44%. With the image-scanning method, our model demonstrated a validation accuracy of 91.2%. When the test images were used, the concordance between the deep learning method and uropathologists was 89%.

CONCLUSION

Deep learning algorithms have a high potential for use in the diagnosis and grading of PCa. Scanning methods are likely to be superior to simple classification methods.

Cancer Trends in Iraq 2000-2016

OBJECTIVES

Precise and quantitative assessment of the trend of cancer burden enables policymakers and health managers to prioritize diseases and allocate resources better. This infers what caused a decrease or increase in the rate of cancer occurrence, and if it denotes timing of implementation of a control measure, it presents the impact on the disease rate. This study's objective was to evaluate trends in child and adult cancer in Iraq from 2000 onwards.

METHODS

We used the registries of the Iraqi Ministry of Health that were gathered from all governorates from 2000-2016. Data were presented as incidence rates to depict the trends of different types of cancers distributed by age, gender, and governorates.

RESULTS

Breast cancer witnessed a significant increase with predominance in females. Lung cancer rate increased significantly from 4.08 to 5.60/100 000 (p = 0.038), affecting males more than females. The brain cancer trend showed a bimodal pattern (two peaks in 2004 and 2011) with no significant trend change (p = 0.788). Both genders were similarly affected. The trend of stomach and colorectal cancer showed an accelerated increase after 2007.

CONCLUSIONS

Almost all cancers (particularly lung and gastrointestinal) showed constantly raising trends, especially after 2007. Only cervical and laryngeal cancer had a decreasing trend. Most cancers were predominant in males.

Trends in End-of-Life Resource Utilization and Costs among Prostate Cancer Patients from 2006 to 2015: A Nationwide Population-Based Study

Purpose

The purpose of this study was to evaluate end-of-life resource utilization and costs for prostate cancer patients during the last year of life in Korea.

Materials and Methods

The study used the National Health Information Database (NHIS-2017-4-031) of the Korean National Health Insurance Service. Healthcare claim data for the years 2002 through 2015 were collected from the Korean National Health Insurance System. Among 83,173 prostate cancer patients, we enrolled 18,419 after excluding 1,082 who never claimed for the last year of life.

Results

From 2006 to 2015, there was a 3.2-fold increase the total number of prostate cancer decedents. The average cost of care during the last year of life increased over the 10-year period, from 14,420,000 Korean won to 20,300,000 Korean won, regardless of survival time. The cost of major treatments and medications, other than analgesics, was relatively high. Radiologic tests, opioids, pain control, and rehabilitation costs were relatively low. Multiple regression analysis identified age and living in rural area as negatively associated with prostate cancer care costs, whereas income level and a higher number of comorbidities were positively associated.

Conclusions

Expenditure of prostate cancer care during the last year of life varied according to patient characteristics. Average costs increased every year. However, the results suggest underutilization of support services, likely due to lack of alternative accommodation for terminal prostate cancer patients. Further examination of patterns of utilization of healthcare resources will allow policymakers to take a better approach to reducing the burden of prostate cancer care.

Men's willingness to pay for prostate cancer screening: a systematic review

BACKGROUND

This study aimed to review studies on willingness to pay (WTP) for prostate cancer screening.

METHODS

This systematic-review was conducted based on the Preferred Reporting Items for Systematic Reviews guidelines. By searching six-health-database, WTP studies on prostate cancer screening using contingent valuation method published in English until March 2020 were included and those with unavailable full-text and inadequate quality-assessment scores were excluded. Smith checklist was used for the quality assessment. Extracted WTPs were converted to US dollar in 2018 using exchange rate parity and net present value formula to make comparison. Factors' effect was assessed by vote counting.

RESULTS

Six final studies published after 2006 reported above 70% Smith checklist items needed to be considered in contingent valuation study reports. Seven factors have positive effects on WTP. The reported WTP value varied from 11$ to 588$ in Japan and Germany, respectively.

CONCLUSION

WTP for prostate cancer screening was positive among all studied men. The results of factors' effect assessment showed that better understanding prostate cancer risks or screening tests and factors such as age, income, family history of cancer, hospitalization history, and educational level have positive effects. Moreover, prostate-specific antigen history, health insurance, employment, and subject's health assessment received less attention. The results' generalization to all countries is not applicable because there are no studies for low- and middle-income countries.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2020 CRD42020172789.

