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Zhang Z, Zhanghuang C, Wang J, Mi T, Liu J, Tian X, Jin L, He D. A Web-Based Prediction Model for Cancer-Specific Survival of Elderly Patients Undergoing Surgery With Prostate Cancer: A Population-Based Study. Front Public Health 2022; 10:935521. [PMID: 35903379 PMCID: PMC9314884 DOI: 10.3389/fpubh.2022.935521] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/20/2022] [Indexed: 12/29/2022] Open
Abstract
Objective Prostate cancer (PC) is the second leading cause of cancer death in men in the United States after lung cancer in global incidence. Elderly male patients over 65 years old account for more than 60% of PC patients, and the impact of surgical treatment on the prognosis of PC patients is controversial. Moreover, there are currently no predictive models that can predict the prognosis of elderly PC patients undergoing surgical treatment. Therefore, we aimed to construct a new nomogram to predict cancer-specific survival (CSS) in elderly PC patients undergoing surgical treatment. Methods Data for surgically treated PC patients aged 65 years and older were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate Cox regression models were used to identify independent risk factors for elderly PC patients undergoing surgical treatment. A nomogram of elderly PC patients undergoing surgical treatment was developed based on the multivariate Cox regression model. The consistency index (C-index), the area under the subject operating characteristic curve (AUC), and the calibration curve were used to test the accuracy and discrimination of the predictive model. Decision curve analysis (DCA) was used to examine the potential clinical value of this model. Results A total of 44,975 elderly PC patients undergoing surgery in 2010–2018 were randomly assigned to the training set (N = 31705) and validation set (N = 13270). the training set was used for nomogram development and the validation set was used for internal validation. Univariate and multivariate Cox regression model analysis showed that age, marriage, TNM stage, surgical style, chemotherapy, radiotherapy, Gleason score(GS), and prostate-specific antigen(PSA) were independent risk factors for CSS in elderly PC patients undergoing surgical treatment. The C index of the training set and validation indices are 0.911(95%CI: 0.899–0.923) and 0.913(95%CI: 0.893–0.933), respectively, indicating that the nomogram has a good discrimination ability. The AUC and the calibration curves also show good accuracy and discriminability. Conclusions To our knowledge, our nomogram is the first predictive model for elderly PC patients undergoing surgical treatment, filling the gap in current predictive models for this PC patient population. Our data comes from the SEER database, which is trustworthy and reliable. Moreover, our model has been internally validated in the validation set using the C-index,AUC and the and the calibration curve, showed that the model have good accuracy and reliability, which can help clinicians and patients make better clinical decision-making. Moreover, the DCA results show that our nomogram has a better potential clinical application value than the TNM staging system.
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Affiliation(s)
- Zhaoxia Zhang
- Department of Urology, Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Higher Institution Engineering Research Center of Children's Medical Big Data Intelligent Application, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Chenghao Zhanghuang
- Department of Urology, Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Higher Institution Engineering Research Center of Children's Medical Big Data Intelligent Application, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jinkui Wang
- Department of Urology, Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Higher Institution Engineering Research Center of Children's Medical Big Data Intelligent Application, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Tao Mi
- Department of Urology, Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Higher Institution Engineering Research Center of Children's Medical Big Data Intelligent Application, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jiayan Liu
- Department of Urology, Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Higher Institution Engineering Research Center of Children's Medical Big Data Intelligent Application, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaomao Tian
- Department of Urology, Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Higher Institution Engineering Research Center of Children's Medical Big Data Intelligent Application, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Liming Jin
- Department of Urology, Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Higher Institution Engineering Research Center of Children's Medical Big Data Intelligent Application, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Dawei He
- Department of Urology, Chongqing Key Laboratory of Children Urogenital Development and Tissue Engineering, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Higher Institution Engineering Research Center of Children's Medical Big Data Intelligent Application, Children's Hospital of Chongqing Medical University, Chongqing, China
- *Correspondence: Dawei He
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Mason BR, Eastham JA, Davis BJ, Mynderse LA, Pugh TJ, Lee RJ, Ippolito JE. Current Status of MRI and PET in the NCCN Guidelines for Prostate Cancer. J Natl Compr Canc Netw 2020; 17:506-513. [PMID: 31085758 DOI: 10.6004/jnccn.2019.7306] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/29/2019] [Indexed: 11/17/2022]
Abstract
Prostate cancer (PCa) represents a significant source of morbidity and mortality for men in the United States, with approximately 1 in 9 being diagnosed with PCa in their lifetime. The role of imaging in the evaluation of men with PCa has evolved and currently plays a central role in diagnosis, treatment planning, and evaluation of recurrence. Appropriate use of multiparametric MRI (mpMRI) and MRI-guided transrectal ultrasound (MR-TRUS) biopsy increases the detection of clinically significant PCa while decreasing the detection of clinically insignificant PCa. This process may help patients with clinically insignificant PCa avoid the adverse effects of unnecessary therapy. In the setting of a known PCa, patients with low-grade disease can be observed using active surveillance, which often includes a combination of prostate-specific antigen (PSA) testing, serial mpMRI, and, if indicated, follow-up systematic and targeted TRUS-guided tissue sampling. mpMRI can provide important information in the posttreatment setting, but PET/CT is creating a paradigm shift in imaging standards for patients with locally recurrent and metastatic PCa. This article examines the strengths and limitations of mpMRI for initial PCa diagnosis, active surveillance, recurrent disease evaluation, and image-guided biopsies, and the use of PET/CT imaging in men with recurrent PCa. The goal of this review is to provide a rational basis for current NCCN Clinical Practice Guidelines in Oncology for PCa as they pertain to the use of these advanced imaging modalities.
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Affiliation(s)
- Brandon R Mason
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - James A Eastham
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Thomas J Pugh
- Department of Radiation Oncology, University of Colorado, Denver, Colorado; and
| | - Richard J Lee
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Joseph E Ippolito
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
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Vernooij RW, Lancee M, Cleves A, Dahm P, Bangma CH, Aben KK. Radical prostatectomy versus deferred treatment for localised prostate cancer. Cochrane Database Syst Rev 2020; 6:CD006590. [PMID: 32495338 PMCID: PMC7270852 DOI: 10.1002/14651858.cd006590.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Prostate cancer is a common cancer but is oftentimes slow growing. When confined to the prostate, radical prostatectomy (RP), which involves removal of the prostate, offers potential cure that may come at the price of adverse events. Deferred treatment, involving observation and palliative treatment only (watchful waiting (WW)) or close monitoring and delayed local treatment with curative intent as needed in the setting of disease progression (active monitoring (AM)/surveillance (AS)) might be an alternative. This is an update of a Cochrane Review previously published in 2010. OBJECTIVES To assess effects of RP compared with deferred treatment for clinically localised prostate cancer. SEARCH METHODS We searched the Cochrane Library (including CDSR, CENTRAL, DARE, and HTA), MEDLINE, Embase, AMED, Web of Science, LILACS, Scopus, and OpenGrey. Additionally, we searched two trial registries and conference abstracts of three conferences (EAU, AUA, and ASCO) until 3 March 2020. SELECTION CRITERIA We included all randomised controlled trials (RCTs) that compared RP versus deferred treatment in patients with localised prostate cancer, defined as T1-2, N0, M0 prostate cancer. