GPs' estimates of men's risk of prostate cancer and screening expectations

Identifying Prostate Cancer Among Men with Lower Urinary Tract Symptoms

Background

In men aged above 50 yr, lower urinary tract symptoms (LUTS), benign prostate hyperplasia, and prostate cancer are common urological conditions. Current guidelines for general practitioners frequently recommend prostate-specific antigen (PSA) testing in patients with LUTS for the detection of prostate cancer.

Objective

To assess the performance of PSA, PSA density, and the Stockholm3 blood test for identification of prostate cancer among men with LUTS.

Design, setting, and participants

In this post hoc analysis of a population-based diagnostic trial (STHLM3, n = 58 588), 4588 men aged 50–69 yr, without previous prostate cancer, with International Prostate Symptom Score (IPSS) data, and having PSA ≥ 3 ng/mL were identified. Men with at least moderate LUTS, defined as an IPSS score of ≥8, were included. PSA density and Stockholm3 scores were calculated.

Intervention

Participants underwent 10–12-core systematic prostate biopsies.

Outcome measurements and statistical analysis

The primary outcome was significant prostate cancer (sPCa) defined as International Society of Urological Pathology (ISUP) grade ≥2. Logistic regression analysis adjusted for age and previous biopsy status was performed. The area under the receiver operating characteristic curve (AUC) was calculated, and decision curve analysis was performed.

Results and limitations

Out of 4588 men, 1544 (34%) reported at least moderate LUTS. The median age was 64 yr, and 11% had undergone a previous prostate biopsy. The Stockholm3 test showed superior discrimination for sPCa to PSA density, which in turn showed superior discrimination to PSA (AUC 0.77 vs 0.70 vs 0.61, p <  0.02). Calibration of the Stockholm3 test was adequate. Performing biopsy only in men with PSA ≥5 ng/mL saved 64% of biopsies, but resulted in missing 52% of detectable sPCa. Recommending biopsy for men with PSA density ≥0.07 resulted in sparing 26% of biopsy procedures and delaying the diagnosis of 12% of sPCa cases, with a 6.1% risk of sPCa among unbiopsied men. Recommending men with Stockholm3 ≥ 0.11 for biopsy resulted in sparing 53% of biopsy procedures and delaying the diagnosis of 20% of sPCa cases, with a 5.1% risk of finding sPCa in unbiopsied men.

Conclusions

PSA density and the Stockholm3 blood test were superior to PSA for the identification of prostate cancer among men with LUTS.

Patient summary

In this analysis of a large Swedish study, we find that the use of prostate-specific antigen (PSA) density or the Stockholm3 blood test instead of only PSA might improve the detection of prostate cancer among men with lower urinary tract symptoms.

Lower urinary tract symptoms (LUTS) are not associated with an increased risk of prostate cancer in men 50-69 years with PSA ≥3 ng/ml

Background: There is conflicting evidence about the association between prostate cancer and Lower Urinary Tract Symptoms (LUTS). We aimed to describe the prevalence of LUTS and its association with prostate cancer risk.Methods: We studied the association between International Prostate Symptom Score (IPSS) and prostate cancer in a population-based sample of men (n = 45,595) aged 50-69 years from the Stockholm3 study. Men with PSA ≥3 ng/ml (n = 4579) underwent systematic prostate biopsies. We used the International Society of Urological Pathology Gleason Grading (ISUP grade) and performed regression analysis for risk of any cancer (n = 1797), ISUP grade ≥2 (n = 840) and advanced cancer, defined as ISUP grade ≥3 or cT ≥3 (n = 353).Results: 74.6% of all men had no or mild LUTS (IPSS ≤7) and 3.2% had severe LUTS (IPSS >19). Men with any, ISUP grade ≥2 or advanced cancer had lower median IPSS compared to men with benign biopsy (any cancer: 4 (IQR 2-9); ISUP grade ≥2: 4 (2-8); advanced cancer: 4 (2-8); benign biopsy: 6 (3-11); p < 0.05). IPSS was not associated with increased risk of cancer in multivariate analyses (OR (any cancer) 0.97; 95% CI 0.96-0.98; OR (ISUP grade ≥2) 0.97; 95% CI 0.96-0.99; OR (advanced cancer) 0.99; 95% CI 0.99-1.01).Conclusions: Three-quarters of men aged 50-69 years report no or mild LUTS. Our data do not support any clinically meaningful association between LUTS and prostate cancer. Specifically, men with advanced prostate cancer did not exhibit more urinary symptoms than men without cancer.

