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Pasanen N, Talala K, Remmers S, Tammela TLJ, Hugosson J, Roobol MJ, Taari K, Arnsrud Godtman R, Bangma C, Auvinen A. Which men benefit from prostate cancer screening? Prostate cancer mortality by subgroup in the European Randomised Study of Screening for Prostate Cancer. BJU Int 2024; 134:291-299. [PMID: 38725182 DOI: 10.1111/bju.16394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
OBJECTIVE To evaluate whether a subgroup of men can be identified that would benefit more from screening than others. MATERIALS AND METHODS This retrospective cohort study was based on three European Randomised Study of Screening for Prostate Cancer (ERSPC) centres, Finland, the Netherlands and Sweden. We identified 126 827 men aged 55-69 years in the study who were followed for maximum of 16 years after randomisation. The primary outcome was prostate cancer (PCa) mortality. We analysed three age groups 55-59, 60-64 and 65-69 years and PCa cases within four European Association of Urology (EAU) risk groups: low, intermediate, high risk, and advanced disease. RESULTS The hazard ratio (HR) for PCa mortality in the screening arm relative to the control arm for men aged 55-59 years was 0.96 (95% confidence interval [CI] 0.75-1.24) in Finland, 0.70 (95% CI 0.44-1.12) in the Netherlands and 0.42 (95% CI 0.24-0.73) in Sweden. The HR for men aged 60-64 years was 1.03 (95% CI 0.77-1.37) in Finland, 0.76 (95% CI 0.50-1.16) in the Netherlands and 0.97 (95% CI 0.64-1.48) in Sweden. The HR for men aged 65-69 years was 0.80 (95% CI 0.62-1.03) in Finland and 0.57 (95% CI 0.38-0.83) in the Netherlands, and this age group was absent in Sweden. In the EAU risk group analysis, PCa mortality rates were materially lower for men with advanced disease at diagnosis in all three countries: 0.67 (95% CI 0.56-0.82) in Finland, 0.28 (95% CI 0.18-0.44) in the Netherlands, and 0.48 (95% CI 0.30-0.78) in Sweden. CONCLUSION We were unable to unequivocally identify the optimal age group for screening, as mortality reduction differed among centres and age groups. Instead, the screening effect appears to depend on screening duration, and the number and frequency of screening rounds. PCa mortality reduction by screening is largely attributable to stage shift.
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Affiliation(s)
- Niko Pasanen
- Faculty of Social Sciences, Tampere University, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Sebastiaan Remmers
- Department of Urology, Erasmus University Medical Centre, Cancer Institute, Rotterdam, The Netherlands
| | - Teuvo L J Tammela
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Urology, Tampere University Hospital, Tampere, Finland
| | - Jonas Hugosson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Urology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Monique J Roobol
- Department of Urology, Erasmus University Medical Centre, Cancer Institute, Rotterdam, The Netherlands
| | - Kimmo Taari
- Department of Urology, Helsinki University Hospital, Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Rebecka Arnsrud Godtman
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Urology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Chris Bangma
- Department of Urology, Erasmus University Medical Centre, Cancer Institute, Rotterdam, The Netherlands
| | - Anssi Auvinen
- Faculty of Social Sciences, Tampere University, Tampere, Finland
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de Vos II, Remmers S, Hogenhout R, Roobol MJ. Prostate Cancer Mortality Among Elderly Men After Discontinuing Organised Screening: Long-term Results from the European Randomized Study of Screening for Prostate Cancer Rotterdam. Eur Urol 2024; 85:74-81. [PMID: 37919190 DOI: 10.1016/j.eururo.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/22/2023] [Accepted: 10/12/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND The optimal timing for discontinuing screening of prostate cancer (PCa) in elderly men is currently not known and remains debated. OBJECTIVE To assess prostate cancer-specific mortality (PCSM) in elderly men who previously underwent prostate-specific antigen (PSA)-based screening and to identify those who may benefit from continued screening. DESIGN, SETTING, AND PARTICIPANTS A total of 7052 men, who participated in the screening arm of the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer and were aged 70-74 yr at their last screening visit after undergoing a maximum of three screening rounds without being diagnosed with PCa, were included. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The cumulative incidence of PCSM by the age of 85 yr was assessed. Additionally, a competing risk regression was performed to assess the potential predictors of PCSM. RESULTS AND LIMITATIONS The median follow-up was 16 yr. The cumulative incidence of PCSM by the age of 85 yr was 0.54% (95% confidence interval [CI]: 0.40-0.70) in all men, 0.11% (95% CI: 0.05-0.27) in men with PSA <2 ng/ml, 0.85% (95% CI: 0.47-1.5) in men with PSA 2-3 ng/ml, and 6.8% (95% CI: 3.1-15) in men with PSA ≥6.5 ng/ml and no previous benign biopsy. PSA (subdistribution hazard ratio [sHR]: 2.0; 95% CI: 1.7-2.3), previous benign prostate biopsy (sHR: 0.41; 95% CI: 0.23-0.72), and hypertension (sHR: 0.48; 95% CI: 0.25-0.91) were significantly associated with PCSM. CONCLUSIONS Men aged 70-74 yr who have previously undergone PSA-based screening without receiving a PCa diagnosis have a very low risk of dying from PCa by the age of 85 yr. These data suggest that screening may be discontinued in men with PSA <3.0 ng/ml or previous benign prostate biopsies. Those with higher PSA levels and no prior biopsies may consider continued screening if life expectancy exceeds 10 yr. PATIENT SUMMARY This study shows that men who participated in a prostate cancer screening trial have a very low risk of dying from prostate cancer if they have not been diagnosed with prostate cancer by the age of 74 yr.
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Affiliation(s)
- Ivo I de Vos
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Sebastiaan Remmers
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Renée Hogenhout
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Monique J Roobol
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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de Vos II, Meertens A, Hogenhout R, Remmers S, Roobol MJ. A Detailed Evaluation of the Effect of Prostate-specific Antigen-based Screening on Morbidity and Mortality of Prostate Cancer: 21-year Follow-up Results of the Rotterdam Section of the European Randomised Study of Screening for Prostate Cancer. Eur Urol 2023; 84:426-434. [PMID: 37029074 DOI: 10.1016/j.eururo.2023.03.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 02/24/2023] [Accepted: 03/14/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Considering the long natural history of prostate cancer (PCa), long-term results of the European Randomised Study of Screening for PCa (ERSPC) are crucial. OBJECTIVE To provide an update on the effect of prostate-specific antigen (PSA)-based screening on PCa-specific mortality (PCSM), metastatic disease, and overdiagnosis in the Dutch arm of the ERSPC. DESIGN, SETTING, AND PARTICIPANTS Between 1993 and 2000, a total of 42376 men, aged 55-74 yr, were randomised to a screening or a control arm. The main analysis was performed with men aged 55-69 yr (n = 34831). Men in the screening arm were offered PSA-based screening with an interval of 4 yr. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Intention-to-screen analyses with Poisson regression were used to calculate rate ratios (RRs) of PCSM and metastatic PCa. RESULTS AND LIMITATIONS After a median follow-up of 21 yr, the RR of PCSM was 0.73 (95% confidence interval [CI]: 0.61-0.88) favouring screening. The numbers of men needed to invite (NNI) and needed to diagnose (NND) to prevent one PCa death were 246 and 14, respectively. For metastatic PCa, the RR was 0.67 (95% CI: 0.58-0.78) favouring screening. The NNI and NND to prevent one metastasis were 121 and 7, respectively. No statistical difference in PCSM (RR of 1.18 [95% CI: 0.87-1.62]) was observed in men aged ≥70 yr at the time of randomisation. In the screening arm, higher rates of PCSM and metastatic disease were observed in men who were screened only once and in a selected group of men above the screening age cut-off of 74 yr. CONCLUSIONS The current analysis illustrates that with a follow-up of 21 yr, both absolute metastasis and mortality reduction continue to increase, resulting in a more favourable harm-benefit ratio than demonstrated previously. These data do not support starting screening at the age of 70-74 yr and show that repeated screening is essential. PATIENT SUMMARY Prostate-specific antigen-based prostate cancer screening reduces metastasis and mortality. Longer follow-up shows fewer invitations and diagnoses needed to prevent one death, a positive note towards the issue of overdiagnosis.
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Affiliation(s)
- Ivo I de Vos
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Annick Meertens
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Renée Hogenhout
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sebastiaan Remmers
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Monique J Roobol
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Remmers S, Nieboer D, Roobol MJ. The Patient Journey from Randomization to Detection of Prostate Cancer and Death: Results from ERSPC Rotterdam. EUR UROL SUPPL 2023; 51:1-6. [PMID: 37187725 PMCID: PMC10175721 DOI: 10.1016/j.euros.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2023] [Indexed: 05/17/2023] Open
Abstract
Background The ERSPC study has demonstrated that prostate-specific antigen (PSA)-based screening results in a relative increase in diagnosis of (low-risk) prostate cancer (PCa) and a reduction in metastatic disease and PCa mortality. Objective To evaluate the burden of PCa among men randomized to active screening compared to those in the control arm in ERSPC Rotterdam. Design setting and participants We analyzed data for participants in the Dutch section of the ERSPC, including 21 169 men randomized to the screening arm and 21 136 randomized to the control arm. Men in the screening arm were invited for PSA-based screening every 4 yr, and transrectal ultrasound-guided prostate biopsy was recommended for those with PSA ≥3.0 ng/ml. Outcome measurements and statistical analysis We analyzed detailed follow-up and mortality data up to January 1, 2019, to a maximum of 21 yr, using multistate models. Results and limitations At 21 yr, 3046 men (14%) had been diagnosed with nonmetastatic PCa and 161 (0.76%) with metastatic PCa in the screening arm. In the control arm, 1698 men (8.0%) had been diagnosed with nonmetastatic PCa and 346 (1.6%) with metastatic PCa. In comparison to the control arm, men in the screening arm were diagnosed with PCa almost 1 yr earlier and if diagnosed with nonmetastatic PCa lived on average for almost 1 yr longer without disease progression. Among those who experienced biochemical recurrence (18-19% after nonmetastatic PCa), progression to metastatic disease or death was quicker in the control arm: men in the screening arm lived for 7.17 yr without progression, while the progression-free interval was only 1.59 yr for men in the control arm over a 10-yr time period. Among those who experienced metastatic disease, men in both study arms lived for 5 yr over a 10-yr time period. Conclusions PCa diagnosis was earlier after study entry for men in the PSA-based screening arm. However, disease progression was not as fast in the screening arm as in the control arm: once men in the control arm experienced biochemical recurrence, progression to metastatic disease or death was 5.6 yr faster than in the screening arm. Our results confirm the ability of early disease detection to reduce suffering and death from PCa at the cost of earlier (and more frequent) treatment-induced reductions in quality of life. Patient summary Our study shows that early detection of prostate cancer can reduce suffering and death from this disease. However, screening based on measurement of prostate-specific antigen (PSA) can also result in an earlier treatment-induced reduction in quality of life.
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Affiliation(s)
- Sebastiaan Remmers
- Department of Urology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
- Corresponding author. Department of Urology, Erasmus University Medical Center, P.O. Box 2040, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands. Tel. +31 10 7032 239; Fax: +31 10 7035 315.
| | - Daan Nieboer
- Department of Urology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Monique J. Roobol
- Department of Urology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
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Orrason AW, Styrke J, Garmo H, Stattin P. Evidence of cancer progression as the cause of death in men with prostate cancer in Sweden. BJU Int 2023; 131:486-493. [PMID: 36088648 DOI: 10.1111/bju.15891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the strength of the evidence indicative of prostate cancer (PCa) progression as the adjudicated cause of death, according to age at death and PCa risk category. PATIENTS AND METHODS Using data from the Prostate Cancer data Base Sweden, we identified a study frame of 5543 men with PCa registered as the cause of death according to the Cause of Death Register. We assessed the evidence of PCa progression through a review of healthcare records for a stratified sample of 495/5543. We extracted data on prostate-specific antigen levels, presence of metastases on imaging, and PCa treatments, and quantified the evidence of disease progression using a points system. RESULTS Both no evidence and moderate evidence for PCa progression was more common in men aged >85 years at death than those aged <85 years (29% vs 14%). Among the latter, the proportion with no evidence or moderate evidence for PCa progression was 21% for low-risk, 14% for intermediate-risk, 8% for high-risk, and 0% for metastatic PCa. In contrast, in men aged >85 years, there was little difference in the proportion with no evidence or moderate evidence of PCa progression between PCa risk categories; 31% for low-risk, 29% for intermediate-risk, 29% for high-risk, and 21% for metastatic PCa. Of the 5543 men who died from PCa, 13% (95% confidence interval 5-19%) were estimated to have either no evidence or moderate evidence of PCa progression. CONCLUSIONS Weak evidence for PCa progression as cause of death was more common in older men with PCa and in those with low-risk PCa. This has implications for interpretation of mortality statistics especially when assessing screening and early treatment of PCa because the beneficial effect of earlier diagnosis could be masked by erroneous adjudication of PCa as cause of death in older men, particular those with localised disease at diagnosis.