Conventional finite element models estimate the strength of metastatic human vertebrae despite alterations of the bone's tissue and structure

INTRODUCTION

Pathologic vertebral fractures are a major clinical concern in the management of cancer patients with metastatic spine disease. These fractures are a direct consequence of the effect of bone metastases on the anatomy and structure of the vertebral bone. The goals of this study were twofold. First, we evaluated the effect of lytic, blastic and mixed (both lytic and blastic) metastases on the bone structure, on its material properties, and on the overall vertebral strength. Second, we tested the ability of bone mineral content (BMC) measurements and standard FE methodologies to predict the strength of real metastatic vertebral bodies.

METHODS

Fifty-seven vertebral bodies from eleven cadaver spines containing lytic, blastic, and mixed metastatic lesions from donors with breast, esophageal, kidney, lung, or prostate cancer were scanned using micro-computed tomography (μCT). Based on radiographic review, twelve vertebrae were selected for nanoindentation testing, while the remaining forty-five vertebrae were used for assessing their compressive strength. The μCT reconstruction was exploited to measure the vertebral BMC and to establish two finite element models. 1) a micro finite element (μFE) model derived at an image resolution of 24.5 μm and 2) homogenized FE (hFE) model derived at a resolution of 0.98 mm. Statistical analyses were conducted to measure the effect of the bone metastases on BV/TV, indentation modulus (E_it), ratio of plastic/total work (W_Pl/W_tot), and in vitro vertebral strength (F_exp). The predictive value of BMC, μFE stiffness, and hFE strength were evaluated against the in vitro measurements.

RESULTS

Blastic vertebral bodies exhibit significantly higher BV/TV compared to the mixed (p = 0.0205) and lytic (p = 0.0216) vertebral bodies. No significant differences were found between lytic and mixed vertebrae (p = 0.7584). Blastic bone tissue exhibited a 5.8% lower median E_it (p< 0.001) and a 3.3% lower median W_pl/W_tot (p<0.001) compared to non-involved bone tissue. No significant differences were measured between lytic and non-involved bone tissues. F_exp ranged from 1.9 to 13.8 kN, was strongly associated with hFE strength (R²=0.78, p< 0.001) and moderately associated with BMC (R²=0.66, p< 0.001) and μFE stiffness (R²=0.66, p< 0.001), independently of the lesion type.

DISCUSSION

Our findings show that tumour-induced osteoblastic metastases lead to slightly, but significantly lower bone tissue properties compared to controls, while osteolytic lesions appear to have a negligible impact. These effects may be attributed to the lower mineralization and woven nature of bone forming in blastic lesions whilst the material properties of bone in osteolytic vertebrae appeared little changed. The moderate association between BMC- and FE-based predictions to fracture strength suggest that vertebral strength is affected by the changes of bone mass induced by the metastatic lesions, rather than altered tissue properties. In a broader context, standard hFE approaches generated from CTs at clinical resolution are robust to the lesion type when predicting vertebral strength. These findings open the door for the development of FE-based prediction tools that overcomes the limitations of BMC in accounting for shape and size of the metastatic lesions. Such tools may help clinicians to decide whether a patient needs the prophylactic fixation of an impending fracture.

The effects of metastatic lesion on the structural determinants of bone: Current clinical and experimental approaches

Metastatic bone disease is incurable with an associated increase in skeletal-related events, particularly a 17-50% risk of pathologic fractures. Current surgical and oncological treatments are palliative, do not reduce overall mortality, and therefore optimal management of adults at risk of pathologic fractures presents an unmet medical need. Plain radiography lacks specificity and may result in unnecessary prophylactic fixation. Radionuclide imaging techniques primarily supply information on the metabolic activity of the tumor or the bone itself. Magnetic resonance imaging and computed tomography provide excellent anatomical and structural information but do not quantitatively assess bone matrix. Research has now shifted to developing unbiased data-driven tools that can predict risk of impending fractures and guide individualized treatment decisions. This review discusses the state-of-the-art in clinical and experimental approaches for prediction of pathologic fractures with bone metastases. Alterations in bone matrix quality are associated with an age-related increase in skeletal fragility but the impact of metastases on the intrinsic material properties of bone is unclear. Engineering-based analyses are non-invasive with the capability to evaluate oncological treatments and predict failure due to the progression of metastasis. The combination of these approaches may improve our understanding of the underlying deterioration in mechanical performance.

Docetaxel-resistant prostate cancer cells become sensitive to gemcitabine due to the upregulation of ABCB1

BACKGROUND

Docetaxel is the preferred chemotherapeutic agent for hormone-refractory prostate cancer (PC) patients. However, patients eventually develop docetaxel resistance, and no effective treatment options are available for them.