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility of references and extracted data from included studies. The primary outcome was time to death from any cause; secondary outcomes were: time to death from prostate cancer; time to disease progression; time to metastatic disease; quality of life, including urinary and sexual function; and adverse events. We assessed the certainty of evidence per outcome using the GRADE approach. MAIN RESULTS: We included four studies with 2635 participants (average age between 60 to 70 years). Three multicentre RCTs, from Europe and USA, compared RP with WW (n = 1537), and one compared RP with AM (n = 1098). Radical prostatectomy versus watchful waiting RP probably reduces the risk of death from any cause (hazard ratio (HR) 0.79, 95% confidence interval (CI) 0.70-0.90; 3 studies with 1537 participants; moderate-certainty evidence). Based on overall mortality at 29 years, this corresponds to 764 deaths per 1000 men in the RP group compared to 839 deaths per 1000 men in the WW group. RP probably also lowers the risk of death from prostate cancer (HR 0.57, 95% CI 0.44-0.73; 2 studies with 1426 participants; moderate-certainty evidence). Based on prostate cancer-specific mortality at 29 years, this corresponds to 195 deaths from prostate cancer per 1000 men in the RP group compared with 316 deaths from prostate cancer per 1000 men in the WW group. RP may reduce the risk of progression (HR 0.43, 95% CI 0.35-0.54; 2 studies with 1426 participants; I² = 54%; low-certainty evidence); at 19.5 years, this corresponds to 391 progressions per 1000 men for the RP group compared with 684 progressions per 1000 men for the WW group) and probably reduces the risk of developing metastatic disease (HR 0.56, 95% CI 0.46-0.70; 2 studies with 1426 participants; I² = 0%; moderate-certainty evidence); at 29 years, this corresponds to 271 metastatic diseases per 1000 men for RP compared with 431 metastatic diseases per 1000 men for WW. General quality of life at 12 years' follow-up is probably similar for both groups (risk ratio (RR) 1.0, 95% CI 0.85-1.16; low-certainty evidence), corresponding to 344 patients with high quality of life per 1000 men for the RP group compared with 344 patients with high quality of life per 1000 men for the WW group. Rates of urinary incontinence may be considerably higher (RR 3.97, 95% CI 2.34-6.74; low-certainty evidence), corresponding to 173 incontinent men per 1000 in the RP group compared with 44 incontinent men per 1000 in the WW group, as are rates of erectile dysfunction (RR 2.67, 95% CI 1.63-4.38; low-certainty evidence), corresponding to 389 erectile dysfunction events per 1000 for the RP group compared with 146 erectile dysfunction events per 1000 for the WW group, both at 10 years' follow-up. Radical prostatectomy versus active monitoring Based on one study including 1098 participants with 10 years' follow-up, there are probably no differences between RP and AM in time to death from any cause (HR 0.93, 95% CI 0.65-1.33; moderate-certainty evidence). Based on overall mortality at 10 years, this corresponds to 101 deaths per 1000 men in the RP group compared with 108 deaths per 1000 men in the AM group. Similarly, risk of death from prostate cancer probably is not different between the two groups (HR 0.63, 95% CI 0.21-1.89; moderate-certainty evidence). Based on prostate cancer-specific mortality at 10 years, this corresponds to nine prostate cancer deaths per 1000 men in the RP group compared with 15 prostate cancer deaths per 1000 men in the AM group. RP probably reduces the risk of progression (HR 0.39, 95% CI 0.27-0.56; moderate-certainty evidence; at 10 years, this corresponds to 86 progressions per 1000 men for RP compared with 206 progressions per 1000 men for AM) and the risk of developing metastatic disease (RR 0.39, 95% CI 0.21-0.73; moderate-certainty evidence; at 10 years, this corresponds to 24 metastatic diseases per 1000 men for the RP group compared with 61 metastatic diseases per 1000 men for the AM group).The general quality of life during follow-up was not different between the treatment groups. However, urinary function (mean difference (MD) 8.60 points lower, 95% CI 11.2-6.0 lower) and sexual function (MD 14.9 points lower, 95% CI 18.5-11.3 lower) on the Expanded Prostate Cancer Index Composite-26 (EPIC-26) instrument, were worse in the RP group. AUTHORS' CONCLUSIONS Based on long-term follow-up, RP compared with WW probably results in substantially improved oncological outcomes in men with localised prostate cancer but also markedly increases rates of urinary incontinence and erectile dysfunction. These findings are largely based on men diagnosed before widespread PSA screening, thereby limiting generalisability. Compared to AM, based on follow-up to 10 years, RP probably has similar outcomes with regard to overall and disease-specific survival yet probably reduces the risks of disease progression and metastatic disease. Urinary function and sexual function are probably decreased for the patients treated with RP.
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Affiliation(s)
- Robin Wm Vernooij
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands
| | - Michelle Lancee
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands
| | - Anne Cleves
- Velindre NHS Trust, Cardiff University Library Services, Cardiff, UK
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chris H Bangma
- Department of Urology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Katja Kh Aben
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands
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4
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Lange JM, Laviana AA, Penson DF, Lin DW, Bill-Axelson A, Carlsson SV, Newcomb LF, Trock BJ, Carter HB, Carroll PR, Cooperberg MR, Cowan JE, Klotz LH, Etzioni RB. Prostate cancer mortality and metastasis under different biopsy frequencies in North American active surveillance cohorts. Cancer 2020; 126:583-592. [PMID: 31639200 PMCID: PMC6980275 DOI: 10.1002/cncr.32557] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Active surveillance (AS) is an accepted means of managing low-risk prostate cancer. Because of the rarity of downstream events, data from existing AS cohorts cannot yet address how differences in surveillance intensity affect metastasis and mortality. This study projected the comparative benefits of different AS schedules in men diagnosed with prostate cancer who had Gleason score (GS) ≤6 disease and risk profiles similar to those in North American AS cohorts. METHODS Times of GS upgrading were simulated based on AS data from the University of Toronto, Johns Hopkins University, the University of California at San Francisco, and the Canary Pass Active Surveillance Cohort. Times to metastasis and prostate cancer death, informed by models from the Scandinavian Prostate Cancer Group 4 trial, were projected under biopsy surveillance schedules ranging from watchful waiting to annual biopsies. Outcomes included the risk of metastasis, the risk of death, remaining life-years (LYs), and quality-adjusted LYs. RESULTS Compared with watchful waiting, AS biopsies reduced the risk of prostate cancer metastasis and prostate cancer death at 20 years by 1.4% to 3.3% and 1.0% to 2.4%, respectively; and 5-year biopsies reduced the risk of metastasis and prostate cancer death by 1.0% to 2.4% and 0.6% to 1.6%, respectively. There was little difference between annual and 5-year biopsy schedules in terms of LYs (range of differences, 0.04-0.16 LYs) and quality-adjusted LYs (range of differences, -0.02 to 0.09 quality-adjusted LYs). CONCLUSIONS Among men diagnosed with GS ≤6 prostate cancer, obtaining a biopsy every 3 or 4 years appears to be an acceptable alternative to more frequent biopsies. Reducing surveillance intensity for those who have a low risk of progression reduces the number of biopsies while preserving the benefit of more frequent schedules.
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Affiliation(s)
- Jane M Lange
- Department of Biostatistics, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Aaron A Laviana
- Vanderbilt Center for Health Services Research, Vanderbilt University, Nashville, Tennessee
| | - David F Penson
- Department of Urologic Surgery, Vanderbilt University, Nashville, Tennessee
- Department of Health Policy, Vanderbilt University, Nashville, Tennessee
| | - Daniel W Lin
- Department of Urology, University of Washington, Seattle, Washington
| | - Anna Bill-Axelson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Sigrid V Carlsson
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
- Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Lisa F Newcomb
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Bruce J Trock
- Brady Urological Institute, Johns Hopkins University, Baltimore, Maryland
| | | | - Peter R Carroll
- Department of Urology, University of California at San Francisco, San Francisco, California
| | - Mathew R Cooperberg
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, San Francisco, California
| | - Janet E Cowan
- Mission Bay Library, University of California at San Francisco, San Francisco, California
| | - Laurence H Klotz
- Department of Urology, University of Toronto, Toronto, Ontario, Canada
| | - Ruth B Etzioni
- Department of Biostatistics, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Department of Health Services, University of Washington, Seattle, Washington
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5
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Belkora J, Chan JM, Cooperberg MR, Neuhaus J, Stupar L, Weinberg T, Broering JM, Tenggara I, Cowan JE, Rosenfeld S, Kenfield SA, Van Blarigan EL, Simko JP, Witte J, Carroll PR. Development and pilot evaluation of a personalized decision support intervention for low risk prostate cancer patients. Cancer Med 2019; 9:125-132. [PMID: 31714037 PMCID: PMC6943165 DOI: 10.1002/cam4.2685] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/10/2019] [Accepted: 10/17/2019] [Indexed: 11/16/2022] Open
Abstract
Objectives Development and pilot evaluation of a personalized decision support intervention to help men with early‐stage prostate cancer choose among active surveillance, surgery, and radiation. Methods We developed a decision aid featuring long‐term survival and side effects data, based on focus group input and stakeholder endorsement. We trained premedical students to administer the intervention to newly diagnosed men with low‐risk prostate cancer seen at the University of California, San Francisco. Before the intervention, and after the consultation with a urologist, we administered the Decision Quality Instrument for Prostate Cancer (DQI‐PC). We hypothesized increases in two knowledge items from the DQI‐PC: How many men diagnosed with early‐stage prostate cancer will eventually die of prostate cancer? How much would waiting 3 months to make a treatment decision affect chances of survival? Correct answers were: “Most will die of something else” and “A little or not at all.” Results The development phase involved 6 patients, 1 family member, 2 physicians, and 5 other health care providers. In our pilot test, 57 men consented, and 44 received the decision support intervention and completed knowledge surveys at both timepoints. Regarding the two knowledge items of interest, before the intervention, 35/56 (63%) answered both correctly, compared to 36/44 (82%) after the medical consultation (P = .04 by chi‐square test). Conclusions The intervention was associated with increased patient knowledge. Data from this pilot have guided the development of a larger scale randomized clinical trial to improve decision quality in men with prostate cancer being treated in community settings.