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Affiliation(s)
| | - Johan Styrke
- Department of Surgical and Perioperative Sciences, Urology and Andrology, Umeå University, Umeå, Sweden
| | - Hans Garmo
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Pär Stattin
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
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Carlsson SV, Arnsrud Godtman R, Pihl CG, Vickers A, Lilja H, Hugosson J, Månsson M. Young Age on Starting Prostate-specific Antigen Testing Is Associated with a Greater Reduction in Prostate Cancer Mortality: 24-Year Follow-up of the Göteborg Randomized Population-based Prostate Cancer Screening Trial. Eur Urol 2023; 83:103-109. [PMID: 36334968 PMCID: PMC10481420 DOI: 10.1016/j.eururo.2022.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/15/2022] [Accepted: 10/04/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The risk of death from prostate cancer (PC) depends on age, but the age at which to start prostate-specific antigen (PSA) screening remains uncertain. OBJECTIVE To study the relationship between risk reduction for PC mortality and age at first PSA screening. DESIGN, SETTING, AND PARTICIPANTS The randomized Göteborg-1 trial invited men for biennial PSA screening between the ages of 50 and 70 yr (screening, n = 10 000) or no invitation but exposure to opportunistic PSA testing (control, n = 10 000). INTERVENTION Regular versus opportunistic PSA screening or no PSA. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We modeled the nonlinear association between starting age and the absolute risk reduction in PC mortality in three settings: (1) intention-to-screen (randomized arms); (2) historical control (screening group and 1990-1994 registry data); and (3) attendees only (screening attendees and matched controls). We tested whether the effect of screening on PC mortality depends on the age at starting screening by comparing survival models with and without an interaction between trial arm and age (intention-to-screen and attendees only). RESULTS AND LIMITATIONS Younger age on starting PSA testing was associated with a greater reduction in PC mortality. Starting screening at age 55 yr approximately halved the risk of PC death compared to first PSA at age 60 yr. The test of association between starting age and the effect of screening on PC mortality was slightly greater than the conventional level of statistical significance (p = 0.052) for the entire cohort, and statistically significant among attendees (p = 0.002). This study is limited by the low number of disease-specific deaths for men starting screening before age 55 yr and the difficulty in discriminating between the effect of starting age and screening duration. CONCLUSIONS Given that prior screening trials included men aged up to 70 yr on starting screening, our results suggest that the effect size reported in prior trials underestimates that of currently recommended programs starting at age 50-55 yr. PATIENT SUMMARY In this study from the Göteborg-1 trial, we looked at the effect of prostate-specific antigen (PSA) screening in reducing men's risk of dying from prostate cancer given the age at which they begin testing. Starting at a younger age reduced the risk of prostate cancer death by a greater amount. We recommend that PSA screening should start no later than at age 55 yr.
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Affiliation(s)
- Sigrid V Carlsson
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Rebecka Arnsrud Godtman
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden; Department of Urology, Sahlgrenska University Hospital, Göteborg, Sweden
| | | | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hans Lilja
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Jonas Hugosson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden; Department of Urology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Marianne Månsson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden.
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Abstract
PURPOSE Our goal was to analyze results from 22 years of followup in the Göteborg randomized prostate cancer (PC) screening trial. MATERIALS AND METHODS In December 1994, 20,000 men born 1930-1944 were randomly extracted from the Swedish population register and were randomized (1:1) into either a screening group (SG) or to a control group (CG). Men in the SG were repeatedly invited for biennial prostate specific antigen testing up to an average age of 69 years. Main endpoints were PC incidence and mortality (intention-to-screen principle). RESULTS After 22 years, 1,528 men in the SG and 1,124 men in the CG had been diagnosed with PC. In total, 112 PC deaths occurred in the SG and 158 in the CG. Compared with the CG, the SG showed a PC incidence rate ratio (RR) of 1.42 (95% CI, 1.31-1.53) and a PC mortality RR of 0.71 (95% CI, 0.55-0.91). The 22-year cumulative PC mortality rate was 1.55% (95% CI, 1.29-1.86) in the SG and 2.13% (95% CI, 1.83-2.49) in the CG. Correction for nonattendance (Cuzick method) yielded a RR of PC mortality of 0.59 (95% CI, 0.43-0.80). Number needed to invite and number needed to diagnose was estimated to 221 and 9, respectively. PC death risk was increased in the following groups: nontesting men, men entering the program after age 60 and men with >10 years of followup after screening termination. CONCLUSIONS Prostate specific antigen-based screening substantially decreases PC mortality. However, not attending, starting after age 60 and stopping at age 70 seem to be major pitfalls regarding PC death risk.
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Intervention-related Deaths in the European Randomized Study of Screening for Prostate Cancer. EUR UROL SUPPL 2021; 34:27-32. [PMID: 34934964 PMCID: PMC8655382 DOI: 10.1016/j.euros.2021.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 11/22/2022] Open
Abstract
Background Identification of intervention-related deaths is important for an accurate assessment of the ratio of benefit to harm in screening trials. Objective To investigate intervention-related deaths by study arm in the European Randomized Study of Prostate Cancer Screening (ERSPC). Design, setting, and participants ERSPC is a multicenter trial initiated in the 1990s to investigate whether screening on the basis of prostate-specific antigen (PSA) can decrease prostate cancer mortality. The present study included men in the core age group (55–69 yr: screening group n = 112 553, control group n = 128 681) with 16-yr follow-up. Outcome measurements and statistical analysis Causes of death among men with prostate cancer in ERSPC were predominantly evaluated by independent national committees via review of medical records according to a predefined algorithm. Intervention-related deaths were defined as deaths caused by complications during the screening procedure, treatment, or follow-up. Descriptive statistics were used for the results. Results and limitations In total, 34 deaths were determined to be intervention-related, of which 21 were in the screening arm and 13 in the control arm. The overall risk of intervention-related death was 1.41 (95% confidence interval 0.99–1.99) per 10 000 randomized men for both arms combined and varied among centers from 0 to 7.0 per 10 000 randomized men. A limitation of this study is that differences in procedures among centers decreased the comparability of the results. Conclusions Intervention-related deaths were rare in ERSPC. Monitoring of intervention-related deaths in screening trials is important for assessment of harms. Patient summary We investigated deaths due to screening or treatment to assess harm in a trial of prostate cancer screening. Few such deaths were identified.
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Hamdy FC, Donovan JL, Lane JA, Mason M, Metcalfe C, Holding P, Wade J, Noble S, Garfield K, Young G, Davis M, Peters TJ, Turner EL, Martin RM, Oxley J, Robinson M, Staffurth J, Walsh E, Blazeby J, Bryant R, Bollina P, Catto J, Doble A, Doherty A, Gillatt D, Gnanapragasam V, Hughes O, Kockelbergh R, Kynaston H, Paul A, Paez E, Powell P, Prescott S, Rosario D, Rowe E, Neal D. Active monitoring, radical prostatectomy and radical radiotherapy in PSA-detected clinically localised prostate cancer: the ProtecT three-arm RCT. Health Technol Assess 2020; 24:1-176. [PMID: 32773013 PMCID: PMC7443739 DOI: 10.3310/hta24370] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Prostate cancer is the most common cancer among men in the UK. Prostate-specific antigen testing followed by biopsy leads to overdetection, overtreatment as well as undertreatment of the disease. Evidence of treatment effectiveness has lacked because of the paucity of randomised controlled trials comparing conventional treatments. OBJECTIVES To evaluate the effectiveness of conventional treatments for localised prostate cancer (active monitoring, radical prostatectomy and radical radiotherapy) in men aged 50-69 years. DESIGN A prospective, multicentre prostate-specific antigen testing programme followed by a randomised trial of treatment, with a comprehensive cohort follow-up. SETTING Prostate-specific antigen testing in primary care and treatment in nine urology departments in the UK. PARTICIPANTS Between 2001 and 2009, 228,966 men aged 50-69 years received an invitation to attend an appointment for information about the Prostate testing for cancer and Treatment (ProtecT) study and a prostate-specific antigen test; 82,429 men were tested, 2664 were diagnosed with localised prostate cancer, 1643 agreed to randomisation to active monitoring (n = 545), radical prostatectomy (n = 553) or radical radiotherapy (n = 545) and 997 chose a treatment. INTERVENTIONS The interventions were active monitoring, radical prostatectomy and radical radiotherapy. TRIAL PRIMARY OUTCOME MEASURE Definite or probable disease-specific mortality at the 10-year median follow-up in randomised participants. SECONDARY OUTCOME MEASURES Overall mortality, metastases, disease progression, treatment complications, resource utilisation and patient-reported outcomes. RESULTS There were no statistically significant differences between the groups for 17 prostate cancer-specific (p = 0.48) and 169 all-cause (p = 0.87) deaths. Eight men died of prostate cancer in the active monitoring group (1.5 per 1000 person-years, 95% confidence interval 0.7 to 3.0); five died of prostate cancer in the radical prostatectomy group (0.9 per 1000 person-years, 95% confidence interval 0.4 to 2.2 per 1000 person years) and four died of prostate cancer in the radical radiotherapy group (0.7 per 1000 person-years, 95% confidence interval 0.3 to 2.0 per 1000 person years). More men developed metastases in the active monitoring group than in the radical prostatectomy and radical radiotherapy groups: active monitoring, n = 33 (6.3 per 1000 person-years, 95% confidence interval 4.5 to 8.8); radical prostatectomy, n = 13 (2.4 per 1000 person-years, 95% confidence interval 1.4 to 4.2 per 1000 person years); and radical radiotherapy, n = 16 (3.0 per 1000 person-years, 95% confidence interval 1.9 to 4.9 per 1000 person-years; p = 0.004). There were higher rates of disease progression in the active monitoring group than in the radical prostatectomy and radical radiotherapy groups: active monitoring (n = 112; 22.9 per 1000 person-years, 95% confidence interval 19.0 to 27.5 per 1000 person years); radical prostatectomy (n = 46; 8.9 per 1000 person-years, 95% confidence interval 6.7 to 11.9 per 1000 person-years); and radical radiotherapy (n = 46; 9.0 per 1000 person-years, 95% confidence interval 6.7 to 12.0 per 1000 person years; p < 0.001). Radical prostatectomy had the greatest impact on sexual function/urinary continence and remained worse than radical radiotherapy and active monitoring. Radical radiotherapy's impact on sexual function was greatest at 6 months, but recovered somewhat in the majority of participants. Sexual and urinary function gradually declined in the active monitoring group. Bowel function was worse with radical radiotherapy at 6 months, but it recovered with the exception of bloody stools. Urinary voiding and nocturia worsened in the radical radiotherapy group at 6 months but recovered. Condition-specific quality-of-life effects mirrored functional changes. No differences in anxiety/depression or generic or cancer-related quality of life were found. At the National Institute for Health and Care Excellence threshold of £20,000 per quality-adjusted life-year, the probabilities that each arm was the most cost-effective option were 58% (radical radiotherapy), 32% (active monitoring) and 10% (radical prostatectomy). LIMITATIONS A single prostate-specific antigen test and transrectal ultrasound biopsies were used. There were very few non-white men in the trial. The majority of men had low- and intermediate-risk disease. Longer follow-up is needed. CONCLUSIONS At a median follow-up point of 10 years, prostate cancer-specific mortality was low, irrespective of the assigned treatment. Radical prostatectomy and radical radiotherapy reduced disease progression and metastases, but with side effects. Further work is needed to follow up participants at a median of 15 years. TRIAL REGISTRATION Current Controlled Trials ISRCTN20141297. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 37. See the National Institute for Health Research Journals Library website for further project information.
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Affiliation(s)
- Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - J Athene Lane
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Malcolm Mason
- School of Medicine, University of Cardiff, Cardiff, UK
| | - Chris Metcalfe
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Holding
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Julia Wade
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Grace Young
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Davis
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Tim J Peters
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Emma L Turner
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Jon Oxley
- Department of Cellular Pathology, North Bristol NHS Trust, Bristol, UK
| | - Mary Robinson
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - John Staffurth
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff, UK
| | - Eleanor Walsh
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane Blazeby
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Richard Bryant
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Prasad Bollina
- Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - James Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Andrew Doble
- Department of Urology, Addenbrooke's Hospital, Cambridge, UK
| | - Alan Doherty
- Department of Urology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Gillatt
- Department of Urology, Southmead Hospital and Bristol Urological Institute, Bristol, UK
| | | | - Owen Hughes
- Department of Urology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Roger Kockelbergh
- Department of Urology, University Hospitals of Leicester, Leicester, UK
| | - Howard Kynaston
- Department of Urology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Alan Paul
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Edgar Paez
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Philip Powell
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Stephen Prescott
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Derek Rosario
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Edward Rowe
- Department of Urology, Southmead Hospital and Bristol Urological Institute, Bristol, UK
| | - David Neal
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
- Academic Urology Group, University of Cambridge, Cambridge, UK
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10
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Verhoef EI, Kweldam CF, Kümmerlin IP, Nieboer D, Bangma CH, Incrocci L, van der Kwast TH, Roobol MJ, van Leenders GJLH. Comparison of Tumor Volume Parameters on Prostate Cancer Biopsies. Arch Pathol Lab Med 2020; 144:991-996. [PMID: 31904279 DOI: 10.5858/arpa.2019-0361-oa] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Prostate biopsy reports require an indication of prostate cancer volume. No consensus exists on the methodology of tumor volume reporting. OBJECTIVE.— To compare the prognostic value of different biopsy prostate cancer volume parameters. DESIGN.— Prostate biopsies of the European Randomized Study of Screening for Prostate Cancer were reviewed (n = 1031). Tumor volume was quantified in 6 ways: average estimated tumor percentage, measured total tumor length, average calculated tumor percentage, greatest tumor length, greatest tumor percentage, and average tumor percentage of all biopsies. Their prognostic value was determined by using either logistic regression for extraprostatic expansion (EPE) and surgical margin status after radical prostatectomy (RP), or Cox regression for biochemical recurrence-free survival (BCRFS) and disease-specific survival (DSS) after RP (n = 406) and radiation therapy (RT) (n = 508). RESULTS.— All tumor volume parameters were significantly mutually correlated (R2 > 0.500, P < .001). None were predictive for EPE, surgical margin, or BCRFS after RP in multivariable analysis, including age, prostate-specific antigen, number of positive biopsies, and grade group. In contrast, all tumor volume parameters were significant predictors for BCRFS (all P < .05) and DSS (all P < .05) after RT, except greatest tumor length. In multivariable analysis including only all tumor volume parameters as covariates, calculated tumor length was the only predictor for EPE after RP (P = .02) and DSS after RT (P = .02). CONCLUSIONS.— All tumor volume parameters had comparable prognostic value and could be used in clinical practice. If tumor volume quantification is a threshold for treatment decision, calculated tumor length seems preferential, slightly outperforming the other parameters.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Geert J L H van Leenders
- From the Departments of Pathology (Ms Verhoef, Drs Kweldam, Kümmerlin, and van Leenders), Public Health (Mr Nieboer), Urology (Mr Nieboer, Drs Bangma and Roobol), and Radiotherapy (Dr Incrocci), Erasmus MC University Medical Center, Rotterdam, the Netherlands; and Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada (Dr van der Kwast)
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11
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Remmers S, Verbeek JFM, Nieboer D, van der Kwast T, Roobol MJ. Predicting biochemical recurrence and prostate cancer-specific mortality after radical prostatectomy: comparison of six prediction models in a cohort of patients with screening- and clinically detected prostate cancer. BJU Int 2019; 124:635-642. [PMID: 31055875 PMCID: PMC6852479 DOI: 10.1111/bju.14790] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To perform a comparison and external validation of three models predicting biochemical recurrence (BCR) and three models predicting prostate cancer (PCa)-specific mortality (PCSM) in a screening setting, i.e. patients with screening-detected PCa (S-PCa) and in those with clinically detected PCa (C-PCa). SUBJECTS AND METHODS We retrospectively evaluated 795 men with S-PCa, from the European Randomized Study of Screening for Prostate Cancer, Rotterdam, and 1123 men with C-PCa initially treated with RP. The discriminative ability of the models was assessed according to the area under the curve (AUC) of the receiver-operating characteristic, and calibration was assessed graphically using calibration plots. RESULTS The median (interquartile range [IQR]) follow-up for the S-PCa group was 10.4 (6.8-14.3) years and for the C-PCa group it was 8.8 (4.8-12.9) years. A total of 123 men with S-PCa (15%) and 389 men with C-PCa (35%) experienced BCR. Of the men with S-PCa and BCR, 24 (20%) died from PCa and 29 (23%) died from other causes. Of the men with C-PCa and BCR, 68 (17%) died from PCa and 105 (27%) died from other causes. The discrimination of the models predicting BCR or PCSM was higher for men with S-PCa (AUC: BCR 0.77-0.84, PCSM 0.60-0.77) than for the men with C-PCa (AUC: BCR 0.75-0.79, PCSM 0.51-0.68) as a result of the similar patient characteristics of the men with S-PCa in the present study and those of the cohorts used to develop these models. The risk of BCR was typically overestimated, while the risk of PCSM was typically underestimated. CONCLUSION Prediction models for BCR showed good discrimination and reasonable calibration for both men with S-PCa and men with C-PCa, and even better discrimination for men with S-PCa. For PCSM, the evaluated models are not applicable in both settings of this Dutch cohort as a result of substantial miscalibration. This warrants caution when using these models to communicate future risks in other clinical settings.