Patient Expectations of Full-Body CT Screening

OBJECTIVE

Despite limited scientific evidence about its risks and benefits, full-body CT screening is available to self-referred individuals. The purpose of this study was to develop a scientific knowledge base about patient expectations of the procedure and to determine whether characteristics of patients influence their expectations of its health benefits.

MATERIALS AND METHODS

Facilities from six diverse, geographically representative U.S. regions performing full-body CT screening were used as the study sites. A pretest only descriptive survey design was used to study 94 patient volunteers scheduled to undergo full-body CT screening. Descriptive statistics were used in examining information about the demographics, health, and knowledge characteristics of the patients. The chi-square test for independence and Spearman's correlation coefficient for ranked data were used to analyze associations among patient characteristics and responses to expectation statements. An alpha value of 0.05 was the level of significance.

RESULTS

Survey participants were 35-65 years old, predominantly white, married, and health conscious with income and educational levels several times above the national averages. The patients' highest expectations related to consumer empowerment and their lowest expectations related to the limitations of the procedure. The five patient characteristics found to have significant associations with patient expectations were patient sex; referral method; level of personal health concern; number of other health screening procedures patient had undergone; and patients' self-estimations of their current health status.

CONCLUSION

This study provided quantitative and descriptive data that are consistent with and add to the existing, primarily anecdotal, knowledge base about patients' expectations of full-body CT screening. These findings can be used to educate patients before they provide informed consent for the procedure.

Lower urinary tract symptoms and risk of prostate cancer in Japanese men

Our aim was to investigate whether or not men with lower urinary tract symptoms are at increased risk of prostate cancer. A total of 3511 men aged 50-79 years who underwent mass screening for prostate cancer between 2002 and 2004 for the first time, and completed the International Prostate Symptom Score (IPSS) questionnaire at the time of the prostate specific antigen (PSA) test, were enrolled in the present study. All men with PSA values greater than 4.0 ng/mL were advised and encouraged to undergo transrectal systematic sextant biopsy. The number of cancers subsequently detected was compared between men with IPSS scores of 0-7 and 8-35. Of the 3511 men, 219 (6.2%) had PSA values greater than 4 ng/mL, 178 (5.1%) underwent biopsy, and 51 (1.5%) were found to have prostate cancer. Although the PSA positivity rate for men with IPSS scores of 8-35 was significantly higher than that in the 0-7 group, there were no significant intergroup differences in the cancer detection rates for biopsied men and for total screened subjects. Multivariate logistic regression analysis revealed that prostate volume was the dominant predictor for the detection of prostate cancer, followed by PSA level, but the IPSS made no significant contribution. No significant difference was noted in the IPSS scores between men with cancer and the others of the same age group. Symptomatic Japanese men are not at higher risk of prostate cancer despite their higher PSA values compared with asymptomatic men of the same age group.

Does 'peer coaching' increase GP capacity to promote informed decision making about PSA screening? A cluster randomised trial

BACKGROUND

Very little effort has been directed to enable GPs to better informed decisions about PSA screening among their male patients.

OBJECTIVES

To evaluate an innovative programme designed to enhance GPs' capacity to promote informed decision making by male patients about PSA screening.

METHODS

The study design was a cluster randomised controlled trial set in New South Wales, Australia's most populous state. 277 GPs were recruited through a major pathology laboratory. The interventions were three telephone-administered 'peer coaching' sessions integrated with educational resources for GPs and patients and the main outcome measures were: GP knowledge; perceptions of patient involvement in informed decision making; GPs' own decisional conflict; and perceptions of medicolegal risk.

RESULTS

Compared with GPs allocated to the control group, GPs allocated to our intervention gained significantly greater knowledge about PSA screening and related information [Mean 6.1 out of 7; 95% confidence interval (CI) = 5.9-6.3 versus 4.8; 95% CI = 4.6-5.0; P < 0.001]. They were less likely to agree that patients should remain passive when making decisions about PSA screening [Odds ratio (OR) = 0.11; 95% CI = 0.04-0.31; P < 0.001]. They perceived less medicolegal risk when not acceding to an 'uninformed' patient request for a PSA test (OR = 0.31; 95% CI 0.19-0.51). They also demonstrated lower levels of personal decisional conflict about the PSA screening (Mean 25.4; 95% CI 24.5-26.3 versus 27.8; 95% CI 26.6-29.0; P = 0.0002).

CONCLUSION

A 'peer coaching' programme, supplemented by education materials, holds promise as a strategy to equip GPs to facilitate informed decision making amongst their patients.