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Affiliation(s)
- Jeffrey Belkora
- Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| | - June M Chan
- Department of Urology, University of California, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Matthew R Cooperberg
- Department of Urology, University of California, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - John Neuhaus
- Department of Urology, University of California, San Francisco, CA, USA
| | - Lauren Stupar
- Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| | - Tia Weinberg
- Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| | | | - Imelda Tenggara
- Department of Urology, University of California, San Francisco, CA, USA
| | - Janet E Cowan
- Department of Urology, University of California, San Francisco, CA, USA
| | - Stan Rosenfeld
- Department of Urology, University of California, San Francisco, CA, USA
| | - Stacey A Kenfield
- Department of Urology, University of California, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Erin L Van Blarigan
- Department of Urology, University of California, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Jeffry P Simko
- Department of Urology, University of California, San Francisco, CA, USA.,Department of Pathology, University of California, San Francisco, CA, USA
| | - John Witte
- Department of Urology, University of California, San Francisco, CA, USA
| | - Peter R Carroll
- Department of Urology, University of California, San Francisco, CA, USA
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Galgano SJ, Glaser ZA, Porter KK, Rais-Bahrami S. Role of Prostate MRI in the Setting of Active Surveillance for Prostate Cancer. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1096:49-67. [DOI: 10.1007/978-3-319-99286-0_3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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7
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de Carvalho TM, Heijnsdijk EAM, de Koning HJ. Comparative effectiveness of prostate cancer screening between the ages of 55 and 69 years followed by active surveillance. Cancer 2017; 124:507-513. [PMID: 29231973 DOI: 10.1002/cncr.31141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 07/18/2017] [Accepted: 07/27/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND Because of the recent grade C draft recommendation by the US Preventive Services Task Force (USPSTF) for prostate cancer screening between the ages of 55 and 69 years, there is a need to determine whether this could be cost-effective in a US population setting. METHODS This study used a microsimulation model of screening and active surveillance (AS), based on data from the European Randomized Study of Screening for Prostate Cancer and the Surveillance, Epidemiology, and End Results Program, for the natural history of prostate cancer and Johns Hopkins AS cohort data to inform the probabilities of referral to treatment during AS. A cohort of 10 million men, based on US life tables, was simulated. The lifetime costs and effects of screening between the ages of 55 and 69 years with different screening frequencies and AS protocols were projected, and their cost-effectiveness was determined. RESULTS Quadrennial screening between the ages of 55 and 69 years (55, 59, 63, and 67 years) with AS for men with low-risk cancers (ie, those with a Gleason score of 6 or lower) and yearly biopsies or triennial biopsies resulted in an incremental cost per quality-adjusted life-year (QALY) of $51,918 or $69,380, respectively. Most policies in which screening was followed by immediate treatment were dominated. In most sensitivity analyses, this study found a policy with which the cost per QALY remained below $100,000. CONCLUSIONS Prostate-specific antigen-based prostate cancer screening in the United States between the ages of 55 and 69 years, as recommended by the USPSTF, may be cost-effective at a $100,000 threshold but only with a quadrennial screening frequency and with AS offered to all low-risk men. Cancer 2018;124:507-13. © 2017 American Cancer Society.
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Affiliation(s)
- Tiago M de Carvalho
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands.,Department of Applied Health Research, University College London, London, United Kingdom
| | | | - Harry J de Koning
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
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8
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de Carvalho TM, Heijnsdijk EAM, de Koning HJ. When should active surveillance for prostate cancer stop if no progression is detected? Prostate 2017; 77:962-969. [PMID: 28419541 DOI: 10.1002/pros.23352] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 03/14/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND A significant proportion of screen-detected men with prostate cancer may be overdiagnosed. Active Surveillance (AS) has emerged as a way to mitigate this problem, by delaying treatment of men, who are at low-risk until this becomes necessary. However, it is not known after how much time or biopsy rounds should patients stop AS and transition to conservative management (CM), if no progression is detected. METHODS We used a microsimulation model with natural history of prostate cancer based on ERSPC and SEER data. We modeled referral to treatment while in AS, based on Johns Hopkins treatment-free survival data. We projected lifetime costs and effects of AS (and radical treatment, if progression is detected) under different biopsy follow-up schedules compared to CM, where radical treatment only occurs when men would be clinically diagnosed in absence of screening. RESULTS For men with low-risk disease in younger age groups (55-65), AS is cost-effective for up to 7 yearly biopsy rounds. For men older than 65, even one biopsy round results in quality adjusted life years (QALYs) lost, though it may result in QALYs gained for men without previous screening. For men with intermediate-risk disease AS is cost-effective even for men in 65-75 age group. CONCLUSIONS The benefit of AS when compared to CM is strongly dependent on life expectancy and disease risk. Clinicians should take this into account when selecting men to AS, deciding on biopsy frequency and when to stop AS surveillance rounds and transition to CM.
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Affiliation(s)
- Tiago M de Carvalho
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Harry J de Koning
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
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Barrett T, Haider MA. The Emerging Role of MRI in Prostate Cancer Active Surveillance and Ongoing Challenges. AJR Am J Roentgenol 2017; 208:131-139. [PMID: 27726415 DOI: 10.2214/ajr.16.16355] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Active surveillance (AS) has emerged as a management strategy for preventing overtreatment of indolent prostate cancer. Selection of patients for AS has traditionally proved challenging and resulted in 20-30% misclassification rates. MRI has potential to help overcome this limitation, broaden selection criteria to increase recruitment, and minimize the invasive nature of AS follow-up. CONCLUSION The main issues surrounding MRI and AS are the heterogeneity of inclusion criteria, the definition of significant disease, and agreement about what constitutes radiologic progression. Prospective cohorts with MRI at enrollment and long-term follow-up are required to further address these issues.
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Affiliation(s)
- Tristan Barrett
- 1 Department of Radiology, Addenbrooke's Hospital and the University of Cambridge, Hills Rd, Cambridge, CB2 0QQ, UK
| | - Masoom A Haider
- 2 Department of Medical Imaging, Sunnybrook Health Sciences Center and University of Toronto, Toronto, ON, Canada
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10
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Leapman MS, Cowan JE, Simko J, Roberge G, Stohr BA, Carroll PR, Cooperberg MR. Application of a Prognostic Gleason Grade Grouping System to Assess Distant Prostate Cancer Outcomes. Eur Urol 2016; 71:750-759. [PMID: 27940155 DOI: 10.1016/j.eururo.2016.11.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 11/24/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is growing enthusiasm for the adoption of a novel grade grouping system to better represent Gleason scores. OBJECTIVE To evaluate the ability of prognostic Gleason grade groups to predict prostate cancer (PCa)-specific mortality (PCSM) and bone metastatic progression. DESIGN, SETTING, AND PARTICIPANTS We identified patients with PCa enrolled in the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) registry across treatment strategies, including conservative and nondefinitive therapy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We examined the prognostic ability of Gleason grade groups to predict risk of PCSM and bone metastasis using the Kaplan-Meier method and unadjusted and adjusted Cox proportional hazards models. RESULTS AND LIMITATIONS We identified 10529 men with PCa followed for a median of 81 mo (interquartile range 40-127), including 64% in group I (< 3 + 4); 17% in group II (3+4); 9% in group III (4+3); 6% in group IV (4+4); and 4% in group V (≥ 4 + 5). Relative to grade group I, the unadjusted risks of PCSM and bone metastasis were significantly associated with prognostic grade groupings for both biopsy and prostatectomy samples (all p<0.01). Pairwise comparisons within Gleason sums collapsed within grade group V were not significant; however, this analysis was limited by a small representation of men with Gleason pattern ≥ 4 + 5. CONCLUSIONS The prognostic grade grouping system is associated with risk of PCSM and metastasis across management strategies, including definitive therapy, conservative management, and primary androgen deprivation. PATIENT SUMMARY A five-level reporting system for prostate cancer pathology is associated with the risk of late prostate cancer endpoints.