OBJECTIVE

We aimed to establish docetaxel resistance in castration-resistant prostate cancer (CRPC) cell lines (DU145/TXR, PC-3/TXR, and CWR22/TXR) and characterized transcriptional changes upon acquiring resistance to the docetaxel.

METHODS

Human PC cells (DU145, PC-3, CWR22) and all docetaxel-resistant cells were maintained in Roswell Park Memorial Institute Medium (RPMI) 1640 media supplemented with 10% fetal bovine serum and 1% penicillin/streptomycin. ABCB1 was detected by using both parental and docetaxel-resistant CRPCs prepared for flow cytometry. For the evaluation of tumor-suppressive effects under each chemotherapeutic agent, subcutaneous xenografts of DU145 or DU145/TXR were implanted at the mouse flank.

RESULTS

The P-glycoprotein-encoding gene ABCB1 was distinctively upregulated in the resistant cells, and its overexpression played an essential role in docetaxel resistance in CRPC. When tested for the cytotoxicity of gemcitabine, another option for chemotherapy, the docetaxel-resistant cells were shown to become sensitive to the drug, implying additional phenotypic transformation in the docetaxel-resistant cells. Studies using xenograft animal models demonstrated that the growth of tumors composed of both docetaxel-sensitive and docetaxel-resistant cells was deterred most profoundly when docetaxel and gemcitabine were administered together.

CONCLUSION

This study suggests that when a drug develops therapeutic resistance, sensitivity tests could be another option, ultimately providing insight into a novel alternative clinical strategy.

Wide-field optical spectroscopy system integrating reflectance and spatial frequency domain imaging to measure attenuation-corrected intrinsic tissue fluorescence in radical prostatectomy specimens

The development of a multimodal optical imaging system is presented that integrates endogenous fluorescence and diffuse reflectance spectroscopy with single-wavelength spatial frequency domain imaging (SFDI) and surface profilometry. The system images specimens at visible wavelengths with a spatial resolution of 70 µm, a field of view of 25 cm2 and a depth of field of ∼1.5 cm. The results of phantom experiments are presented demonstrating the system retrieves absorption and reduced scattering coefficient maps using SFDI with <6% reconstruction errors. A phase-shifting profilometry technique is implemented and the resulting 3-D surface used to compute a geometric correction ensuring optical properties reconstruction errors are maintained to <6% in curved media with height variations <20 mm. Combining SFDI-computed optical properties with data from diffuse reflectance spectra is shown to correct fluorescence using a model based on light transport in tissue theory. The system is used to image a human prostate, demonstrating its ability to distinguish prostatic tissue (anterior stroma, hyperplasia, peripheral zone) from extra-prostatic tissue (urethra, ejaculatory ducts, peri-prostatic tissue). These techniques could be integrated in robotic-assisted surgical systems to enhance information provided to surgeons and improve procedural accuracy by minimizing the risk of damage to extra-prostatic tissue during radical prostatectomy procedures and eventually detect residual cancer.

Impact of Benign Prostatic Hyperplasia and/or Prostatitis on the Risk of Prostate Cancer in Korean Patients

Purpose

We evaluated the impact of benign prostatic hyperplasia (BPH) and prostatitis on the risk of prostate cancer (PCa) in patients using nationally representative data of the Korean population from the National Health Insurance Service.

Materials and Methods

A total of 5,580,495 Korean men, aged >20 years, who had undergone health screening in 2009 were followed-up for 9 years until 2017. Multivariate adjusted Cox regression analysis was conducted to determine the hazard ratio (HR) and 95% confidence interval (CI) for the association between BPH and/or prostatitis and PCa. The HR for PCa according to the presence of BPH and/or prostatitis was stratified by a combination of BPH and prostatitis in multivariable-adjusted models.

Results

The HR for PCa significantly increased in patients with BPH and prostatitis than in patients without BPH and prostatitis (adjusted HR, 1.626; 95% CI, 1.567–1.688 and adjusted HR, 1.557; 95% CI, 1.500–1.618, respectively). In particular, for the combination of BPH and prostatitis, the adjusted HR was 1.856 (95% CI, 1.743–1.976), which was the highest when a diagnosis of both BPH and prostatitis was made.

Conclusions

BPH and/or prostatitis are associated with an increased incidence for PCa in Korean patients, which is likely associated with similar effects to prostate-specific antigen (PSA) screening, so care must be taken in the interpretation. However, if follow-up survival studies demonstrate differences between the two groups (BPH and prostatitis vs. general), it could be one of the evidence for the introduction of PSA screening in Korea.