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Affiliation(s)
- Sebastiaan Remmers
- Department of UrologyErasmus University Medical CentreRotterdamThe Netherlands
| | - Jan F. M. Verbeek
- Department of UrologyErasmus University Medical CentreRotterdamThe Netherlands
| | - Daan Nieboer
- Department of UrologyErasmus University Medical CentreRotterdamThe Netherlands
- Department of Public HealthErasmus University Medical CentreRotterdamThe Netherlands
| | - Theo van der Kwast
- Department of PathologyErasmus University Medical CentreRotterdamThe Netherlands
- Department of PathologyToronto General HospitalTorontoONCanada
| | - Monique J. Roobol
- Department of UrologyErasmus University Medical CentreRotterdamThe Netherlands
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12
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Chapa J, Haslam A, Prasad V. Interpreting the Effectiveness of Cancer Screening From National Population Statistics: Is It Sound Practice? Mayo Clin Proc 2019; 94:951-956. [PMID: 31171133 DOI: 10.1016/j.mayocp.2019.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 02/19/2019] [Accepted: 02/27/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Joaquin Chapa
- Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Alyson Haslam
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR
| | - Vinay Prasad
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR; Department of Public Health and Preventive Medicine, Oregon Health and Science University, Portland, OR; Center for Ethics in Health Care, Oregon Health and Science University, Portland, OR.
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13
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Could Differences in Treatment Between Trial Arms Explain the Reduction in Prostate Cancer Mortality in the European Randomized Study of Screening for Prostate Cancer? Eur Urol 2019; 75:1015-1022. [PMID: 30928162 DOI: 10.1016/j.eururo.2019.03.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 03/08/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Differential treatment between trial arms has been suggested to bias prostate cancer (PC) mortality in the European Randomized Study of Screening for Prostate Cancer (ERSPC). OBJECTIVE To quantify the contribution of treatment differences to the observed PC mortality reduction between the screening arm (SA) and the control arm (CA). DESIGN, SETTING, AND PARTICIPANTS A total of 14 136 men with PC (SA: 7310; CA: 6826) in the core age group (55-69yr) at 16yr of follow-up. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The outcomes measurements were observed and estimated numbers of PC deaths by treatment allocation in the SA and CA, respectively. Primary treatment allocation was modeled using multinomial logistic regression adjusting for center, age, year, prostate-specific antigen, grade group, and tumor-node-metastasis stage. For each treatment, logistic regression models were fitted for risk of PC death, separately for the SA and CA, and using the same covariates as for the treatment allocation model. Treatment probabilities were multiplied by estimated PC death risks for each treatment based on one arm, and then summed and compared with the observed number of deaths. RESULTS AND LIMITATIONS The difference between the observed and estimated treatment distributions (hormonal therapy, radical prostatectomy, radiotherapy, and active surveillance/watchful waiting) in the two arms ranged from -3.3% to 3.3%. These figures, which represent the part of the treatment differences between arms that cannot be explained by clinicopathological differences, are small compared with the observed differences between arms that ranged between 7.2% and 10.1%. The difference between the observed and estimated numbers of PC deaths among men with PC was 0.05% (95% confidence interval [CI] -0.1%, 0.2%) when applying the CA model to the SA, had the two groups received identical primary treatment, given their clinical characteristics. When instead applying the SA model to the CA, the difference was, as expected, very similar-0.01% (95% CI -0.3%, 0.2%). Consistency of the results of the models demonstrates the robustness of the modeling approach. As the observed difference between trial arms was 4.2%, our findings suggest that differential treatment explains only a trivial proportion of the main findings of ERSPC. A limitation of the study is that only data on primary treatment were available. CONCLUSIONS Use of prostate-specific antigen remains the predominant explanation for the reduction in PC mortality seen in the ERSPC trial and is not attributable to differential treatment between trial arms. PATIENT SUMMARY This study shows that prostate cancer deaths in the European screening trial (European Randomized Study of Screening for Prostate Cancer) were prevented because men were diagnosed and treated earlier through prostate-specific antigen screening, and not because of different, or better, treatment in the screening arm compared with the control arm.
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14
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A 16-yr Follow-up of the European Randomized study of Screening for Prostate Cancer. Eur Urol 2019; 76:43-51. [PMID: 30824296 DOI: 10.1016/j.eururo.2019.02.009] [Citation(s) in RCA: 324] [Impact Index Per Article: 64.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 02/07/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND The European Randomized study of Screening for Prostate Cancer (ERSPC) has previously demonstrated that prostate-specific antigen (PSA) screening decreases prostate cancer (PCa) mortality. OBJECTIVE To determine whether PSA screening decreases PCa mortality for up to 16yr and to assess results following adjustment for nonparticipation and the number of screening rounds attended. DESIGN, SETTING, AND PARTICIPANTS This multicentre population-based randomised screening trial was conducted in eight European countries. Report includes 182160 men, followed up until 2014 (maximum of 16yr), with a predefined core age group of 162389 men (55-69yr), selected from population registry. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The outcome was PCa mortality, also assessed with adjustment for nonparticipation and the number of screening rounds attended. RESULTS AND LIMITATIONS The rate ratio of PCa mortality was 0.80 (95% confidence interval [CI] 0.72-0.89, p<0.001) at 16yr. The difference in absolute PCa mortality increased from 0.14% at 13yr to 0.18% at 16yr. The number of men needed to be invited for screening to prevent one PCa death was 570 at 16yr compared with 742 at 13yr. The number needed to diagnose was reduced to 18 from 26 at 13yr. Men with PCa detected during the first round had a higher prevalence of PSA >20ng/ml (9.9% compared with 4.1% in the second round, p<0.001) and higher PCa mortality (hazard ratio=1.86, p<0.001) than those detected subsequently. CONCLUSIONS Findings corroborate earlier results that PSA screening significantly reduces PCa mortality, showing larger absolute benefit with longer follow-up and a reduction in excess incidence. Repeated screening may be important to reduce PCa mortality on a population level. PATIENT SUMMARY In this report, we looked at the outcomes from prostate cancer in a large European population. We found that repeated screening reduces the risk of dying from prostate cancer.
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15
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Verhoef EI, Kweldam CF, Kümmerlin IP, Nieboer D, Bangma CH, Incrocci L, van der Kwast TH, Roobol MJ, van Leenders GJ. Characteristics and outcome of prostate cancer patients with overall biopsy Gleason score 3 + 4 = 7 and highest Gleason score 3 + 4 = 7 or > 3 + 4 = 7. Histopathology 2018; 72:760-765. [DOI: 10.1111/his.13427] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 10/27/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Esther I Verhoef
- Department of Pathology; Erasmus Medical Centre Rotterdam; Rotterdam the Netherlands
| | - Charlotte F Kweldam
- Department of Pathology; Erasmus Medical Centre Rotterdam; Rotterdam the Netherlands
| | - Intan P Kümmerlin
- Department of Pathology; Erasmus Medical Centre Rotterdam; Rotterdam the Netherlands
| | - Daan Nieboer
- Department of Public Health; Erasmus Medical Centre Rotterdam; Rotterdam the Netherlands
| | - Chris H Bangma
- Department of Urology; Erasmus Medical Centre Rotterdam; Rotterdam the Netherlands
| | - Luca Incrocci
- Department of Radiotherapy; Erasmus Medical Centre Rotterdam; Rotterdam the Netherlands
| | | | - Monique J Roobol
- Department of Urology; Erasmus Medical Centre Rotterdam; Rotterdam the Netherlands
| | - Geert J van Leenders
- Department of Pathology; Erasmus Medical Centre Rotterdam; Rotterdam the Netherlands
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16
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Yousaf-Khan AU, van der Aalst CM, Aerts JGJV, den Bakker MA, de Koning HJ. Uniform and blinded cause of death verification of the NELSON lung cancer screening participants. Lung Cancer 2017; 111:131-134. [PMID: 28838383 DOI: 10.1016/j.lungcan.2017.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 07/12/2017] [Accepted: 07/14/2017] [Indexed: 11/17/2022]
Abstract
Primary outcome of the Dutch-Belgian lung cancer screening trial (NELSON) is lung cancer-specific mortality. Accurate assessment of the cause of death (CoD) is crucial. As death certificates regarding the CoD can be inaccurate, a clinical expert committee (CEC) was formed to assign the CoD. In this study, the medical files of deceased lung cancer patients were reviewed and the outcomes were compared with official death certificates. The first 266 completed medical files of Dutch deceased participants who were diagnosed with lung cancer during the study or of those with lung cancer on the death certificate were selected and blinded towards arms and patients identity. The end product of the review process consisted of six possible categories which defined the graduation of certainty that lung cancer was the primary CoD. The percentage agreement and the Cohen's kappa statistics between the two CEC-memberswere calculated. The sensitivity and specificity of the official death certificates were determined. The results indicated that, the overall concordance and the Cohen's kappa between the CEC-memberswere 86.1% and 0.57(0.45-0.69, p<0.001), respectively. This level increased with the numbers of cases evaluated. The sensitivity and the specificity of the official death certificate were 92.6% and 98.8%; 6.5% cases were reclassified to lung cancer specific death, which is lower than in the National Lung Screening trial(22.0%). Concluding, each death should be reviewed by at least two members. So far, in the NELSON trial, possible biases related to lung cancer death seem relatively small.
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Affiliation(s)
- A U Yousaf-Khan
- Erasmus Medical Center, University Medical Center Rotterdam, Department of Public Health, P.O. Box 2040, 3000CA, Rotterdam, The Netherlands.
| | - C M van der Aalst
- Erasmus Medical Center, University Medical Center Rotterdam, Department of Public Health, P.O. Box 2040, 3000CA, Rotterdam, The Netherlands
| | - J G J V Aerts
- Erasmus Medical Center, University Medical Center Rotterdam, Department of Pulmonary Medicine, P.O. Box 2040, 3000CA, Rotterdam, The Netherlands; Amphia Hospital Breda, Department of Pulmonary Medicine, P.O. box 90158, The Netherlands
| | - M A den Bakker
- Maasstad Hospital Rotterdam, Department of Pathology, P.O. box 9100, The Netherlands
| | - H J de Koning
- Erasmus Medical Center, University Medical Center Rotterdam, Department of Public Health, P.O. Box 2040, 3000CA, Rotterdam, The Netherlands
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17
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Walter SD, de Koning HJ, Hugosson J, Talala K, Roobol MJ, Carlsson S, Zappa M, Nelen V, Kwiatkowski M, Páez Á, Moss S, Auvinen A. Impact of cause of death adjudication on the results of the European prostate cancer screening trial. Br J Cancer 2017; 116:141-148. [PMID: 27855442 PMCID: PMC5220145 DOI: 10.1038/bjc.2016.378] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 09/22/2016] [Accepted: 10/09/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The European Randomised Study of Prostate Cancer Screening has shown a 21% relative reduction in prostate cancer mortality at 13 years. The causes of death can be misattributed, particularly in elderly men with multiple comorbidities, and therefore accurate assessment of the underlying cause of death is crucial for valid results. To address potential unreliability of end-point assessment, and its possible impact on mortality results, we analysed the study outcome adjudication data in six countries. METHODS Latent class statistical models were formulated to compare the accuracy of individual adjudicators, and to assess whether accuracy differed between the trial arms. We used the model to assess whether correcting for adjudication inaccuracies might modify the study results. RESULTS There was some heterogeneity in adjudication accuracy of causes of death, but no consistent differential accuracy by trial arm. Correcting the estimated screening effect for misclassification did not alter the estimated mortality effect of screening. CONCLUSIONS Our findings were consistent with earlier reports on the European screening trial. Observer variation, while demonstrably present, is unlikely to have materially biased the main study results. A bias in assigning causes of death that might have explained the mortality reduction by screening can be effectively ruled out.