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Affiliation(s)
- Michael S Leapman
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA; Department of Urology, Yale University School of Medicine, New Haven, CT, USA.
| | - Janet E Cowan
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Jeffry Simko
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA; Department of Pathology, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Gray Roberge
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Bradley A Stohr
- Department of Pathology, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Peter R Carroll
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Matthew R Cooperberg
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
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11
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Whitson JM, Murray KS, Thrasher JB. Prostate Biopsy is Associated with an Increased Risk of Erectile Dysfunction. J Urol 2016; 196:21-3. [DOI: 10.1016/j.juro.2016.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Jared M. Whitson
- Urologic Oncology, Kaiser Permanente South Sacramento Medical Center, Sacramento, California
| | - Katie S. Murray
- Department of Urology, Kansas University Medical Center, Kansas City, Kansas
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12
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PTEN loss and chromosome 8 alterations in Gleason grade 3 prostate cancer cores predicts the presence of un-sampled grade 4 tumor: implications for active surveillance. Mod Pathol 2016; 29:764-71. [PMID: 27080984 PMCID: PMC4925272 DOI: 10.1038/modpathol.2016.63] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 02/17/2016] [Accepted: 02/23/2016] [Indexed: 12/11/2022]
Abstract
Men who enter active surveillance because their biopsy exhibits only Gleason grade 3 (G3) frequently have higher grade tumor missed by biopsy. Thus, biomarkers are needed that, when measured on G3 tissue, can predict the presence of higher grade tumor in the whole prostate. We evaluated whether PTEN loss, chromosome 8q gain (MYC) and/or 8p loss (LPL) measured only on G3 cores is associated with un-sampled G4 tumor. A tissue microarray was constructed of prostatectomy tissue from patients whose prostates exhibited only Gleason score 3+3, only 3+4 or only 4+3 tumor (n=50 per group). Cores sampled only from areas of G3 were evaluated for PTEN loss by immunohistochemistry, and PTEN deletion, LPL/8p loss and MYC/8q gain by fluorescence in situ hybridization. Biomarker results were compared between Gleason score 6 vs 7 tumors using conditional logistic regression. PTEN protein loss, odds ratio=4.99, P=0.033; MYC/8q gain, odds ratio=5.36, P=0.010; and LPL/8p loss, odds ratio=3.96, P=0.003 were significantly more common in G3 cores derived from Gleason 7 vs Gleason 6 tumors. PTEN gene deletion was not statistically significant. Associations were stronger comparing Gleason 4+3 vs 6 than for Gleason 3+4 vs 6. MYC/8q gain, LPL/8p loss and PTEN protein loss measured in G3 tissue microarray cores strongly differentiate whether the core comes from a Gleason 6 or Gleason 7 tumor. If validated to predict upgrading from G3 biopsy to prostatectomy these biomarkers could reduce the likelihood of enrolling high-risk men and facilitate safe patient selection for active surveillance.
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13
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de Carvalho TM, Heijnsdijk EAM, de Koning HJ. Estimating the risks and benefits of active surveillance protocols for prostate cancer: a microsimulation study. BJU Int 2016; 119:560-566. [PMID: 27222299 DOI: 10.1111/bju.13542] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To estimate the increase in prostate cancer mortality (PCM) and the reduction in overtreatment resulting from different active surveillance (AS) protocols, compared with treating men immediately. PATIENTS AND METHODS We used a microsimulation model (MISCAN-Prostate), with the natural history of prostate cancer based on European Randomized Study of Screening for Prostate Cancer data. We estimated the probabilities of referral to radical treatment while on AS, depending on disease stage, using data from the Johns Hopkins AS cohort. We sampled 10 million men, representative of the US population, and projected the effects of applying AS protocols that differed by time between biopsies and compared these with the effects of treating men immediately. RESULTS We found that AS with yearly follow-up biopsies for men with low-risk prostate cancer (≤ T2a stage and Gleason 6) increases the probability of PCM to 2.6% (1% increase) and reduces overtreatment from 2.5 to 2.1% (18.4% reduction). With biopsies every 3 years after the first year, PCM increases by 2.3% and overtreatment reduces from 2.5 to 1.9% (30.3% reduction). The inclusion of men in the intermediate-risk group (> T2a stage or Gleason 3+4) in AS protocols increases PCM by 2.7% and reduces overtreatment from 2.5 to 2.0% (23.1% reduction). These results may not apply to African-American men. CONCLUSIONS Offering AS to men with low-risk prostate cancer is relatively safe. Increasing the biopsy interval from yearly to up to every 3 years after the first year will significantly reduce overtreatment among men in the low-risk group, with limited PCM risk.
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Affiliation(s)
- Tiago M de Carvalho
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eveline A M Heijnsdijk
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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14
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Gandaglia G, Bray F, Cooperberg MR, Karnes RJ, Leveridge MJ, Moretti K, Murphy DG, Penson DF, Miller DC. Prostate Cancer Registries: Current Status and Future Directions. Eur Urol 2016; 69:998-1012. [PMID: 26056070 DOI: 10.1016/j.eururo.2015.05.046] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 05/26/2015] [Indexed: 01/08/2023]
Abstract
CONTEXT Disease-specific registries that enroll a considerable number of patients play a major role in prostate cancer (PCa) research. OBJECTIVE To evaluate available registries, describe their strengths and limitations, and discuss the potential future role of PCa registries in outcomes research. EVIDENCE ACQUISITION We performed a literature review of the Medline, Embase, and Web of Science databases. The search strategy included the terms prostate cancer, outcomes, statistical approaches, population-based cohorts, registries of outcomes, and epidemiological studies, alone or in combination. We limited our search to studies published between January 2005 and January 2015. EVIDENCE SYNTHESIS Several population-based and prospective disease-specific registries are currently available for prostate cancer. Studies performed using these data sources provide important information on incidence and mortality, disease characteristics at presentation, risk factors, trends in utilization of health care services, disparities in access to treatment, quality of care, long-term oncologic and health-related quality of life outcomes, and costs associated with management of the disease. Although data from these registries have some limitations, statistical methods are available that can address certain biases and increase the internal and external validity of such analyses. In the future, improvements in data quality, collection of tissue samples, and the availability of data feedback to health care providers will increase the relevance of studies built on population-based and disease-specific registries. CONCLUSIONS The strengths and limitations of PCa registries should be carefully considered when planning studies using these databases. Although randomized controlled trials still provide the highest level of evidence, large registries play an important and growing role in advancing PCa research and care. PATIENT SUMMARY Several population-based and prospective disease-specific registries for prostate cancer are currently available. Analyses of data from these registries yield information that is clinically relevant for the management of patients with prostate cancer.
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Affiliation(s)
- Giorgio Gandaglia
- Unit of Urology/Department of Oncology, San Raffaele Hospital, Milan, Italy.
| | - Freddie Bray
- Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
| | - Matthew R Cooperberg
- Departments of Urology and Epidemiology & Biostatistics, Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | | | | | - Kim Moretti
- South Australian Prostate Cancer Clinical Outcomes Collaborative, Repatriation General Hospital, Daw Park, and the University of South Australia and the University of Adelaide, South Australia, Australia
| | - Declan G Murphy
- Division of Cancer Surgery, University of Melbourne, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - David F Penson
- Department of Urologic Surgery, Vanderbilt University, and the VA Tennessee Valley Geriatric Research, Education, and Clinical Center (GRECC), Nashville, TN, USA
| | - David C Miller
- Division of Urologic Oncology, Department of Urology, University of Michigan, Ann Arbor, MI, USA
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15
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Hefermehl LJ, Disteldorf D, Lehmann K. Acknowledging unreported problems with active surveillance for prostate cancer: a prospective single-centre observational study. BMJ Open 2016; 6:e010191. [PMID: 26888730 PMCID: PMC4762090 DOI: 10.1136/bmjopen-2015-010191] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To report outcomes of patients with localised prostate cancer (PCa) managed with active surveillance (AS) in a standard clinical setting. DESIGN Single-centre, prospective, observational study. SETTING Non-academic, average-size hospital in Switzerland. PARTICIPANTS Prospective, observational study at a non-academic, average-size hospital in Switzerland. Inclusion and progression criteria meet general recommendations. 157 patients at a median age of 67 (61-70) years were included from December 1999 to March 2012. Follow-up (FU) ended June 2013. RESULTS Median FU was 48 (30-84) months. Overall confirmed reclassification rate was 20% (32/157). 20 men underwent radical prostatectomy with 1 recurrence, 11 had radiation therapy with 2 prostate-specific antigen relapses, and 1 required primary hormone ablation with a fatal outcome. Kaplan-Meier estimates for those remaining in the study showed an overall survival of 92%, cancer-specific survival of 99% and reclassification rate of 41%. Dropout rate was 36% and occurred at a median of 48 (21-81) months after inclusion. 68 (43%) men are still under AS. CONCLUSIONS Careful administration of AS can and will yield excellent results in long-term management of PCa, and also helps physicians and patients alike to balance quality of life and mortality. Our data revealed significant dropout from FU. Patient non-compliance can be a relevant problem in AS.