Reducing preoperative blood orders and costs for radical prostatectomy

Aim: A maximum surgical blood order schedule (MSBOS) was implemented at our institution to optimize preoperative blood ordering and reduce unnecessary blood preparation for patients undergoing radical prostatectomy (RP), a common urologic procedure. Materials & methods: We conducted a retrospective review of patients who underwent RP from 2010 to 2016 and categorized patients by date of RP (pre- or post-MSBOS) and compared preoperative blood-ordering practices. Results: After MSBOS implementation, preoperative blood orders changed from predominantly type and cross-match 2 units (53%) to no sample (56%) for robot-assisted laparoscopic RP, and from mostly type and cross-match 2 units (62%) to type and screen (75%) for open RP with resultant cost savings. Conclusion: MSBOS implementation and compliance decreases unnecessary preoperative blood orders.

Cost-effective survival prediction for patients with advanced prostate cancer using clinical trial and real-world hospital registry datasets

INTRODUCTION

Predictive survival modeling offers systematic tools for clinical decision-making and individualized tailoring of treatment strategies to improve patient outcomes while reducing overall healthcare costs. In 2015, a number of machine learning and statistical models were benchmarked in the DREAM 9.5 Prostate Cancer Challenge, based on open clinical trial data for metastatic castration resistant prostate cancer (mCRPC). However, applying these models into clinical practice poses a practical challenge due to the inclusion of a large number of model variables, some of which are not routinely monitored or are expensive to measure.

OBJECTIVES

To develop cost-specified variable selection algorithms for constructing cost-effective prognostic models of overall survival that still preserve sufficient model performance for clinical decision making.

METHODS

Penalized Cox regression models were used for the survival prediction. For the variable selection, we implemented two algorithms: (i) LASSO regularization approach; and (ii) a greedy cost-specified variable selection algorithm. The models were compared in three cohorts of mCRPC patients from randomized clinical trials (RCT), as well as in a real-world cohort (RWC) of advanced prostate cancer patients treated at the Turku University Hospital. Hospital laboratory expenses were utilized as a reference for computing the costs of introducing new variables into the models.

RESULTS

Compared to measuring the full set of clinical variables, economic costs could be reduced by half without a significant loss of model performance. The greedy algorithm outperformed the LASSO-based variable selection with the lowest tested budgets. The overall top performance was higher with the LASSO algorithm.

CONCLUSION

The cost-specified variable selection offers significant budget optimization capability for the real-world survival prediction without compromising the predictive power of the model.

Clinical characteristics, treatment pattern, and medical costs associated with metastatic castration-resistant prostate cancer in Chinese tertiary care hospital settings

Objectives: To describe the clinical characteristics, treatment pattern, and medical costs associated with metastatic castration-resistant prostate cancer (mCRPC) in Chinese patients. Methods: This retrospective study identified a group of patients with newly-developed mCRPC from 2012 to 2016 to extract information from their medical and billing records in two tertiary care hospitals. Descriptive statistical methods were used to summarize patient clinical characteristics, treatment pattern, and monthly medical costs. Conventional regression analyses explored the predictors for the utilization of chemotherapy and monthly medical costs. Results: Seventy-eight identified mCRPC patients were characterized with a high proportion of stage IV tumors at diagnosis of prostate cancer (75.0%) and high prevalence of bone metastasis (91.0%). Sixty-six percent of the identified patients only received one treatment episode. Among the patients receiving the first treatment episode, hormone therapy, chemotherapy, and best supportive care (BSC) accounted for 75.7%, 21.4%, and 2.9%, respectively; the previous orchiectomy was significantly associated with chemotherapy (odds ratio = 5.325, p = 0.034); and chemotherapy was associated with comparable drug costs and higher non-drug costs (coefficient = 0.657, p = 0.056) when compared to hormone therapy after the adjustment of patient characteristics. Conclusions: Chinese mCRPC patients were characterized with delayed diagnosis of prostate cancer and high prevalence of bone metastasis. The treatment options for mCRPC were limited in Chinese patients as the conventional hormone therapy was still heavily used after the development of mCRPC. The medical costs associated with mCRPC were mainly driven by chemotherapy in Chinese patients.