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Affiliation(s)
- Stephen D Walter
- Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, CRL 233, 1280 Main Street, Hamilton, Ontario, Canada L8S 4K1
| | - Harry J de Koning
- Department of Public Health, Erasmus University Medical Center, Postbus 2040, 3000 CA Rotterdam, The Netherlands
| | - Jonas Hugosson
- Department of Urology, Sahlgrenska universitetssjukhuset, Bruna stråket 11b v 2 su/sahlgrenska, 41345 Göteborg, Sweden
| | - Kirsi Talala
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Unioninkatu 22, FI-00130 Helsinki, Finland
| | - Monique J Roobol
- Department of Public Health, Erasmus University Medical Center, Postbus 2040, 3000 CA Rotterdam, The Netherlands
| | - Sigrid Carlsson
- Department of Urology, Sahlgrenska universitetssjukhuset, Bruna stråket 11b v 2 su/sahlgrenska, 41345 Göteborg, Sweden
- Department of Surgery (Urology Service), Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Marco Zappa
- ISPO–Cancer Research and Prevention Institute, Clinical and Descriptive Epidemiology Unit, Via delle Oblate 2, 50141 Florence, Italy
| | - Vera Nelen
- Provinciaal Instituut Voor Hygiëne (Labo's), Kronenburgstraat 45, 2000 Antwerpen, Belgium
| | - Maciej Kwiatkowski
- Department of Urology, Kantonsspital Aarau, Aarau, Switzerland
- Department of Urology, Academic Hospital Braunschweig, Braunschweig, Germany
| | - Álvaro Páez
- Department of Urology, Hospital Universitario de Fuenlabrada, Camino del Molino 2, 28942 FUENLABRADA (Madrid), Spain
| | - Sue Moss
- Wolfson Institute, St Mary University, Charterhouse Square, London EC1M 6BQ, UK
| | - Anssi Auvinen
- School of Health Sciences, University of Tampere, FI-33014 Tampere, Finland
| | - the ERSPC Cause of Death Committees
- Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, CRL 233, 1280 Main Street, Hamilton, Ontario, Canada L8S 4K1
- Department of Public Health, Erasmus University Medical Center, Postbus 2040, 3000 CA Rotterdam, The Netherlands
- Department of Urology, Sahlgrenska universitetssjukhuset, Bruna stråket 11b v 2 su/sahlgrenska, 41345 Göteborg, Sweden
- Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Unioninkatu 22, FI-00130 Helsinki, Finland
- Department of Surgery (Urology Service), Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
- ISPO–Cancer Research and Prevention Institute, Clinical and Descriptive Epidemiology Unit, Via delle Oblate 2, 50141 Florence, Italy
- Provinciaal Instituut Voor Hygiëne (Labo's), Kronenburgstraat 45, 2000 Antwerpen, Belgium
- Department of Urology, Kantonsspital Aarau, Aarau, Switzerland
- Department of Urology, Academic Hospital Braunschweig, Braunschweig, Germany
- Department of Urology, Hospital Universitario de Fuenlabrada, Camino del Molino 2, 28942 FUENLABRADA (Madrid), Spain
- Wolfson Institute, St Mary University, Charterhouse Square, London EC1M 6BQ, UK
- School of Health Sciences, University of Tampere, FI-33014 Tampere, Finland
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18
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Estimating bias in causes of death ascertainment in the Finnish Randomized Study of Screening for Prostate Cancer. Cancer Epidemiol 2016; 45:1-5. [DOI: 10.1016/j.canep.2016.08.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/23/2016] [Accepted: 08/30/2016] [Indexed: 01/12/2023]
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19
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Hakama M, Moss SM, Stenman UH, Roobol MJ, Zappa M, Carlsson S, Randazzo M, Nelen V, Hugosson J. Design-corrected variation by centre in mortality reduction in the ERSPC randomised prostate cancer screening trial. J Med Screen 2016; 24:98-103. [PMID: 27510947 DOI: 10.1177/0969141316652174] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives To calculate design-corrected estimates of the effect of screening on prostate cancer mortality by centre in the European Randomised Study of Screening for Prostate Cancer (ERSPC). Setting The ERSPC has shown a 21% reduction in prostate cancer mortality in men invited to screening with follow-up truncated at 13 years. Centres either used pre-consent randomisation (effectiveness design) or post-consent randomisation (efficacy design). Methods In six centres (three effectiveness design, three efficacy design) with follow-up until the end of 2010, or maximum 13 years, the effect of screening was estimated as both effectiveness (mortality reduction in the target population) and efficacy (reduction in those actually screened). Results The overall crude prostate cancer mortality risk ratio in the intervention arm vs control arm for the six centres was 0.79 ranging from a 14% increase to a 38% reduction. The risk ratio was 0.85 in centres with effectiveness design and 0.73 in those with efficacy design. After correcting for design, overall efficacy was 27%, 24% in pre-consent and 29% in post-consent centres, ranging between a 12% increase and a 52% reduction. Conclusion The estimated overall effect of screening in attenders (efficacy) was a 27% reduction in prostate cancer mortality at 13 years' follow-up. The variation in efficacy between centres was greater than the range in risk ratio without correction for design. The centre-specific variation in the mortality reduction could not be accounted for by the randomisation method.
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Affiliation(s)
| | - Sue M Moss
- 2 Centre for Cancer Prevention, Queen Mary University of London, London, UK
| | - Ulf-Hakan Stenman
- 3 Department of Clinical Chemistry, Helsinki University and HUSLAB, Helsinki, Finland
| | - Monique J Roobol
- 4 Department of Urology Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marco Zappa
- 5 Unit of Clinical and Descriptive Epidemiology, ISPO, Florence, Italy
| | - Sigrid Carlsson
- 6 Department of Urology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,7 Department of Surgery (Urology), Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Marco Randazzo
- 8 Department of Urology, Cantonal Hospital Aarau, Aarau, Switzerland.,9 Department of Urology, University Hospital Zürich and University of Zürich, Switzerland
| | - Vera Nelen
- 10 Provincial Instituut voor Hygiene, Antwerp, Belgium
| | - Jonas Hugosson
- 6 Department of Urology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
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20
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Turner EL, Metcalfe C, Donovan JL, Noble S, Sterne JAC, Lane JA, I Walsh E, Hill EM, Down L, Ben-Shlomo Y, Oliver SE, Evans S, Brindle P, Williams NJ, Hughes LJ, Davies CF, Ng SY, Neal DE, Hamdy FC, Albertsen P, Reid CM, Oxley J, McFarlane J, Robinson MC, Adolfsson J, Zietman A, Baum M, Koupparis A, Martin RM. Contemporary accuracy of death certificates for coding prostate cancer as a cause of death: Is reliance on death certification good enough? A comparison with blinded review by an independent cause of death evaluation committee. Br J Cancer 2016; 115:90-4. [PMID: 27253172 PMCID: PMC4931376 DOI: 10.1038/bjc.2016.162] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/18/2016] [Accepted: 04/30/2016] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Accurate cause of death assignment is crucial for prostate cancer epidemiology and trials reporting prostate cancer-specific mortality outcomes. METHODS We compared death certificate information with independent cause of death evaluation by an expert committee within a prostate cancer trial (2002-2015). RESULTS Of 1236 deaths assessed, expert committee evaluation attributed 523 (42%) to prostate cancer, agreeing with death certificate cause of death in 1134 cases (92%, 95% CI: 90%, 93%). The sensitivity of death certificates in identifying prostate cancer deaths as classified by the committee was 91% (95% CI: 89%, 94%); specificity was 92% (95% CI: 90%, 94%). Sensitivity and specificity were lower where death occurred within 1 year of diagnosis, and where there was another primary cancer diagnosis. CONCLUSIONS UK death certificates accurately identify cause of death in men with prostate cancer, supporting their use in routine statistics. Possible differential misattribution by trial arm supports independent evaluation in randomised trials.
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Affiliation(s)
- Emma L Turner
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Chris Metcalfe
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Sian Noble
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Jonathan A C Sterne
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - J Athene Lane
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Eleanor I Walsh
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Elizabeth M Hill
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Liz Down
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Yoav Ben-Shlomo
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Steven E Oliver
- Department of Health Sciences, University of York and the Hull York Medical School, YO10 5DD, UK
| | - Simon Evans
- Urology Department, Royal United Hospital, Combe Park, Bath BA1 3NG, UK
| | - Peter Brindle
- Avon Primary Care Research Collaborative, South Plaza, Marlborough Street, Bristol BS1 3NX, UK
| | - Naomi J Williams
- School of Social and Community Medicine, University of Bristol, Royal Hallamshire Hospital, Sheffield S10 2JF, UK
| | - Laura J Hughes
- Department of Oncology, University of Cambridge, Addenbrooke's Hospital, Box 279 (S4), Cambridge CB2 0QQ, UK
| | - Charlotte F Davies
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Siaw Yein Ng
- School of Social and Community Medicine, University of Bristol, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - David E Neal
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Freddie C Hamdy
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Peter Albertsen
- University of Connecticut Health Center, Farmington, St Francis Hospital and Medical Center, Hartford, CT, USA
| | - Colette M Reid
- Department of Palliative Medicine, Bristol Haematology and Oncology Centre, Bristol BS2 8ED, UK
| | - Jon Oxley
- Department of Cellular Pathology, North Bristol NHS Trust, Southmead Hospital, Bristol BS10 5NB, UK
| | - John McFarlane
- Urology Department, Royal United Hospital, Combe Park, Bath BA1 3NG, UK
| | - Mary C Robinson
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
| | - Jan Adolfsson
- Department of Clinical Science, Karolinska Institutet, Stokholm, Sweden
| | - Anthony Zietman
- Harvard Radiation Oncology Program, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Baum
- Department of Surgery, University College London, Gower Street, London WC1E 6BT, UK
| | - Anthony Koupparis
- Department of Urology, North Bristol NHS Trust, Southmead Hospital, Bristol BS10 5NB, UK
| | - Richard M Martin
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
- School of Social and Community Medicine, MRC/University of Bristol Integrative Epidemiology Unit, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
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21
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Kweldam CF, Kümmerlin IP, Nieboer D, Verhoef EI, Steyerberg EW, van der Kwast TH, Roobol MJ, van Leenders GJ. Disease-specific survival of patients with invasive cribriform and intraductal prostate cancer at diagnostic biopsy. Mod Pathol 2016; 29:630-6. [PMID: 26939875 DOI: 10.1038/modpathol.2016.49] [Citation(s) in RCA: 165] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/28/2016] [Accepted: 01/28/2016] [Indexed: 11/09/2022]
Abstract
Invasive cribriform and intraductal carcinoma in radical prostatectomy specimens have been associated with an adverse clinical outcome. Our objective was to determine the prognostic value of invasive cribriform and intraductal carcinoma in pre-treatment biopsies on time to disease-specific death. We pathologically revised the diagnostic biopsies of 1031 patients from the first screening round of the European Randomized Study of Screening for Prostate Cancer (1993-2000). Ninety percent of all patients (n=923) had received active treatment, whereas 10% (n=108) had been followed by watchful waiting. The median follow-up was 13 years. Patients who either had invasive cribriform growth pattern or intraductal carcinoma were categorized as CR/IDC+. The outcome was disease-specific survival. Relationships with outcome were analyzed using multivariable Cox regression and log-rank analysis. In total, 486 patients had Gleason score 6 (47%) and 545 had ≥7 (53%). The 15-year disease-specific-survival probabilities were 99% in Gleason score 6 (n=486), 94% in CR/IDC- Gleason score ≥7 (n=356) and 67% in CR/IDC+ Gleason score ≥7 (n=189). CR/IDC- Gleason score 3+4=7 patients did not have statistically different survival probabilities from those with Gleason score 6 (P=0.30), while CR/IDC+ Gleason score 3+4=7 patients did (P<0.001). In multivariable analysis, CR/IDC+ status was independently associated with a poorer disease-specific survival (HR 2.6, 95% CI 1.4-4.8, P=0.002). We conclude that CR/IDC+ status in prostate cancer biopsies is associated with a worse disease-specific survival. Our findings indicate that men with biopsy CR/IDC- Gleason score 3+4=7 prostate cancer could be candidates for active surveillance, as these patients have similar survival probabilities to those with Gleason score 6.
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Affiliation(s)
| | - Intan P Kümmerlin
- Department of Pathology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Esther I Verhoef
- Department of Pathology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Monique J Roobol
- Department of Urology, Erasmus Medical Centre, Rotterdam, The Netherlands
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22
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Non-Steroidal Anti-Inflammatory Drugs and Cancer Death in the Finnish Prostate Cancer Screening Trial. PLoS One 2016; 11:e0153413. [PMID: 27100876 PMCID: PMC4839624 DOI: 10.1371/journal.pone.0153413] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 03/29/2016] [Indexed: 12/21/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs), especially aspirin, have been associated with lowered cancer incidence and mortality. We examined overall cancer mortality and mortality from specific cancer sites among the 80,144 men in the Finnish Prostate Cancer Screening Trial. Information on prescription drug use was acquired from the national drug reimbursement database. Over-the-counter use information was gathered by a questionnaire. Hazard ratios (HR) and 95% confidence intervals (CI) by prescription and over-the-counter NSAID use for overall and specific cancer deaths were calculated using Cox regression. During the median follow-up time of 15 years, 7,008 men died from cancer. Men with prescription NSAID use had elevated cancer mortality (HR 2.02 95% CI 1.91–2.15) compared to non-users. The mortality risk was increased for lung, colorectal and pancreas cancer mortality (HR 2.68, 95%CI 2.40–2.99, HR 1.91, 95% CI 1.57–2.32 and HR 1.93, 95% CI 1.58–2.37, respectively). The increased risk remained in competing risks regression (HR 1.11, 95% CI 1.05–1.18). When the usage during the last three years of follow-up was excluded, the effect was reversed (HR 0.69, 95% CI 0.65–0.73). Cancer mortality was not decreased for prescription or over-the-counter aspirin use. However, in the competing risk regression analysis combined prescription and over-the-counter aspirin use was associated with decreased overall cancer mortality (HR 0.76, 95% CI 0.70–0.82). Cancer mortality was increased for NSAID users. However, the risk disappeared when the last 3 years were excluded.