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Affiliation(s)
- Lukas J Hefermehl
- Division of Urology, Department of Surgery, Kantonsspital Baden, Baden, Switzerland
| | - Daniel Disteldorf
- Division of Urology, Department of Surgery, Kantonsspital Baden, Baden, Switzerland
| | - Kurt Lehmann
- Division of Urology, Department of Surgery, Kantonsspital Baden, Baden, Switzerland
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16
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Albala D, Kemeter MJ, Febbo PG, Lu R, John V, Stoy D, Denes B, McCall M, Shindel AW, Dubeck F. Health Economic Impact and Prospective Clinical Utility of Oncotype DX® Genomic Prostate Score. Rev Urol 2016; 18:123-132. [PMID: 27833462 PMCID: PMC5102928 DOI: 10.3909/riu0725] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Prostate cancer (CaP) will be diagnosed in approximately 181,000 American men in 2016. Despite the high number of deaths from CaP in the United States, the disease has a protracted natural history and many men diagnosed with CaP will not die of the disease regardless of treatment. Unfortunately, identification of men with truly indolent/ nonaggressive CaP is challenging; limitations of conventional diagnostic modalities diminish the ability of physicians to accurately stage every case of CaP based on biopsy results alone. The resulting uncertainty in prognosis may prompt men with low-risk CaP to proceed to morbid and expensive treatments for an unclear survival benefit. Incorporation of the Genomic Prostate Score (GPS) as part of the decision algorithm for patients with National Comprehensive Cancer Network very low-risk and low-risk cancer led to a substantial increase in uptake of active surveillance and substantial cost savings. GPS provides physicians and patients with an additional tool in assessing personalized risk and helps guide individual decision making.
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Affiliation(s)
- David Albala
- Associated Medical Professionals of NY, PLLC Syracuse, NY
| | | | | | | | - Vincy John
- Excellus BlueCross BlueShield Rochester, NY
| | - Dylan Stoy
- Associated Medical Professionals of NY, PLLC Syracuse, NY
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17
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Jo JK, Lee HS, Lee YI, Lee SE, Hong SK. Analysis of expanded criteria to select candidates for active surveillance of low-risk prostate cancer. Asian J Androl 2015; 17:248-52. [PMID: 25432498 PMCID: PMC4650476 DOI: 10.4103/1008-682x.142136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We aimed to analyze the value of each criterion for clinically insignificant prostate cancer (PCa) in the selection of men for active surveillance (AS) of low-risk PCa. We identified 532 men who were treated with radical prostatectomy from 2006 to 2013 who met 4 or all 5 of the criteria for clinically insignificant PCa (clinical stage ≤ T1, prostate specific antigen [PSA] density ≤ 0.15, biopsy Gleason score ≤ 6, number of positive biopsy cores ≤ 2, and no core with > 50% involvement) and analyzed their pathologic and biochemical outcomes. Patients who met all 5 criteria for clinically insignificant PCa were designated as group A (n = 172), and those who met 4 of 5 criteria were designated as group B (n = 360). The association of each criterion with adverse pathologic features was assessed via logistic regression analyses. Comparison of group A and B and also logistic regression analyses showed that PSA density > 0.15 ng ml−1 and high (≥7) biopsy Gleason score were associated with adverse pathologic features. Higher (> T1c) clinical stage was not associated with any adverse pathologic features. Although ≤ 3 positive cores were not associated with any adverse pathology, ≥4 positive cores were associated with higher risk of extracapsular extension. Among potential candidates for AS, PSA density > 0.15 ng ml−1 and biopsy Gleason score > 6 pose significantly higher risks of harboring more aggressive disease. The eligibility criteria for AS may be expanded to include men with clinical stage T2 tumor and 3 positive cores.
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Affiliation(s)
| | | | | | | | - Sung Kyu Hong
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Korea
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18
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Adeniran AJ, Humphrey PA. Morphologic Updates in Prostate Pathology. Surg Pathol Clin 2015; 8:539-60. [PMID: 26612214 DOI: 10.1016/j.path.2015.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In the past several years, modifications have been made to the original Gleason system with resultant therapeutic and prognostic implications. Several morphologic variants of prostatic adenocarcinoma have also been described. Prostate pathology has also evolved over the years with the discovery and utility of new immunohistochemical stains. The topics discussed in this update include the Gleason grading system, prognostic grade grouping, variants of prostatic adenocarcinoma, and the application of immunohistochemistry to prostate pathology.
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Affiliation(s)
- Adebowale J Adeniran
- Department of Pathology, Yale University School of Medicine, 310 Cedar Street, LH 108, New Haven, CT 06520, USA.
| | - Peter A Humphrey
- Department of Pathology, Yale University School of Medicine, 310 Cedar Street, LH 108, New Haven, CT 06520, USA
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19
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Eggener SE, Badani K, Barocas DA, Barrisford GW, Cheng JS, Chin AI, Corcoran A, Epstein JI, George AK, Gupta GN, Hayn MH, Kauffman EC, Lane B, Liss MA, Mirza M, Morgan TM, Moses K, Nepple KG, Preston MA, Rais-Bahrami S, Resnick MJ, Siddiqui MM, Silberstein J, Singer EA, Sonn GA, Sprenkle P, Stratton KL, Taylor J, Tomaszewski J, Tollefson M, Vickers A, White WM, Lowrance WT. Gleason 6 Prostate Cancer: Translating Biology into Population Health. J Urol 2015; 194:626-34. [PMID: 25849602 PMCID: PMC4551510 DOI: 10.1016/j.juro.2015.01.126] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Gleason 6 (3+3) is the most commonly diagnosed prostate cancer among men with prostate specific antigen screening, the most histologically well differentiated and is associated with the most favorable prognosis. Despite its prevalence, considerable debate exists regarding the genetic features, clinical significance, natural history, metastatic potential and optimal management. MATERIALS AND METHODS Members of the Young Urologic Oncologists in the Society of Urologic Oncology cooperated in a comprehensive search of the peer reviewed English medical literature on Gleason 6 prostate cancer, specifically focusing on the history of the Gleason scoring system, histological features, clinical characteristics, practice patterns and outcomes. RESULTS The Gleason scoring system was devised in the early 1960s, widely adopted by 1987 and revised in 2005 with a more restrictive definition of Gleason 6 disease. There is near consensus that Gleason 6 meets pathological definitions of cancer, but controversy about whether it meets commonly accepted molecular and genetic criteria of cancer. Multiple clinical series suggest that the metastatic potential of contemporary Gleason 6 disease is negligible but not zero. Population based studies in the U.S. suggest that more than 90% of men newly diagnosed with prostate cancer undergo treatment and are exposed to the risk of morbidity for a cancer unlikely to cause symptoms or decrease life expectancy. Efforts have been proposed to minimize the number of men diagnosed with or treated for Gleason 6 prostate cancer. These include modifications to prostate specific antigen based screening strategies such as targeting high risk populations, decreasing the frequency of screening, recommending screening cessation, incorporating remaining life expectancy estimates, using shared decision making and novel biomarkers, and eliminating prostate specific antigen screening entirely. Large nonrandomized and randomized studies have shown that active surveillance is an effective management strategy for men with Gleason 6 disease. Active surveillance dramatically reduces the number of men undergoing treatment without apparent compromise of cancer related outcomes. CONCLUSIONS The definition and clinical relevance of Gleason 6 prostate cancer have changed substantially since its introduction nearly 50 years ago. A high proportion of screen detected cancers are Gleason 6 and the metastatic potential is negligible. Dramatically reducing the diagnosis and treatment of Gleason 6 disease is likely to have a favorable impact on the net benefit of prostate cancer screening.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - William T. Lowrance