Cartilage oligomeric matrix protein in patients with osteoarthritis is independently associated with metastatic disease in prostate cancer

Metastatic prostate cancer has a 5-year survival rate of 30%. Identifying predictors of metastasis outcome could potentially reduce patient mortality. The objective of this study was to determine whether osteoarthritis had an impact on outcomes of prostate cancer including death, local recurrence and/or metastasis and to determine whether cartilage oligomeric matrix protein was involved. We performed a retrospective case-control study of patients with prostate cancer with and without the diagnosis of osteoarthritis and completed immunohistochemistry (IHC) analysis of prostate (n=20) and lymph node (n=7) surgical specimens. We evaluated death, local recurrence and metastatic disease by various IHC biomarkers including prostate specific membrane antigen (PSMA), cartilage oligomeric matrix protein (COMP), CD31, and Ki-67. Our model identified osteoarthritis as an independent risk factor for metastatic disease (OR 5.24, 95% CI 1.49 - 18.41). Most notably, when joint arthroplasty was included in the model, osteoarthritis was no longer an independent risk factor for this outcome (p=0.071). IHC demonstrated that those with osteoarthritis, had greater expression of COMP in the prostate samples (mean 23.9% vs 5.84%, p<0.05) but not of Ki-67, CD31, or PSMA. This study identified and quantified increased metastatic disease in patients with osteoarthritis. Also, patients with osteoarthritis expressed increased COMP levels in the prostate and most likely in distant lymphatic nodes. Moreover, our findings suggest that joint arthroplasty may affect the ability of osteoarthritis to promote metastasis, which could impact treatment protocols and survival outcomes of the most common cause of cancer-related death (metastasis) in the United States.

Cost-of-illness studies in chronic ulcers: a systematic review

OBJECTIVE

To systematically review the published academic literature on the cost of chronic ulcers.

METHODS

A literature search was conducted in MEDLINE, EMBASE, HealthSTAR, Econlit and CINAHL up to 12 May 2016 to identify potential studies for review. Cost search terms were based on validated algorithms. Clinical search terms were based on recent Cochrane reviews of interventions for chronic ulcers. Titles and abstracts were screened by two reviewers to determine eligibility for full text review. Study characteristics were summarised. The quality of reporting was evaluated using a modified cost-of-illness checklist. Mean costs were adjusted and inflated to 2015 $US and presented for different durations and perspectives.

RESULTS

Of 2267 studies identified, 36 were eligible and included in the systematic review. Most studies presented results from the health-care public payer or hospital perspective. Many studies included hospital costs in the analysis and only reported total costs without presenting condition-specific attributable costs. The mean cost of chronic ulcers ranged from $1000 per year for patient out of pocket costs to $30,000 per episode from the health-care public payer perspective. Mean one year cost from a health-care public payer perspective was $44,200 for diabetic foot ulcer (DFU), $15,400 for pressure ulcer (PU) and $11,000 for leg ulcer (LU).

CONCLUSIONS

There was large variability in study methods, perspectives, cost components and jurisdictions, making interpretation of costs difficult. Nevertheless, it appears that the cost for the treatment of chronic ulcers is substantial and greater attention needs to be made for preventive measures.

Real-world data: towards achieving the achievable in cancer care

The use of data from the real world to address clinical and policy-relevant questions that cannot be answered using data from clinical trials is garnering increased interest. Indeed, data from cancer registries and linked treatment records can provide unique insights into patients, treatments and outcomes in routine oncology practice. In this Review, we explore the quality of real-world data (RWD), provide a framework for the use of RWD and draw attention to the methodological pitfalls inherent to using RWD in studies of comparative effectiveness. Randomized controlled trials and RWD remain complementary forms of medical evidence; studies using RWD should not be used as substitutes for clinical trials. The comparison of outcomes between nonrandomized groups of patients who have received different treatments in routine practice remains problematic. Accordingly, comparative effectiveness studies need to be designed and interpreted very carefully. With due diligence, RWD can be used to identify and close gaps in health care, offering the potential for short-term improvement in health-care systems by enabling them to achieve the achievable.

Phytochemicals in Prostate Cancer: From Bioactive Molecules to Upcoming Therapeutic Agents

Prostate cancer is a heterogeneous disease, the second deadliest malignancy in men and the most commonly diagnosed cancer among men. Traditional plants have been applied to handle various diseases and to develop new drugs. Medicinal plants are potential sources of natural bioactive compounds that include alkaloids, phenolic compounds, terpenes, and steroids. Many of these naturally-occurring bioactive constituents possess promising chemopreventive properties. In this sense, the aim of the present review is to provide a detailed overview of the role of plant-derived phytochemicals in prostate cancers, including the contribution of plant extracts and its corresponding isolated compounds.