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23
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Carlsson S, Assel M, Ulmert D, Gerdtsson A, Hugosson J, Vickers A, Lilja H. Screening for Prostate Cancer Starting at Age 50-54 Years. A Population-based Cohort Study. Eur Urol 2016; 71:46-52. [PMID: 27084245 DOI: 10.1016/j.eururo.2016.03.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 03/16/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Current prostate cancer screening guidelines conflict with respect to the age at which to initiate screening. OBJECTIVE To evaluate the effect of prostate-specific antigen (PSA) screening versus zero screening, starting at age 50-54 yr, on prostate cancer mortality. DESIGN, SETTING, AND PARTICIPANTS This is a population-based cohort study comparing 3479 men aged 50 yr through 54 yr randomized to PSA-screening in the Göteborg population-based prostate cancer screening trial, initiated in 1995, versus 4060 unscreened men aged 51-55 yr providing cryopreserved blood in the population-based Malmö Preventive Project in the pre-PSA era, during 1982-1985. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Cumulative incidence and incidence rate ratios of prostate cancer diagnosis, metastasis, and prostate cancer death. RESULTS AND LIMITATIONS At 17 yr, regular PSA-screening in Göteborg of men in their early 50s carried a more than two-fold higher risk of prostate cancer diagnosis compared with the unscreened men in Malmö (incidence rate ratio [IRR] 2.56, 95% confidence interval [CI] 2.18, 3.02), but resulted in a substantial decrease in the risk of metastases (IRR 0.43, 95% CI 0.22, 0.79) and prostate cancer death (IRR 0.29, 95% CI 0.11, 0.67). There were 57 fewer prostate cancer deaths per 10000 men (95% CI 22, 92) in the screened group. At 17 yr, the number needed to invite to PSA-screening and the number needed to diagnose to prevent one prostate cancer death was 176 and 16, respectively. The study is limited by lack of treatment information and the comparison of the two different birth cohorts. CONCLUSIONS PSA screening for prostate cancer can decrease prostate cancer mortality among men aged 50-54 yr, with the number needed to invite and number needed to detect to prevent one prostate cancer death comparable to those previously reported from the European Randomized Study of Screening for Prostate Cancer for men aged 55-69 yr, at a similar follow-up. Guideline groups could consider whether guidelines for PSA screening should recommend starting no later than at ages 50-54 yr. PATIENT SUMMARY Guideline recommendations about the age to start prostate-specific antigen screening could be discussed.
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Affiliation(s)
- Sigrid Carlsson
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA; Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Göteborg, Sweden
| | - Melissa Assel
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - David Ulmert
- Molecular Pharmacology and Chemistry Program, Sloan Kettering Institute, New York, NY, USA; Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Axel Gerdtsson
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Jonas Hugosson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Göteborg, Sweden; Sahlgrenska University Hospital, Göteborg, Sweden
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA.
| | - Hans Lilja
- Department of Translational Medicine, Lund University, Malmö, Sweden; Departments of Laboratory Medicine, Surgery (Urology Service) and Medicine (Genitourinary Oncology), Memorial Sloan Kettering Cancer Center, New York, USA; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
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24
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Auvinen A, Moss SM, Tammela TLJ, Taari K, Roobol MJ, Schröder FH, Bangma CH, Carlsson S, Aus G, Zappa M, Puliti D, Denis LJ, Nelen V, Kwiatkowski M, Randazzo M, Paez A, Lujan M, Hugosson J. Absolute Effect of Prostate Cancer Screening: Balance of Benefits and Harms by Center within the European Randomized Study of Prostate Cancer Screening. Clin Cancer Res 2016; 22:243-9. [PMID: 26289069 PMCID: PMC4951205 DOI: 10.1158/1078-0432.ccr-15-0941] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 07/26/2015] [Indexed: 11/16/2022]
Abstract
PURPOSE The balance of benefits and harms in prostate cancer screening has not been sufficiently characterized. We related indicators of mortality reduction and overdetection by center within the European Randomized Study of Prostate Cancer Screening (ERSPC). EXPERIMENTAL DESIGN We analyzed the absolute mortality reduction expressed as number needed to invite (NNI = 1/absolute risk reduction; indicating how many men had to be randomized to screening arm to avert a prostate cancer death) for screening and the absolute excess of prostate cancer detection as number needed for overdetection (NNO = 1/absolute excess incidence; indicating the number of men invited per additional prostate cancer case), and compared their relationship across the seven ERSPC centers. RESULTS Both absolute mortality reduction (NNI) and absolute overdetection (NNO) varied widely between the centers: NNI, 200-7,000 and NNO, 16-69. Extent of overdiagnosis and mortality reduction was closely associated [correlation coefficient, r = 0.76; weighted linear regression coefficient, β = 33; 95% confidence interval (CI), 5-62; R(2) = 0.72]. For an averted prostate cancer death at 13 years of follow-up, 12 to 36 excess cases had to be detected in various centers. CONCLUSIONS The differences between the ERSPC centers likely reflect variations in prostate cancer incidence and mortality, as well as in screening protocol and performance. The strong interrelation between the benefits and harms suggests that efforts to maximize the mortality effect are bound to increase overdiagnosis and might be improved by focusing on high-risk populations. The optimal balance between screening intensity and risk of overdiagnosis remains unclear.
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Affiliation(s)
- Anssi Auvinen
- University of Tampere, School of Health Sciences, Tampere, Finland.
| | - Sue M Moss
- Centre for Cancer Prevention, Queen Mary University of London, London, United Kingdom
| | - Teuvo L J Tammela
- Department of Urology, Tampere University Hospital and Medical School, University of Tampere, Finland
| | - Kimmo Taari
- Department of Urology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Monique J Roobol
- Department of Urology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Fritz H Schröder
- Department of Urology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Chris H Bangma
- Department of Urology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sigrid Carlsson
- Department of Urology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden. Department of Surgery (Urology Service), Memorial Sloan-Kettering Cancer Center, New York
| | - Gunnar Aus
- Department of Urology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Marco Zappa
- Clinical and Descriptive Epidemiology and Registries Unit, ISPO-Cancer Research and Prevention Institute, Florence, Italy
| | - Donella Puliti
- Clinical and Descriptive Epidemiology and Registries Unit, ISPO-Cancer Research and Prevention Institute, Florence, Italy
| | - Louis J Denis
- Provinciaal Instituut voor Hygiene, Antwerp, Belgium
| | - Vera Nelen
- Provinciaal Instituut voor Hygiene, Antwerp, Belgium
| | - Maciej Kwiatkowski
- Department of Urology, Kantonsspital Aarau, Aarau, Switzerland. Department of Urology, Academic Hospital Braunschweig, Braunschweig, Germany
| | - Marco Randazzo
- Department of Urology, Kantonsspital Aarau, Aarau, Switzerland. Department of Urology, University Hospital Zürich, Zürich, Switzerland
| | - Alvaro Paez
- Department of Urology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Marcos Lujan
- Urology Department, Hospital Infanta Cristina, Parla, Madrid, Spain
| | - Jonas Hugosson
- Department of Urology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
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25
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Buzzoni C, Auvinen A, Roobol MJ, Carlsson S, Moss SM, Puliti D, de Koning HJ, Bangma CH, Denis LJ, Kwiatkowski M, Lujan M, Nelen V, Paez A, Randazzo M, Rebillard X, Tammela TLJ, Villers A, Hugosson J, Schröder FH, Zappa M. Metastatic Prostate Cancer Incidence and Prostate-specific Antigen Testing: New Insights from the European Randomized Study of Screening for Prostate Cancer. Eur Urol 2015; 68:885-90. [PMID: 25791513 PMCID: PMC4982869 DOI: 10.1016/j.eururo.2015.02.042] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 02/27/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND The European Randomized Study of Screening for Prostate Cancer (ERSPC) has shown a 21% reduction in prostate cancer (PCa) mortality and a 1.6-fold increase in PCa incidence with prostate-specific antigen (PSA)-based screening (at 13 yr of follow-up). We evaluated PCa incidence by risk category at diagnosis across the study arms to assess the potential impact on PCa mortality. DESIGN, SETTING, AND PARTICIPANTS Information on arm, centre, T and M stage, Gleason score, serum PSA at diagnosis, age at randomisation, follow-up time, and vital status were extracted from the ERSPC database. Four risk categories at diagnosis were defined: 1, low; 2, intermediate; 3, high; 4, metastatic disease. PSA (≤100 or >100 ng/ml) was used as the indicator of metastasis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Incidence rate ratios (IRRs) for screening versus control arm by risk category at diagnosis and follow-up time were calculated using Poisson regression analysis for seven centres. Follow-up was truncated at 13 yr. Missing data were imputed using chained equations. The analyses were carried out on an intention-to-treat basis. RESULTS AND LIMITATIONS In the screening arm, 7408 PCa cases were diagnosed and 6107 in the control arm. The proportion of missing stage, Gleason score, or PSA value was comparable in the two arms (8% vs 10%), but differed among centres. The IRRs were elevated in the screening arm for the low-risk (IRR: 2.14; 95% CI, 2.03-2.25) and intermediate-risk (IRR: 1.24; 95% CI, 1.16-1.34) categories at diagnosis, equal to unity for the high-risk category at diagnosis (IRR: 1.00; 95% CI, 0.89-1.13), and reduced for metastatic disease at diagnosis (IRR: 0.60; 95% CI, 0.52-0.70). The IRR of metastatic disease had temporal pattern similar to mortality, shifted forwards an average of almost 3 yr, although the mortality reduction was smaller. CONCLUSIONS The results confirm a reduction in metastatic disease at diagnosis in the screening arm, preceding mortality reduction by almost 3 yr. PATIENT SUMMARY The findings of this study indicate that the decrease in metastatic disease at diagnosis is the major determinant of the prostate cancer mortality reduction in the European Randomized study of Screening for Prostate Cancer.
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Affiliation(s)
- Carlotta Buzzoni
- Clinical and Descriptive Epidemiology and Registries Unit, ISPO - Cancer Research and Prevention Institute, Florence, Italy
| | - Anssi Auvinen
- School of Health Sciences, University of Tampere, Tampere, Finland
| | - Monique J Roobol
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sigrid Carlsson
- Department of Urology, Sahlgrenska Academy at University of Gothenburg, Sweden; Department of Surgery (Urology Service), Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Sue M Moss
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Donella Puliti
- Clinical and Descriptive Epidemiology and Registries Unit, ISPO - Cancer Research and Prevention Institute, Florence, Italy
| | - Harry J de Koning
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Chris H Bangma
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Maciej Kwiatkowski
- Department of Urology, Kantonsspital Aarau, Aarau, Switzerland; Department of Urology, Academic Hospital Braunschweig, Braunschweig, Germany
| | - Marcos Lujan
- Urology Department, Hospital Infanta Cristina, Parla, Madrid, Spain
| | - Vera Nelen
- Provinciaal Instituut voor Hygiene, Antwerp, Belgium
| | - Alvaro Paez
- Department of Urology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Marco Randazzo
- Department of Urology, Kantonsspital Aarau, Aarau, Switzerland; Department of Urology University Hospital Zürich, Zürich, Switzerland
| | - Xavier Rebillard
- Department of Urology, Clinique BeauSoleil - EA2415, Montpellier, France
| | - Teuvo L J Tammela
- Department of Urology, Tampere University Hospital and Medical School, University of Tampere, Tampere, Finland
| | - Arnauld Villers
- Department of Urology, CHU Lille, Univ Lille Nord de France, Lille, France
| | - Jonas Hugosson
- Department of Urology, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Fritz H Schröder
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marco Zappa
- Clinical and Descriptive Epidemiology and Registries Unit, ISPO - Cancer Research and Prevention Institute, Florence, Italy.
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Morisot A, Bessaoud F, Landais P, Rébillard X, Trétarre B, Daurès JP. Prostate cancer: net survival and cause-specific survival rates after multiple imputation. BMC Med Res Methodol 2015. [PMID: 26216355 PMCID: PMC4517373 DOI: 10.1186/s12874-015-0048-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Estimations of survival rates are diverse and the choice of the appropriate method depends on the context. Given the increasing interest in multiple imputation methods, we explored the interest of a multiple imputation approach in the estimation of cause-specific survival, when a subset of causes of death was observed. Methods By using European Randomized Study of Screening for Prostate Cancer (ERSPC), 20 multiply imputed datasets were created and analyzed with a Multivariate Imputation by Chained Equation (MICE) algorithm. Then, cause-specific survival was estimated on each dataset with two methods: Kaplan-Meier and competing risks. The two pooled cause-specific survival and confidence intervals were obtained using Rubin’s rules after complementary log-log transformation. Net survival was estimated using Pohar-Perme’s estimator and was compared to pooled cause-specific survival. Finally, a sensitivity analysis was performed to test the robustness of our constructed multiple imputation model. Results Cause-specific survival performed better than net survival, since this latter exceeded 100 % for almost the first 2 years of follow-up and after 9 years whereas the cause-specific survival decreased slowly and than stabilized at around 94 % at 9 years. Sensibility study results were satisfactory. Conclusions On our basis of prostate cancer data, the results obtained by cause-specific survival after multiple imputation appeared to be better and more realistic than those obtained using net survival. Electronic supplementary material The online version of this article (doi:10.1186/s12874-015-0048-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adeline Morisot
- University of Montpellier, Laboratory of Biostatistics, Epidemiology and Public Health (EA2415), 641, avenue du doyen Gaston Giraud, Montpellier Cedex 5, 34093, France.
| | - Faïza Bessaoud
- Hérault Cancer Registry, 208, rue des Apothicaires, Montpellier Cedex 5, 34298, France
| | - Paul Landais
- University of Montpellier, Laboratory of Biostatistics, Epidemiology and Public Health (EA2415), 641, avenue du doyen Gaston Giraud, Montpellier Cedex 5, 34093, France
| | - Xavier Rébillard
- Department of Urology - BeauSoleil Clinic, 119 avenue de Lodève, Montpellier, 34070, France
| | - Brigitte Trétarre
- Hérault Cancer Registry, 208, rue des Apothicaires, Montpellier Cedex 5, 34298, France
| | - Jean-Pierre Daurès
- University of Montpellier, Laboratory of Biostatistics, Epidemiology and Public Health (EA2415), 641, avenue du doyen Gaston Giraud, Montpellier Cedex 5, 34093, France
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Impact of Early Diagnosis of Prostate Cancer on Survival Outcomes. Eur Urol Focus 2015; 1:137-146. [PMID: 28723424 DOI: 10.1016/j.euf.2015.01.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 12/20/2014] [Accepted: 01/15/2015] [Indexed: 11/20/2022]
Abstract
CONTEXT The relationship between early detection of prostate cancer (PCa) and disease-specific mortality is still the subject of much debate. OBJECTIVE This review describes developments in PCa mortality rates and disease-stage shift on a population level. The main findings from the randomised screening trials are also discussed. Finally, we consider the expected consequences for the individual man interested in screening. EVIDENCE ACQUISITION The PubMed database was searched for trials of screening for PCa from inception through October 11, 2014. Supplementary information was collected by cross-referencing the reference lists. EVIDENCE SYNTHESIS Since the introduction of prostate-specific antigen testing, PCa incidence has risen, and a stage shift towards more favourable disease at diagnosis has been observed. PCa mortality rates are gradually decreasing. Although screening trials show conflicting results, the largest randomised trial of screening for PCa shows a 21% decrease in PCa-specific mortality. After correction for noncompliance and contamination, a risk reduction in PCa-specific mortality of up to 49% has been reported. The main side effect of screening is that some studies have estimated that approximately 50% of detected cases may represent overdiagnosis, which may be reduced by stopping screening in older men and using an individual risk-based approach. CONCLUSIONS To maximise the benefits while minimising the risk of overdiagnosis, future screening should follow an individual risk-based approach. PATIENT SUMMARY On a population level, the introduction of screening for prostate cancer (PCa) is associated with more men diagnosed but with more favourable disease. The largest screening study confirmed the reduction in death due to PCa. Individual risk estimation is important to best balance the benefits and potential harms of early detection.