- Correspondence: Department of Surgery, Division of Urology, Huntsman Cancer Institute, University of Utah, 1950 Circle of Hope, #6405, Salt Lake City, Utah 84112 (telephone: 801-587-4282; FAX: 801-585-3749; )
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20
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Cantiello F, Russo GI, Cicione A, Ferro M, Cimino S, Favilla V, Perdonà S, De Cobelli O, Magno C, Morgia G, Damiano R. PHI and PCA3 improve the prognostic performance of PRIAS and Epstein criteria in predicting insignificant prostate cancer in men eligible for active surveillance. World J Urol 2015; 34:485-93. [PMID: 26194612 DOI: 10.1007/s00345-015-1643-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 07/11/2015] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To assess the performance of prostate health index (PHI) and prostate cancer antigen 3 (PCA3) when added to the PRIAS or Epstein criteria in predicting the presence of pathologically insignificant prostate cancer (IPCa) in patients who underwent radical prostatectomy (RP) but eligible for active surveillance (AS). METHODS An observational retrospective study was performed in 188 PCa patients treated with laparoscopic or robot-assisted RP but eligible for AS according to Epstein or PRIAS criteria. Blood and urinary specimens were collected before initial prostate biopsy for PHI and PCA3 measurements. Multivariate logistic regression analyses and decision curve analysis were carried out to identify predictors of IPCa using the updated ERSPC definition. RESULTS At the multivariate analyses, the inclusion of both PCA3 and PHI significantly increased the accuracy of the Epstein multivariate model in predicting IPCa with an increase of 17 % (AUC = 0.77) and of 32 % (AUC = 0.92), respectively. The inclusion of both PCA3 and PHI also increased the predictive accuracy of the PRIAS multivariate model with an increase of 29 % (AUC = 0.87) and of 39 % (AUC = 0.97), respectively. DCA revealed that the multivariable models with the addition of PHI or PCA3 showed a greater net benefit and performed better than the reference models. In a direct comparison, PHI outperformed PCA3 performance resulting in higher net benefit. CONCLUSIONS In a same cohort of patients eligible for AS, the addition of PHI and PCA3 to Epstein or PRIAS models improved their prognostic performance. PHI resulted in greater net benefit in predicting IPCa compared to PCA3.
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Affiliation(s)
- Francesco Cantiello
- Urology Unit, Doctorate Research Program, Magna Græcia University of Catanzaro, Viale Europa, Germaneto, Catanzaro, 88100, Italy.
| | - Giorgio Ivan Russo
- Urology Section, Department of Surgery, University of Catania, Catania, Italy
| | - Antonio Cicione
- Urology Unit, Doctorate Research Program, Magna Græcia University of Catanzaro, Viale Europa, Germaneto, Catanzaro, 88100, Italy
| | - Matteo Ferro
- Department of Urology, European Institute of Oncology, Milan, Italy
| | - Sebastiano Cimino
- Urology Section, Department of Surgery, University of Catania, Catania, Italy
| | - Vincenzo Favilla
- Urology Section, Department of Surgery, University of Catania, Catania, Italy
| | - Sisto Perdonà
- Department of Urology, National Cancer Institute of Naples, Naples, Italy
| | | | - Carlo Magno
- Department of Urology, University of Messina, Messina, Italy
| | - Giuseppe Morgia
- Urology Section, Department of Surgery, University of Catania, Catania, Italy
| | - Rocco Damiano
- Urology Unit, Doctorate Research Program, Magna Græcia University of Catanzaro, Viale Europa, Germaneto, Catanzaro, 88100, Italy
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Abstract
Since the dissemination of prostate-specific antigen screening, most men with prostate cancer are now diagnosed with localized, low-risk prostate cancer that is unlikely to be lethal. Nevertheless, nearly all of these men undergo primary treatment with surgery or radiation, placing them at risk for longstanding side effects, including erectile dysfunction and impaired urinary function. Active surveillance and other observational strategies (ie, expectant management) have produced excellent long-term disease-specific survival and minimal morbidity for men with prostate cancer. Despite this, expectant management remains underused for men with localized prostate cancer. In this review, various approaches to the expectant management of men with prostate cancer are summarized, including watchful waiting and active surveillance strategies. Contemporary cancer-specific and health care quality-of-life outcomes are described for each of these approaches. Finally, contemporary patterns of use, potential disparities in care, and ongoing research and controversies surrounding expectant management of men with localized prostate cancer are discussed.
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Affiliation(s)
- Christopher P Filson
- Health Services Research Fellow, Department of Urology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA
| | - Leonard S Marks
- Professor of Urology, Department of Urology, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA
| | - Mark S Litwin
- Chair and Professor of Urology, Department of Urology, David Geffen School of Medicine at UCLA; Professor of Health Services, Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA
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22
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Singanamalli A, Rusu M, Sparks RE, Shih NNC, Ziober A, Wang LP, Tomaszewski J, Rosen M, Feldman M, Madabhushi A. Identifying in vivo DCE MRI markers associated with microvessel architecture and gleason grades of prostate cancer. J Magn Reson Imaging 2015; 43:149-58. [PMID: 26110513 DOI: 10.1002/jmri.24975] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 05/29/2015] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND To identify computer extracted in vivo dynamic contrast enhanced (DCE) MRI markers associated with quantitative histomorphometric (QH) characteristics of microvessels and Gleason scores (GS) in prostate cancer. METHODS This study considered retrospective data from 23 biopsy confirmed prostate cancer patients who underwent 3 Tesla multiparametric MRI before radical prostatectomy (RP). Representative slices from RP specimens were stained with vascular marker CD31. Tumor extent was mapped from RP sections onto DCE MRI using nonlinear registration methods. Seventy-seven microvessel QH features and 18 DCE MRI kinetic features were extracted and evaluated for their ability to distinguish low from intermediate and high GS. The effect of temporal sampling on kinetic features was assessed and correlations between those robust to temporal resolution and microvessel features discriminative of GS were examined. RESULTS A total of 12 microvessel architectural features were discriminative of low and intermediate/high grade tumors with area under the receiver operating characteristic curve (AUC) > 0.7. These features were most highly correlated with mean washout gradient (WG) (max rho = -0.62). Independent analysis revealed WG to be moderately robust to temporal resolution (intraclass correlation coefficient [ICC] = 0.63) and WG variance, which was poorly correlated with microvessel features, to be predictive of low grade tumors (AUC = 0.77). Enhancement ratio was the most robust (ICC = 0.96) and discriminative (AUC = 0.78) kinetic feature but was moderately correlated with microvessel features (max rho = -0.52). CONCLUSION Computer extracted features of prostate DCE MRI appear to be correlated with microvessel architecture and may be discriminative of low versus intermediate and high GS.