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28
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Schröder F, Hugosson J, Carlsson S, Moss S, Roobol M, Auvinen A. Prostate cancer screening in Europe - Authors' reply. Lancet 2015; 385:1507-8. [PMID: 25933276 DOI: 10.1016/s0140-6736(15)60749-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Fritz Schröder
- Department of Urology, Erasmus University Medical Center, 3000 CA Rotterdam, Netherlands.
| | - Jonas Hugosson
- Sahlgrenska Academy at Goteborg University, Goteborg, Sweden
| | - Sigrid Carlsson
- Sahlgrenska Academy at Goteborg University, Goteborg, Sweden; Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Sue Moss
- Centre for Cancer Prevention, Queen Mary University of London, London, UK
| | - Monique Roobol
- Department of Urology, Erasmus University Medical Center, 3000 CA Rotterdam, Netherlands
| | - Anssi Auvinen
- School of Health Sciences, University of Tampere, Tampere, Finland
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29
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Bokhorst LP, Venderbos LDF, Schröder FH, Bangma CH, Steyerberg EW, Roobol MJ. Do Treatment Differences between Arms Affect the Main Outcome of ERSPC Rotterdam? J Urol 2015; 194:336-42. [PMID: 25698407 DOI: 10.1016/j.juro.2015.02.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2015] [Indexed: 10/24/2022]
Abstract
PURPOSE We assessed differences in treatment between the screening and control arms of ERSPC Rotterdam and studied whether possible treatment differences could explain the positive study outcome. MATERIALS AND METHODS In ERSPC Rotterdam men 55 to 74 years old were randomized to a screening arm of 21,210 and a control arm of 21,166. Treatment after diagnosis was at the discretion of the care provider chosen by the patient. Initial treatment was compared in 4 risk groups. The relation between prostate cancer incidence and prostate cancer mortality was assessed by risk group by correlating the incidence RR and the mortality RR. A direct relation would have supported a stage shift as the main cause of changes in prostate cancer mortality. RESULTS Initial treatment differed between the arms in the low, intermediate and high risk groups but not in the metastatic group. The RRs of prostate cancer incidence and mortality per risk group were related 1:1 (regression line slope 1.00, 95% CI 0.30-1.74). Of changes in prostate cancer mortality 94% could be explained by changes in prostate cancer incidence. This made treatment differences unlikely as the reason for the observed decrease in prostate cancer mortality. CONCLUSIONS Differences in treatment between the ERSPC Rotterdam screening and control arms were unlikely to explain the differences in prostate cancer mortality. Results are instead consistent with a decrease in prostate cancer mortality as the result of a favorable stage through screening.
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Affiliation(s)
- Leonard P Bokhorst
- Departments of Urology and Public Health (EWS), Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - Lionne D F Venderbos
- Departments of Urology and Public Health (EWS), Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Fritz H Schröder
- Departments of Urology and Public Health (EWS), Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Chris H Bangma
- Departments of Urology and Public Health (EWS), Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Departments of Urology and Public Health (EWS), Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Monique J Roobol
- Departments of Urology and Public Health (EWS), Erasmus University Medical Centre, Rotterdam, The Netherlands
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Williams NJ, Hill EM, Ng SY, Martin RM, Metcalfe C, Donovan JL, Evans S, Hughes LJ, Davies CF, Hamdy FC, Neal DE, Turner EL. Standardisation of information submitted to an endpoint committee for cause of death assignment in a cancer screening trial – lessons learnt from CAP (Cluster randomised triAl of PSA testing for Prostate cancer). BMC Med Res Methodol 2015; 15:6. [PMID: 25613468 PMCID: PMC4429825 DOI: 10.1186/1471-2288-15-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 01/15/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND In cancer screening trials where the primary outcome is target cancer-specific mortality, the unbiased determination of underlying cause of death (UCD) is crucial. To minimise bias, the UCD should be independently verified by expert reviewers, blinded to death certificate data and trial arm. We investigated whether standardising the information submitted for UCD assignment in a population-based randomised controlled trial of prostate-specific antigen (PSA) testing for prostate cancer reduced the reviewers' ability to correctly guess the trial arm. METHODS Over 550 General Practitioner (GP) practices (>415,000 men aged 50-69 years) were cluster-randomised to PSA testing (intervention arm) or the National Health Service (NHS) prostate cancer risk management programme (control arm) between 2001 and 2007. Assignment of UCD was by independent reviews of researcher-written clinical vignettes that masked trial arm and death certificate information. A period of time after the process began (the initial phase), we analysed whether the reviewers could correctly identify trial arm from the vignettes, and the reasons for their choice. This feedback led to further standardisation of information (second phase), after which we re-assessed the extent of correct identification of trial arm. RESULTS 1099 assessments of 509 vignettes were completed by January 2014. In the initial phase (n = 510 assessments), reviewers were unsure of trial arm in 33% of intervention and 30% of control arm assessments and were influenced by symptoms at diagnosis, PSA test result and study-specific criteria. In the second phase (n = 589), the respective proportions of uncertainty were 45% and 48%. The percentage of cases whereby reviewers were unable to determine the trial arm was greater following the standardisation of information provided in the vignettes. The chances of a correct guess and an incorrect guess were equalised in each arm, following further standardisation. CONCLUSIONS It is possible to mask trial arm from cause of death reviewers, by using their feedback to standardise the information submitted to them. TRIAL REGISTRATION ISRCTN92187251.
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Affiliation(s)
- Naomi J Williams
- School of Social and Community Medicine, University of Bristol, based at Royal Hallamshire Hospital, Sheffield, S10 2JF, UK.
| | - Elizabeth M Hill
- School of Social and Community Medicine, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK.
| | - Siaw Yein Ng
- School of Social and Community Medicine, University of Bristol, based at Freeman Hospital, High Heaton, Newcastle-upon-Tyne, NE7 7DN, UK.
| | - Richard M Martin
- School of Social and Community Medicine, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK.
| | - Chris Metcalfe
- School of Social and Community Medicine, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK.
| | - Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK.
| | | | - Laura J Hughes
- Department of Oncology, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK.
| | - Charlotte F Davies
- School of Social and Community Medicine, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK.
| | - Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
| | - David E Neal
- Department of Oncology, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK.
| | - Emma L Turner
- School of Social and Community Medicine, University of Bristol, Canynge Hall, Bristol, BS8 2PS, UK.
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Schröder FH, Hugosson J, Roobol MJ, Tammela TLJ, Zappa M, Nelen V, Kwiatkowski M, Lujan M, Määttänen L, Lilja H, Denis LJ, Recker F, Paez A, Bangma CH, Carlsson S, Puliti D, Villers A, Rebillard X, Hakama M, Stenman UH, Kujala P, Taari K, Aus G, Huber A, van der Kwast TH, van Schaik RHN, de Koning HJ, Moss SM, Auvinen A. Screening and prostate cancer mortality: results of the European Randomised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up. Lancet 2014; 384:2027-35. [PMID: 25108889 PMCID: PMC4427906 DOI: 10.1016/s0140-6736(14)60525-0] [Citation(s) in RCA: 1014] [Impact Index Per Article: 101.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND The European Randomised study of Screening for Prostate Cancer (ERSPC) has shown significant reductions in prostate cancer mortality after 9 years and 11 years of follow-up, but screening is controversial because of adverse events such as overdiagnosis. We provide updated results of mortality from prostate cancer with follow-up to 2010, with analyses truncated at 9, 11, and 13 years. METHODS ERSPC is a multicentre, randomised trial with a predefined centralised database, analysis plan, and core age group (55-69 years), which assesses prostate-specific antigen (PSA) testing in eight European countries. Eligible men aged 50-74 years were identified from population registries and randomly assigned by computer generated random numbers to screening or no intervention (control). Investigators were masked to group allocation. The primary outcome was prostate cancer mortality in the core age group. Analysis was by intention to treat. We did a secondary analysis that corrected for selection bias due to non-participation. Only incidence and no mortality data at 9 years' follow-up are reported for the French centres. This study is registered with Current Controlled Trials, number ISRCTN49127736. FINDINGS With data truncated at 13 years of follow-up, 7408 prostate cancer cases were diagnosed in the intervention group and 6107 cases in the control group. The rate ratio of prostate cancer incidence between the intervention and control groups was 1·91 (95% CI 1·83-1·99) after 9 years (1·64 [1·58-1·69] including France), 1·66 (1·60-1·73) after 11 years, and 1·57 (1·51-1·62) after 13 years. The rate ratio of prostate cancer mortality was 0·85 (0·70-1·03) after 9 years, 0·78 (0·66-0·91) after 11 years, and 0·79 (0·69-0·91) at 13 years. The absolute risk reduction of death from prostate cancer at 13 years was 0·11 per 1000 person-years or 1·28 per 1000 men randomised, which is equivalent to one prostate cancer death averted per 781 (95% CI 490-1929) men invited for screening or one per 27 (17-66) additional prostate cancer detected. After adjustment for non-participation, the rate ratio of prostate cancer mortality in men screened was 0·73 (95% CI 0·61-0·88). INTERPRETATION In this update the ERSPC confirms a substantial reduction in prostate cancer mortality attributable to testing of PSA, with a substantially increased absolute effect at 13 years compared with findings after 9 and 11 years. Despite our findings, further quantification of harms and their reduction are still considered a prerequisite for the introduction of populated-based screening. FUNDING Each centre had its own funding responsibility.
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Affiliation(s)
- Fritz H Schröder
- Department of Urology, Erasmus University Medical Center, Rotterdam, Netherlands.
| | - Jonas Hugosson
- Department of Urology, Sahlgrenska Academy at Goteborg University, Goteborg, Sweden
| | - Monique J Roobol
- Department of Urology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Teuvo L J Tammela
- Department of Urology, Tampere University Hospital, Tampere, Finland; School of Medicine, University of Tampere, Tampere, Finland
| | - Marco Zappa
- Unit of Clinical and Descriptive Epidemiology, ISPO, Florence, Italy
| | - Vera Nelen
- Provinciaal Instituut voor Hygiene, Antwerp, Belgium
| | - Maciej Kwiatkowski
- Department of Urology, Kantonsspital Aarau, Aarau, Switzerland; Department of Urology, Academic Hospital Braunschweig, Braunschweig, Germany
| | - Marcos Lujan
- Department of Urology, Hospital Infanta Cristina, Parla, Madrid, Spain; Department of Urology, Hospital Universitario de Getafe, Getafe, Madrid, Spain; Universidad Complutense de Madrid, Madrid, Spain
| | | | - Hans Lilja
- Department of Surgery (Urology), Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Departments of Laboratory Medicine and Medicine (GU-Oncology), Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK; Department of Laboratory Medicine, Lund University, Malmö, Sweden; Institute of Biomedical Technology, University of Tampere, Tampere, Finland
| | | | - Franz Recker
- Department of Urology, Kantonsspital Aarau, Aarau, Switzerland
| | - Alvaro Paez
- Department of Urology, Hospital Universitario de Fuenlabrada, Madrid, Spain; Department of Urology, Hospital Universitario de Getafe, Getafe, Madrid, Spain; Universidad Rey Juan Carlos, Madrid, Spain
| | - Chris H Bangma
- Department of Urology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Sigrid Carlsson
- Department of Urology, Sahlgrenska Academy at Goteborg University, Goteborg, Sweden; Department of Surgery (Urology), Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Donella Puliti
- Unit of Clinical and Descriptive Epidemiology, ISPO, Florence, Italy
| | - Arnauld Villers
- Department of Urology, CHU Lille, Univ Lille Nord de France, Lille, France
| | | | - Matti Hakama
- Finnish Cancer Registry, Helsinki, Finland; School of Health Sciences, University of Tampere, Tampere, Finland
| | - Ulf-Hakan Stenman
- Department of Clinical Chemistry, Helsinki University Central Hospital Laboratory Division (HUSLAB), Helsinki, Finland
| | - Paula Kujala
- FIMLAB, Department of Pathology, Tampere, Finland
| | - Kimmo Taari
- Department of Urology, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Gunnar Aus
- Department of Urology, Carlanderska Sjukhuset Göteborg, Sweden
| | - Andreas Huber
- Centre of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Theo H van der Kwast
- Department of Pathology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Sue M Moss
- Centre for Cancer Prevention, Queen Mary University of London, London, UK
| | - Anssi Auvinen
- School of Health Sciences, University of Tampere, Tampere, Finland
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Turner EL, Metcalfe C, Donovan JL, Noble S, Sterne JAC, Lane JA, Avery KN, Down L, Walsh E, Davis M, Ben-Shlomo Y, Oliver SE, Evans S, Brindle P, Williams NJ, Hughes LJ, Hill EM, Davies C, Ng SY, Neal DE, Hamdy FC, Martin RM. Design and preliminary recruitment results of the Cluster randomised triAl of PSA testing for Prostate cancer (CAP). Br J Cancer 2014; 110:2829-36. [PMID: 24867688 PMCID: PMC4056057 DOI: 10.1038/bjc.2014.242] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 04/08/2014] [Accepted: 04/10/2014] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Screening for prostate cancer continues to generate controversy because of concerns about over-diagnosis and unnecessary treatment. We describe the rationale, design and recruitment of the Cluster randomised triAl of PSA testing for Prostate cancer (CAP) trial, a UK-wide cluster randomised controlled trial investigating the effectiveness and cost-effectiveness of prostate-specific antigen (PSA) testing. METHODS Seven hundred and eighty-five general practitioner (GP) practices in England and Wales were randomised to a population-based PSA testing or standard care and then approached for consent to participate. In the intervention arm, men aged 50-69 years were invited to undergo PSA testing, and those diagnosed with localised prostate cancer were invited into a treatment trial. Control arm practices undertook standard UK management. All men were flagged with the Health and Social Care Information Centre for deaths and cancer registrations. The primary outcome is prostate cancer mortality at a median 10-year-follow-up. RESULTS Among randomised practices, 271 (68%) in the intervention arm (198,114 men) and 302 (78%) in the control arm (221,929 men) consented to participate, meeting pre-specified power requirements. There was little evidence of differences between trial arms in measured baseline characteristics of the consenting GP practices (or men within those practices). CONCLUSIONS The CAP trial successfully met its recruitment targets and will make an important contribution to international understanding of PSA-based prostate cancer screening.
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Affiliation(s)
- E L Turner
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - C Metcalfe
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - J L Donovan
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - S Noble
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - J A C Sterne
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - J A Lane
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - K N Avery
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - L Down
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - E Walsh
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - M Davis
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Y Ben-Shlomo
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - S E Oliver
- Department of Health Sciences, University of York and the Hull York Medical School, York YO10 5DD, UK
| | - S Evans
- Royal United Hospital Bath, Combe Park, Bath BA1 3NG, UK
| | - P Brindle
- Avon Primary Care Research Collaborative, Marlborough Street, South Plaza, Bristol BS1 3NX, UK
| | - N J Williams
- School of Social and Community Medicine, University of Bristol, Royal Hallamshire Hospital, Sheffield S10 2JF, UK
| | - L J Hughes
- Department of Oncology, University of Cambridge, Box 279 (S4), Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - E M Hill
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - C Davies
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - S Y Ng
- School of Social and Community Medicine, University of Bristol, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - D E Neal
- Department of Oncology, University of Cambridge, Box 279 (S4), Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - F C Hamdy
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - R M Martin
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
- MRC/University of Bristol Integrative Epidemiology Unit, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
| | - the CAP trial group
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
- Department of Health Sciences, University of York and the Hull York Medical School, York YO10 5DD, UK
- Royal United Hospital Bath, Combe Park, Bath BA1 3NG, UK
- Avon Primary Care Research Collaborative, Marlborough Street, South Plaza, Bristol BS1 3NX, UK
- School of Social and Community Medicine, University of Bristol, Royal Hallamshire Hospital, Sheffield S10 2JF, UK
- Department of Oncology, University of Cambridge, Box 279 (S4), Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
- School of Social and Community Medicine, University of Bristol, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, UK
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford OX3 9DU, UK
- MRC/University of Bristol Integrative Epidemiology Unit, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
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Luján M, Páez A, Angulo JC, Granados R, Nevado M, Torres GM, Berenguer A. Prostate cancer incidence and mortality in the Spanish section of the European Randomized Study of Screening for Prostate Cancer (ERSPC). Prostate Cancer Prostatic Dis 2014; 17:187-91. [PMID: 24614694 DOI: 10.1038/pcan.2014.7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Revised: 01/13/2014] [Accepted: 01/26/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND To present the long-term results of a prostate cancer (PC) screening trial conducted in a Mediterranean setting. METHODS A total of 4276 men aged 45-70 years were randomized to screening arm (PSA test performed) and control arm (no tests). Transrectal ultrasonography-guided sextant prostate biopsy was conducted when PSA > or = 3 ng ml(-1). Date and cause of death were retrieved from death certificates. PC incidence, and disease-specific and overall mortality curves were plotted and comparison between arms was made. Analysis of causes of death was also performed. RESULTS Median age at randomization was 57.0 years. Median follow-up time was 15.2 years. A total of 241 men were diagnosed with PC, 161 (6.7%) in the screening arm and 80 (4.3%) in the control arm (P<0.01). Eventually, 554 men (13%) died. No difference in all-cause mortality was found between arms (P=0.34). Only 10 men (10/4276, 0.23%) died from PC, no differences between arms (P=0.67). Overall, the main causes of death were malignancy (54.2%), cardiovascular (17.9%) and respiratory (9.2%) diseases. Main cancer causes of death were lung and bronchus cancer (37.2%), colorectum (15.0%) and stomach (9.0%) cancer. PC only accounted for 3.0% of all malignant causes of death (ranked 10th). CONCLUSIONS Our study failed to demonstrate benefits of PC screening in terms of all-cause and PC-specific mortality after a median follow-up of 15 years. The limited sample size and the low long-term PC mortality observed in our setting were probably the most important factors to explain these results.
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Affiliation(s)
- M Luján
- Department of Urology, Hospital Universitario Infanta Cristina, Universidad Complutense de Madrid, Madrid, Spain
| | - A Páez
- Department of Urology, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, Madrid, Spain
| | - J C Angulo
- Department of Urology, Hospital Universitario de Getafe, Universidad Europea de Madrid, Madrid, Spain
| | - R Granados
- Department of Pathology, Hospital Universitario de Getafe, Universidad Europea de Madrid, Madrid, Spain
| | - M Nevado
- Department of Pathology, Universitario Infanta Cristina, Universidad Complutense de Madrid, Madrid, Spain
| | - G M Torres
- Department of Urology, Hospital Universitario de Torrejón, Madrid, Spain
| | - A Berenguer
- Department of Urology, Hospital Universitario Madrid Norte Sanchinarro, Universidad San Pablo CEU, Madrid, Spain
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[Early detection of prostate cancer: harm verified, benefit not verifiable]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2014; 57:318-26. [PMID: 24562707 DOI: 10.1007/s00103-013-1904-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The results of randomized studies on the early detection of prostate cancer and those of a systematic Cochrane review are compiled and interpreted. Some fundamental and inherent weaknesses of screening studies are pointed out and discussed. The meta-analysis of studies involving a total of 321,594 participants shows no reduction in prostate cancer mortality or all-cause mortality, but describes disadvantages such as unnecessary biopsies, overdiagnosis, and overtreatment. A relevant increase in overall mortality cannot be excluded. Even in future trials, the possible reduction of prostate cancer mortality or all-cause mortality by prostate cancer screening will not be detectable because of inherent methodological problems, e.g., an extremely high number of participants are needed. Furthermore, by nature, studies on the early detection of cancer last very long, such that the results are inevitably outdated at the end of the study. There is a risk that studies on the early detection of cancer suggest an advantage and at the same time overlook a relevant increase in overall mortality. Prostate cancer screening also ignores important WHO criteria for screening programs: There is evidence that early treatment of prostate cancer is not better than late treatment. There is no suitable or reliable test to identify the early stages of the disease. The benefit-risk ratio is not clearly favorable, and there is doubt whether the costs and the benefits are in an acceptable balance. There are valid reasons to advise against population-based prostate cancer screening.
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Bokhorst LP, Bangma CH, van Leenders GJ, Lous JJ, Moss SM, Schröder FH, Roobol MJ. Prostate-specific Antigen–Based Prostate Cancer Screening: Reduction of Prostate Cancer Mortality After Correction for Nonattendance and Contamination in the Rotterdam Section of the European Randomized Study of Screening for Prostate Cancer. Eur Urol 2014; 65:329-36. [DOI: 10.1016/j.eururo.2013.08.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 08/01/2013] [Indexed: 10/26/2022]
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Zappa M, Puliti D, Hugosson J, Schröder FH, van Leeuwen PJ, Kranse R, Auvinen A, Carlsson S, Kwiatkowski M, Nelen V, Paez Borda A, Roobol MJ, Villers A. A different method of evaluation of the ERSPC trial confirms that prostate-specific antigen testing has a significant impact on prostate cancer mortality. Eur Urol 2014; 66:401-3. [PMID: 24412230 DOI: 10.1016/j.eururo.2013.12.055] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 12/23/2013] [Indexed: 10/25/2022]
Abstract
The advantages and disadvantages of two different methods of analyzing the European Randomized Study of Screening for Prostate Cancer (ERSPC) trial with respect to the effect of prostate-specific antigen (PSA) screening on prostate cancer (PCa) mortality (ie, disease-specific mortality analysis and excess mortality analysis) are discussed in depth. The traditional disease-specific mortality is the best end point, but it could be biased by misclassification of causes of death, and it does not take into account the possible effect of the screening process on other causes of death. Excess mortality analysis overcomes these problems, but the results could be biased if the expected mortality is not corrected for attendance status. Both methods, when applied to the ERSPC trials, demonstrate that no increase in non-PCa mortality occurred in the screening group and confirm that PSA screening decreases PCa mortality.
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Affiliation(s)
- Marco Zappa
- Clinical and Descriptive Epidemiology Unit, ISPO-Cancer Research and Prevention Institute, Florence, Italy.
| | - Donella Puliti
- Clinical and Descriptive Epidemiology Unit, ISPO-Cancer Research and Prevention Institute, Florence, Italy
| | - Jonas Hugosson
- Department of Urology, Sahlgrenska University Hospital, Göteborg, Sweden
| | | | | | - Ries Kranse
- Department of Urology, Erasmus MC, Rotterdam, The Netherlands; Comprehensive Cancer Centre The Netherlands, Utrecht, The Netherlands
| | - Anssi Auvinen
- School of Health Sciences, University of Tampere, Tampere, Finland
| | - Sigrid Carlsson
- Department of Urology, Sahlgrenska University Hospital, Göteborg, Sweden; Department of Surgery (Urology Service), Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Maciej Kwiatkowski
- Department of Urology, Kantonsspital Aarau, Aarau, Switzerland; Department of Urology, Academic Hospital Braunschweig, Braunschweig, Germany
| | - Vera Nelen
- Provinciaal Instituut voor Hygiëne, Antwerp, Belgium
| | - Alvaro Paez Borda
- Department of Urology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | | | - Arnauld Villers
- Department of Urology, CHU Lille, University Lille Nord de France, Lille, France
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Roobol MJ, Kranse R, Bangma CH, van Leenders AG, Blijenberg BG, van Schaik RH, Kirkels WJ, Otto SJ, van der Kwast TH, de Koning HJ, Schröder FH. Screening for Prostate Cancer: Results of the Rotterdam Section of the European Randomized Study of Screening for Prostate Cancer. Eur Urol 2013; 64:530-9. [DOI: 10.1016/j.eururo.2013.05.030] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 05/09/2013] [Indexed: 11/24/2022]
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38
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Kranse R, van Leeuwen PJ, Hakulinen T, Hugosson J, Tammela TL, Ciatto S, Roobol MJ, Zappa M, Aus G, Bangma CH, Moss SM, Auvinen A, Schröder FH. Excess all-cause mortality in the evaluation of a screening trial to account for selective participation. J Med Screen 2013; 20:39-45. [PMID: 23390204 DOI: 10.1177/0969141312474443] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE In addition to disease-specific mortality, a randomized controlled cancer screening trial may be evaluated in terms of excess mortality, in which case no patient-specific information on causes of death is needed. We studied the effect of not accounting for attendance on the calculated excess mortality in a prostate cancer screening trial. METHODS The numerator of the excess mortality rate related to prostate cancer diagnoses in each study arm equals the excess number of deaths observed in the cancer patients. The estimation of the expected number of deaths in the absence of the prostate cancer diagnoses has to account for the self-selection of those participating in the trial, particularly if the proportion of non-participants is substantial. SETTING The European prostate cancer screening trial (ERSPC). RESULTS In the screening arm, non-attendees had roughly twice the mortality rate of attendees. Approximately twice as many cancers were detected in the screening arm compared with the control arm, primarily in attendees. Unless attendance is properly accounted for, the expected mortality of prostate cancer patients in the screening arm is overestimated by 0.9-3.6 deaths per 1000 person-years. CONCLUSIONS Attendees have a lower all-cause mortality rate (are healthier) and a higher probability of a prostate cancer diagnosis than non-attendees and the men randomized to the control arm. If attendance is not accounted for, the excess mortality and the between-arm excess mortality rate ratio are underestimated and screening is considered more effective than it actually is. These effects may be sizeable, notably if non-attendance is common. Correcting for attendance status is important in the calculation of the excess mortality rate in prostate cancer patients that can be used in conjunction with a disease-specific mortality analysis in a randomized controlled cancer screening trial.
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Affiliation(s)
- Ries Kranse
- Department of Urology, Erasmus Medical Centre, Rotterdam, The Netherlands and Comprehensive Cancer Center the Netherlands (IKNL), Utrecht, The Netherlands.
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Goldstraw MA. Critical role of prostate biopsy mortality in the number of years of life gained and lost within a prostate cancer screening programme. BJU Int 2013; 111:E140-1. [DOI: 10.1111/j.1464-410x.2013.11397_7.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zhu X, van Leeuwen PJ, Holmberg E, Bul M, Carlsson S, Schröder FH, Roobol MJ, Hugosson J. Efficacy versus effectiveness study design within the European screening trial for prostate cancer: consequences for cancer incidence, overall mortality and cancer-specific mortality. J Med Screen 2013; 19:133-40. [PMID: 23093731 DOI: 10.1258/jms.2012.012071] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess the impact of different study designs on outcome data within the European Randomized Study of Screening for Prostate Cancer (ERSPC). METHODS Observed data from the Gothenburg centre (effectiveness trial with upfront randomization before informed consent) and the Rotterdam centre (efficacy trial with randomization after informed consent) were compared with expected data, which were retrieved from national cancer registries and life tables. Endpoints were 11-year cumulative prostate cancer (PC) incidence, overall mortality and PC-specific mortality. RESULTS In Gothenburg, the 11-year PC incidence was higher than predicted (5.8%) in both the intervention (12.4%) and control arms (7.3%). The observed overall mortality was higher than predicted (15.9%) in both the intervention (17.8%) and control arms (18.5%). The observed PC-specific mortality in the intervention arm was 0.56% versus 0.83% in the control arm, while the expected mortality was 0.83%. In Rotterdam, the observed PC incidence in the intervention arm (10.4%) was higher than expected (4.4%). The incidence in the control arm was 4.6%. The observed overall mortality was lower than expected: 13.6% in the intervention arm and 14.0% in the control arm versus an expected mortality of 16.1%. The observed PC-specific mortality was lower than expected (0.65%) in both the intervention (0.27%) and control arms (0.41%). CONCLUSIONS Our results suggest that an efficacy trial with informed consent prior to randomization may have introduced a 'healthy screenee bias'. Therefore, an effectiveness trial with consent after randomization may more accurately estimate the PC-specific mortality reduction if population-based screening is introduced.