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Affiliation(s)
- Asha Singanamalli
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mirabela Rusu
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Rachel E Sparks
- Centre for Medical Image Computing, University College of London, London, United Kingdom
| | - Natalie N C Shih
- Department of Pathology & Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amy Ziober
- Department of Pathology & Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Li-Ping Wang
- Department of Pathology & Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Tomaszewski
- Department of Pathology & Anatomical Sciences, University of Buffalo, Buffalo, New York, USA
| | - Mark Rosen
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Feldman
- Department of Pathology & Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anant Madabhushi
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
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Reis LDO, Carter HB. The Mind: Focal Cryotherapy in Low-Risk Prostate Cancer: Are We Treating the Cancer or the Mind? Int Braz J Urol 2015; 41:10-4. [PMID: 25928505 DOI: 10.1590/s1677-5538.ibju.2015.01.03] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Leonardo de Oliveira Reis
- Department of Urology, Johns Hopkins Hospital, Baltimore, MD, USA.,Faculty of Medicine (Urology) Center for Life Sciences, Pontifical Catholic University of Campinas(PUC-Campinas) Campinas, SP, Brazil.,Department of Surgery, Division of Urology, School of Medical Sciences, University of Campinas, UNICAMP, Campinas, SP, Brazil
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Ross AE, Yousefi K, Davicioni E, Ghadessi M, Johnson MH, Sundi D, Tosoian JJ, Han M, Humphreys EB, Partin AW, Walsh PC, Trock BJ, Schaeffer EM. Utility of Risk Models in Decision Making After Radical Prostatectomy: Lessons from a Natural History Cohort of Intermediate- and High-Risk Men. Eur Urol 2015; 69:496-504. [PMID: 25922274 DOI: 10.1016/j.eururo.2015.04.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 04/13/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Current guidelines suggest adjuvant radiation therapy for men with adverse pathologic features (APFs) at radical prostatectomy (RP). We examine at-risk men treated only with RP until the time of metastasis. OBJECTIVE To evaluate whether clinicopathologic risk models can help guide postoperative therapeutic decision making. DESIGN, SETTING, AND PARTICIPANTS Men with National Comprehensive Cancer Network intermediate- or high-risk localized prostate cancer undergoing RP in the prostate-specific antigen (PSA) era were identified (n=3089). Only men with initial undetectable PSA after surgery and who received no therapy prior to metastasis were included. APFs were defined as pT3 disease or positive surgical margins. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Area under the receiver operating characteristic curve (AUC) for time to event data was used to measure the discrimination performance of the risk factors. Cumulative incidence curves were constructed using Fine and Gray competing risks analysis to estimate the risk of biochemical recurrence (BCR) or metastasis, taking censoring and death due to other causes into consideration. RESULTS AND LIMITATIONS Overall, 43% of the cohort (n=1327) had APFs at RP. Median follow-up for censored patients was 5 yr. Cumulative incidence of metastasis was 6% at 10 yr after RP for all patients. Cumulative incidence of metastasis among men with APFs was 7.5% at 10 yr after RP. Among men with BCR, the incidence of metastasis was 38% 5 yr after BCR. At 10 yr after RP, time-dependent AUC for predicting metastasis by Cancer of the Prostate Risk Assessment Postsurgical or Eggener risk models was 0.81 (95% confidence interval [CI], 0.72-0.97) and 0.78 (95% CI, 0.67-0.97) in the APF population, respectively. At 5 yr after BCR, these values were lower (0.58 [95% CI, 0.50-0.66] and 0.70 [95% CI, 0.63-0.76]) among those who developed BCR. Use of risk model cut points could substantially reduce overtreatment while minimally increasing undertreatment (ie, use of an Eggener cut point of 2.5% for treatment of men with APFs would spare 46% from treatment while only allowing for metastatic events in 1% at 10 yr after RP). CONCLUSIONS Use of risk models reduces overtreatment and should be a routine part of patient counseling when considering adjuvant therapy. Risk model performance is significantly reduced among men with BCR. PATIENT SUMMARY Use of current risk models can help guide decision making regarding therapy after surgery and reduce overtreatment.
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Affiliation(s)
- Ashley E Ross
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | | | | | | | - Michael H Johnson
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Debasish Sundi
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Jeffery J Tosoian
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Misop Han
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Elizabeth B Humphreys
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Alan W Partin
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Patrick C Walsh
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Bruce J Trock
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Edward M Schaeffer
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Basu A, Gore JL. Are Elderly Patients With Clinically Localized Prostate Cancer Overtreated? Exploring Heterogeneity in Survival Effects. Med Care 2015; 53:79-86. [PMID: 25397964 PMCID: PMC5845767 DOI: 10.1097/mlr.0000000000000260] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Clinical trial evidence shows minimal survival gains and higher complication rates from radical prostatectomy (RP) versus watchful waiting (WW) for elderly men with localized prostate cancer (PCa). It is believed that these patients are overtreated. The current analyses aim to explore patient-level heterogeneity in survival effects, examine matching of patients to treatments in practice, and identify patient characteristics driving heterogenous effects, in order to present more comprehensive evidence about the concerns of overtreatment. METHODS Eleven-year all-cause and PCa-specific survival among SEER-Medicare patients diagnosed during 1996-2002 were analyzed using local instrumental variable approaches. RESULTS A total of 8462 (77%) of 11,036 patients received RP. The average effects of RP over WW on 11-year overall and cancer-specific survival were 1.1 months (95%CI, -25, 28; P=0.94) and 1.7 months (95%CI, -25, 29; P=0.90) respectively; effects did not differ significantly according to age, race, grade, and stage. Fewer than 1% of patients had significant cancer-specific survival benefit from RP at the 10% level; 6% were expected to gain over 15 months from RP. However, patients with larger expected survival gains from RP were much more likely to receive RP in practice. Such positive self-selection was driven by PCa-specific survival than overall survival. Several comorbidities may play a critical role in predicting who could benefit from RP. CONCLUSIONS Our analyses corroborate concerns about PCa overtreatment. A small fraction of screen-detected PCa patients derive survival benefits from RP. Prediction tools should account for patient comorbidities to accurately predict survival benefits of RP over WW.
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Affiliation(s)
- Anirban Basu
- Department of Health Services, University of Washington, Seattle 1959 NE Pacific St, Box-357660, Seattle WA 98195
| | - John L. Gore
- Department of Urology, University of Washington, Seattle 1959 NE Pacific St, Box-356510, Seattle WA 98195, Tel: 206 221-6430, Fax: (206) 543-3964,
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27
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Reis LDO, Carter HB. The Mind: Focal Cryotherapy in Low-Risk Prostate Cancer: Are We Treating the Cancer or the Mind? Int Braz J Urol 2015. [PMID: 25928505 PMCID: PMC4752051 DOI: 10.1590/s1677-5538.ibju.2015.01.0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Leonardo de Oliveira Reis
- Department of Urology, Johns Hopkins Hospital, Baltimore, MD, USA;,Professor of Urology, Faculty of Medicine (Urology) Center for Life Sciences, Pontifical Catholic University of Campinas (PUC-Campinas) Campinas, SP, Brazil;,Department of Surgery, Division of Urology, School of Medical Sciences, University of Campinas, UNICAMP, Campinas, SP, Brazil
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Matthew Andrews J, Ashfield JE, Morse M, Whelan TF. Five-year follow-up of active surveillance for prostate cancer: A Canadian community-based urological experience. Can Urol Assoc J 2014; 8:E768-74. [PMID: 25485002 DOI: 10.5489/cuaj.2186] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTON We assessed oncological outcomes of active surveillance (AS) using a community database and identified factors associated with disease reclassification on surveillance biopsy. METHODS A retrospective review was performed on 200 men on AS. Prostate-specific antigen (PSA) was measured every 3 to 6 months. Prostate biopsies were performed every 1 to 4 years, and at the individual physician's discretion. Disease reclassification was defined as clinical T1 to cT2 progression, or histologically as >2 cores positive, Gleason score >6, or >50% core involvement on surveillance biopsy. Multivariate Cox regression analysis evaluated factors associated with disease reclassification. Kaplan-Meier survival curves were plotted. RESULTS We assessed a heterogeneous cohort of 86 patients, with a median age 67.2 years, who received ≥1 surveillance biopsies. The median follow-up was 5.2 years. The median times to first and second surveillance biopsies were 730 and 763 days, respectively. Overall, 47% of patients were reclassified on surveillance biopsy after a median 2.1 years. Factors associated with disease reclassification were PSA density >0.20 (p < 0.0001, hazard ratio [HR] 4.55, 95% confidence interval [CI] 2.116-9.782) and ≥3 positive cores (p = 0.0152, HR 3.956, 95% CI 1.304-12.003) at diagnosis, and number of positive cores on surveillance biopsy. In total, 25 (29%) patients received delayed intervention, with a median time to intervention of 2.6 years. The median time on AS was 4.4 years, with an overall survival of 95% and prostate-specific survival of 100%. CONCLUSIONS Our community study supports AS to reduce over-treatment of prostate cancer. PSA density >0.20 and ≥3 cores positive are associated with disease reclassification on surveillance biopsy.