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Affiliation(s)
- Xiaoye Zhu
- Department of Urology, Erasmus MC, University Medical Center, Room NH-227, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
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Loeb S, Zhu X, Schroder FH, Roobol MJ. Long-term radical prostatectomy outcomes among participants from the European Randomized Study of Screening for Prostate Cancer (ERSPC) Rotterdam. BJU Int 2012; 110:1678-83. [PMID: 22998182 DOI: 10.1111/j.1464-410x.2012.11367.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
UNLABELLED Study Type--Therapy (cohort) Level of Evidence 2b. What's known on the subject? and What does the study add? Radical prostatectomy was previously shown to improve long-term outcomes among men with clinically-detected prostate cancer. Our data suggests that radical prostatectomy is also associated with improved outcomes in men with screen-detected prostate cancer. OBJECTIVE • To examine the long-term outcomes of radical prostatectomy (RP) among men diagnosed with prostate cancer from the screening and control arms of the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer (ERSPC). PATIENTS AND METHODS • Among 42,376 men randomised during the period of the first round of the trial (1993-1999), 1151 and 210 in the screening and control arms were diagnosed with prostate cancer, respectively. • Of these men, 420 (36.5%) screen-detected and 54 (25.7%) controls underwent RP with long-term follow-up data (median follow-up 9.9 years). • Progression-free (PFS), metastasis-free (MFS) and cancer-specific survival (CSS) rates were examined, and multivariable Cox proportional hazards models were used to determine whether screen-detected (vs control) was associated with RP outcomes after adjusting for standard predictors. RESULTS • RP cases from the screening and control arms had statistically similar clinical stage and biopsy Gleason score, although screen-detected cases had significantly lower prostate-specific antigen (PSA) levels at diagnosis. • Men from the screening arm had a significantly higher PFS (P = 0.003), MFS (P < 0.001) and CSS (P = 0.048). • In multivariable models adjusting for age, PSA level, clinical stage, and biopsy Gleason score, the screening group had a significantly lower risk of biochemical recurrence (hazard ratio [HR] 0.43, 95% confidence interval [CI] 0.23-0.83, P = 0.011) and metastasis (HR 0.18, 95% CI 0.06-0.59, P = 0.005). • Additionally adjusting for tumour volume and other RP pathology features, there was no longer a significant difference in biochemical recurrence between the screening and control arms. • Limitations of the present study include lead-time bias and non-randomised treatment selection. CONCLUSIONS • After RP, screen-detected cases had significantly improved PFS, MFS and CSS compared with controls within the available follow-up time. • The screening arm remained significantly associated with lower rates of biochemical recurrence and metastasis after adjusting for other preoperative variables. • However, considering also RP pathology, the improved outcomes in the screening group appeared to be mediated by a significantly lower tumour volume.
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Affiliation(s)
- Stacy Loeb
- Department of Urology, New York University, New York, NY, USA.
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Schröder FH, Hugosson J, Roobol MJ, Tammela TLJ, Ciatto S, Nelen V, Kwiatkowski M, Lujan M, Lilja H, Zappa M, Denis LJ, Recker F, Páez A, Määttänen L, Bangma CH, Aus G, Carlsson S, Villers A, Rebillard X, van der Kwast T, Kujala PM, Blijenberg BG, Stenman UH, Huber A, Taari K, Hakama M, Moss SM, de Koning HJ, Auvinen A. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med 2012; 366:981-90. [PMID: 22417251 PMCID: PMC6027585 DOI: 10.1056/nejmoa1113135] [Citation(s) in RCA: 866] [Impact Index Per Article: 72.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Several trials evaluating the effect of prostate-specific antigen (PSA) testing on prostate-cancer mortality have shown conflicting results. We updated prostate-cancer mortality in the European Randomized Study of Screening for Prostate Cancer with 2 additional years of follow-up. METHODS The study involved 182,160 men between the ages of 50 and 74 years at entry, with a predefined core age group of 162,388 men 55 to 69 years of age. The trial was conducted in eight European countries. Men who were randomly assigned to the screening group were offered PSA-based screening, whereas those in the control group were not offered such screening. The primary outcome was mortality from prostate cancer. RESULTS After a median follow-up of 11 years in the core age group, the relative reduction in the risk of death from prostate cancer in the screening group was 21% (rate ratio, 0.79; 95% confidence interval [CI], 0.68 to 0.91; P=0.001), and 29% after adjustment for noncompliance. The absolute reduction in mortality in the screening group was 0.10 deaths per 1000 person-years or 1.07 deaths per 1000 men who underwent randomization. The rate ratio for death from prostate cancer during follow-up years 10 and 11 was 0.62 (95% CI, 0.45 to 0.85; P=0.003). To prevent one death from prostate cancer at 11 years of follow-up, 1055 men would need to be invited for screening and 37 cancers would need to be detected. There was no significant between-group difference in all-cause mortality. CONCLUSIONS Analyses after 2 additional years of follow-up consolidated our previous finding that PSA-based screening significantly reduced mortality from prostate cancer but did not affect all-cause mortality. (Current Controlled Trials number, ISRCTN49127736.).
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Affiliation(s)
- Fritz H Schröder
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands.
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van Leeuwen PJ, Otto SJ, Kranse R, Roobol MJ, Bul M, Zhu X, de Koning H, Schröder FH. Increased non-prostate cancer death risk in clinically diagnosed prostate cancer. BJU Int 2012; 110:188-94. [PMID: 22288823 DOI: 10.1111/j.1464-410x.2011.10811.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED Study Type - Prognosis (case control). Level of Evidence 3a. What's known on the subject? and What does the study add? Treatment of advanced PC might put patients at an increased risk of cardiovascular events. Recent studies have suggested that the excess mortality is lower among men who were diagnosed with screen detected PC in comparison to men with clinically diagnosed PC, possibly due to the use of medications for cardiovascular disease and the change to a healthier lifestyle of men with a screen detected PC. Men with clinically diagnosed PC have an increased risk of death unrelated to PC itself, i.e., the excess mortality is based on an increased risk of dying from other neoplasm and diseases of the circulatory or respiratory system. OBJECTIVE • To assess the cause-specific mortality unrelated to prostate cancer (PC) itself in patients with screen- and clinically diagnosed PC. PATIENTS AND METHODS • The present study was conducted among participants of the European Randomized Study of Screening for Prostate Cancer. • Based on consensus of the causes of death committee (CODC), all patients who died from PC were excluded. • In the intervention arm, cases were patients with a screen-detected PC, aged 55-74 years, between 1993 and 2001. • These cases were matched to two controls in whom no cancer was found after biopsy, and two controls in whom no cancer was suspected after screening. In the control arm, cases were patients with clinically diagnosed PC, aged 55-74 years, between 1993 and 2001. These cases were matched to four controls without PC. Matching was done with respect to date of birth, screening and/or diagnosis. Men were followed up to 31 December 2007. RESULTS • No statistically significant difference in overall mortality between cases and controls in the intervention arm was observed: relative risk (RR) 1.26 (95% confidence interval [CI] 0.96-1.65; P = 0.102) and RR 1.13 (95% CI 0.86-1.47; P = 0.381). • In the control arm, the overall mortality was statistically significantly higher in cases relative to controls: RR 1.43 (95% CI 1.03-2.00; P = 0.033). • This difference was because of an increased risk of dying from neoplasms and disease of the circulatory or respiratory system among cases: RR 1.61 (95% CI 1.12-2.29; P = 0.009). • The present study was limited by the relatively small sample size. CONCLUSIONS • Increased mortality unrelated to PC itself was observed in men with clinically diagnosed PC, but not in screen-detected PC. • The excess mortality in men with clinically diagnosed PC seems to be as a result of a significantly increased risk of dying from neoplasm and disease of the circulatory or respiratory system. • Results have to be studied more thoroughly in further clinical trials.
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Affiliation(s)
- Pim J van Leeuwen
- Department of Urology Public Health, Erasmus Medical Centre, Rotterdam Cancer Registry Rotterdam, Rotterdam, the Netherlands.
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Schröder FH. Screening for prostate cancer. Eur J Cancer 2011; 47 Suppl 3:S164-70. [DOI: 10.1016/s0959-8049(11)70160-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Zhu X, van Leeuwen PJ, Bul M, Otto SJ, de Koning HJ, Bangma CH, Schröder FH, Roobol MJ. Disease-Specific Survival of Men With Prostate Cancer Detected During the Screening Interval: Results of the European Randomized Study of Screening for Prostate Cancer–Rotterdam After 11 Years of Follow-Up. Eur Urol 2011; 60:330-6. [DOI: 10.1016/j.eururo.2011.05.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Accepted: 05/03/2011] [Indexed: 10/18/2022]
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Ablin RJ, Haythorn MR. Screening for prostate cancer: Controversy? What controversy? ACTA ACUST UNITED AC 2011; 16:1-2. [PMID: 19526077 PMCID: PMC2695709 DOI: 10.3747/co.v16i3.459] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- R J Ablin
- Departments of Immunobiology and Pathology, University of Arizona College of Medicine, Arizona Cancer Center and the BIO5 Institute, Tucson, AZ, U.S.A.
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van Leeuwen PJ, Kranse R, Hakulinen T, Roobol MJ, de Koning HJ, Bangma CH, Schröder FH. Disease-specific mortality may underestimate the total effect of prostate cancer screening. J Med Screen 2011; 17:204-10. [PMID: 21258131 DOI: 10.1258/jms.2010.010074] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To study the difference between the disease-specific and excess mortality rate in the European Randomized Study of Screening for Prostate Cancer section Rotterdam. METHODS A total of 42,376 men were randomized to systematic screening or usual care. The excess number of deaths was defined as the difference between the observed number of deaths in the prostate cancer (PC) patients and the expected number of deaths up to 31 December 2006. The expected number was derived from mortality of all study participants before a possible diagnosis with PC. The disease-specific mortality rate was based on the number of men who died from PC. The excess mortality rate based on the arm-specific excess number of deaths and the disease-specific mortality rate were compared between the two study arms. RESULTS The overall mortality rate was not significantly different between the intervention and the control arms of the study: RR 1.02 (95% CI 0.98-1.07). The disease-specific mortality rate was 0.42 men per 1000 person-years in the intervention and 0.48 men per 1000 person-years in the control arm: RR 0.86 (95% CI 0.64-1.17). The excess mortality rate was 0.40 per 1000 person-years in the intervention arm and 0.61 men per 1000 person-years in the control arm, and the RR for excess mortality was 0.66 (95% CI 0.39-1.13). CONCLUSIONS In contrast to the disease-specific mortality rates an increased difference in the excess mortality rates was observed between the two arms. This observation may be due to a systematic underestimation of the disease-specific deaths, and/or an additional disease-related mortality that is measured by an excess mortality analysis but not by a disease-specific mortality.
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Lane JA, Hamdy FC, Martin RM, Turner EL, Neal DE, Donovan JL. Latest results from the UK trials evaluating prostate cancer screening and treatment: the CAP and ProtecT studies. Eur J Cancer 2011; 46:3095-101. [PMID: 21047592 DOI: 10.1016/j.ejca.2010.09.016] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Revised: 08/11/2010] [Accepted: 09/07/2010] [Indexed: 11/19/2022]
Abstract
The European Randomised Study of Screening for Prostate Cancer (ERSPC) demonstrated a significant reduction in prostate cancer-specific mortality. The ongoing Comparison Arm for ProtecT (CAP) cluster randomised controlled trial (RCT) evaluates prostate cancer screening effectiveness by comparing primary care centres allocated to a round of prostate specific antigen (PSA) testing (intervention) or standard clinical care. Over 550 centres (around 450,000 men) were randomised in eight United Kingdom areas (2002-2008). Intervention group participants were also eligible for the ProtecT (Prostate testing for cancer and Treatment) RCT evaluating active monitoring, radiotherapy and radical prostatectomy treatments for localised prostate cancer. In ProtecT, over 1500 of around 3000 men with prostate cancer were randomised from over 10,000 with an elevated PSA in around 111,000 attendees at clinics. Investigation of the psychological impact of screening in a sub-sample showed that 10% of men still experienced high distress up to 3 months following prostate biopsies (22/227), although most were relatively unaffected. The risk of prostate cancer with a raised PSA was lower if urinary symptoms were present (frequent nocturia odds ratio (OR) 0.44, 95% confidence interval (CI) 0.22-0.83) or if a repeat PSA decreased by > or = 20% prior to biopsy (OR 0.43, 95% CI 0.35-0.52). Men aged 45-49 years attended PSA clinics less frequently (442/1299, 34%) in a nested cohort with a cancer detection rate of 2.3% (10/442). The CAP and ProtecT trials (ISRCTN92187251 and ISRCTN20141217) will help resolve the prostate cancer screening debate, define the optimum treatment for localised disease and generate evidence to improve men's health.
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Affiliation(s)
- J A Lane
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
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Godtman R, Holmberg E, Stranne J, Hugosson J. High accuracy of Swedish death certificates in men participating in screening for prostate cancer: A comparative study of official death certificates with a cause of death committee using a standardized algorithm. ACTA ACUST UNITED AC 2011; 45:226-32. [DOI: 10.3109/00365599.2011.559950] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences,
Sahlgrenska Academy at University of Göteborg, Sweden
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Bul M, van Leeuwen PJ, Zhu X, Schröder FH, Roobol MJ. Prostate Cancer Incidence and Disease-Specific Survival of Men with Initial Prostate-Specific Antigen Less Than 3.0ng/ml Who Are Participating in ERSPC Rotterdam. Eur Urol 2011; 59:498-505. [DOI: 10.1016/j.eururo.2011.01.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Accepted: 01/03/2011] [Indexed: 02/01/2023]
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