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Affiliation(s)
| | | | - Michael Morse
- Department of Urology, Dalhousie University, Saint John, NB
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29
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Consensus statement with recommendations on active surveillance inclusion criteria and definition of progression in men with localized prostate cancer: the critical role of the pathologist. Virchows Arch 2014; 465:623-8. [DOI: 10.1007/s00428-014-1668-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
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30
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Amin MB, Lin DW, Gore JL, Srigley JR, Samaratunga H, Egevad L, Rubin M, Nacey J, Carter HB, Klotz L, Sandler H, Zietman AL, Holden S, Montironi R, Humphrey PA, Evans AJ, Epstein JI, Delahunt B, McKenney JK, Berney D, Wheeler TM, Chinnaiyan AM, True L, Knudsen B, Hammond MEH. The critical role of the pathologist in determining eligibility for active surveillance as a management option in patients with prostate cancer: consensus statement with recommendations supported by the College of American Pathologists, International Society of Urological Pathology, Association of Directors of Anatomic and Surgical Pathology, the New Zealand Society of Pathologists, and the Prostate Cancer Foundation. Arch Pathol Lab Med 2014; 138:1387-405. [PMID: 25092589 DOI: 10.5858/arpa.2014-0219-sa] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
CONTEXT Prostate cancer remains a significant public health problem. Recent publications of randomized trials and the US Preventive Services Task Force recommendations have drawn attention to overtreatment of localized, low-risk prostate cancer. Active surveillance, in which patients undergo regular visits with serum prostate-specific antigen tests and repeat prostate biopsies, rather than aggressive treatment with curative intent, may address overtreatment of low-risk prostate cancer. It is apparent that a greater awareness of the critical role of pathologists in determining eligibility for active surveillance is needed. OBJECTIVES To review the state of current knowledge about the role of active surveillance in the management of prostate cancer and to provide a multidisciplinary report focusing on pathologic parameters important to the successful identification of patients likely to succeed with active surveillance, to determine the role of molecular tests in increasing the safety of active surveillance, and to provide future directions. DESIGN Systematic review of literature on active surveillance for low-risk prostate cancer, pathologic parameters important for appropriate stratification, and issues regarding interobserver reproducibility. Expert panels were created to delineate the fundamental questions confronting the clinical and pathologic aspects of management of men on active surveillance. RESULTS Expert panelists identified pathologic parameters important for management and the related diagnostic and reporting issues. Consensus recommendations were generated where appropriate. CONCLUSIONS Active surveillance is an important management option for men with low-risk prostate cancer. Vital to this process is the critical role pathologic parameters have in identifying appropriate candidates for active surveillance. These findings need to be reproducible and consistently reported by surgical pathologists with accurate pathology reporting.
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Affiliation(s)
- Mahul B Amin
- From the Departments of Pathology and Laboratory Medicine (Drs Amin and Knudsen), Radiation Oncology (Dr Sandler), Urology (Dr Holden), and Biomedical Sciences (Dr Knudsen), Cedars-Sinai Medical Center, Los Angeles, California; the Departments of Urology (Drs Lin and Gore) and Pathology (Dr True), University of Washington, Seattle; Trillium Health Partners, Mississauga, Ontario, Canada, and McMaster University, Hamilton, Ontario, Canada (Dr Srigley); Aquesta Pathology, Toowong, Queensland, Australia, and the University of Queensland, Brisbane (Dr Samaratunga); the Department of Oncology and Pathology, Karolinska Institutet, Karolinska University Hospital, Solna, Stockholm, Sweden (Dr Egevad); the Institute for Precision Medicine and the Department of Pathology and Laboratory Medicine, Weill Medical College of Cornell University, Ithaca, New York, and New York-Presbyterian Hospital, New York (Dr Rubin); the Departments of Surgery (Dr Nacey) and Pathology and Molecular Medicine (Dr Delahunt), Wellington School of Medicine and Health Sciences, University of Otago, Newtown, Wellington, New Zealand; the James Buchanan Brady Urological Institute (Dr Carter) and the Departments of Pathology (Dr Epstein), Urology (Dr Epstein), and Oncology (Dr Epstein), Johns Hopkins School of Medicine, Baltimore, Maryland; Division of Urology, the Sunnybrook Health Sciences Centre (Dr Klotz) and the University Health Network (Dr Evans), University of Toronto, Toronto, Ontario, Canada; the Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston (Dr Zietman); the Section of Pathological Anatomy, Department of Biomedical Sciences and Public Health, Polytechnic University of the Marche Region, Ancona, Italy (Dr Montironi); the Department of Pathology, Yale University School of Medicine, New Haven, Connecticut (Dr Humphrey); the Pathology and Laboratory Medicine Institute, Cleveland Clinic Foundation, Cleveland, Ohio (Dr McKenney); the Department of Cell
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Welty CJ, Cowan JE, Nguyen H, Shinohara K, Perez N, Greene KL, Chan JM, Meng MV, Simko JP, Cooperberg MR, Carroll PR. Extended followup and risk factors for disease reclassification in a large active surveillance cohort for localized prostate cancer. J Urol 2014; 193:807-11. [PMID: 25261803 DOI: 10.1016/j.juro.2014.09.094] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE Active surveillance to manage prostate cancer provides an alternative to immediate treatment in men with low risk prostate cancer. We report updated outcomes from a long-standing active surveillance cohort and factors associated with reclassification. MATERIALS AND METHODS We retrospectively reviewed data on all men enrolled in the active surveillance cohort at our institution with at least 6 months of followup between 1990 and 2013. Surveillance consisted of quarterly prostate specific antigen testing, repeat imaging with transrectal ultrasound at provider discretion and periodic repeat prostate biopsies. Factors associated with repeat biopsy reclassification and local treatment were determined by multivariate Cox proportional hazards regression. We also analyzed the association of prostate specific antigen density and outcomes stratified by prostate size. RESULTS A total of 810 men who consented to participate in the research cohort were followed on active surveillance for a median of 60 months. Of these men 556 (69%) met strict criteria for active surveillance. Five-year overall survival was 98%, treatment-free survival was 60% and biopsy reclassification-free survival was 40%. There were no prostate cancer related deaths. On multivariate analysis prostate specific antigen density was positively associated with the risk of biopsy reclassification and treatment while the number of biopsies and time between biopsies were inversely associated with the 2 outcomes (each p <0.01). When stratified by prostate volume, prostate specific antigen density remained significantly associated with biopsy reclassification for all strata but prostate specific antigen density was only significantly associated with treatment in men with a smaller prostate. CONCLUSIONS Significant prostate cancer related morbidity and mortality remained rare at intermediate followup. Prostate specific antigen density was independently associated with biopsy reclassification and treatment while on active surveillance.
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Affiliation(s)
- Christopher J Welty
- Department of Urology, University of California-San Francisco Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, California.
| | - Janet E Cowan
- Department of Urology, University of California-San Francisco Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, California
| | - Hao Nguyen
- Department of Urology, University of California-San Francisco Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, California
| | - Katsuto Shinohara
- Department of Urology, University of California-San Francisco Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, California
| | - Nannette Perez
- Department of Urology, University of California-San Francisco Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, California
| | - Kirsten L Greene
- Department of Urology, University of California-San Francisco Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, California
| | - June M Chan
- Department of Urology, University of California-San Francisco Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, California
| | - Maxwell V Meng
- Department of Urology, University of California-San Francisco Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, California
| | - Jeffry P Simko
- Department of Urology, University of California-San Francisco Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, California
| | - Matthew R Cooperberg
- Department of Urology, University of California-San Francisco Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, California
| | - Peter R Carroll
- Department of Urology, University of California-San Francisco Helen Diller Family Comprehensive Cancer Center, University of California-San Francisco, San Francisco, California
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Welty CJ, Cooperberg MR, Carroll PR. Meaningful end points and outcomes in men on active surveillance for early-stage prostate cancer. Curr Opin Urol 2014; 24:288-92. [PMID: 24614347 PMCID: PMC6586410 DOI: 10.1097/mou.0000000000000039] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE OF REVIEW Active surveillance is a management strategy for early-stage prostate cancer designed to balance early detection of aggressive disease and overtreatment of indolent disease. We evaluate recently reported outcomes and discuss the potentially most important endpoints for such an approach. RECENT FINDINGS The past 2 years have seen the publication of two trials of watchful waiting versus immediate treatment and updates of multiple active surveillance cohorts for men with early-stage prostate cancer. The watchful waiting trials demonstrated a small potential mortality benefit to immediate treatment when applied to all risk levels (6% absolute difference at 15 years), emphasizing the importance of a risk-adapted strategy. In reported active surveillance cohorts, prostate cancer death and metastasis remain rare events. Intermediate outcomes such as progression to treatment and upgrading/upstaging on final disease appear consistent among cohorts, but must be interpreted with caution when compared with historical controls of immediate treatment because of potential selection bias. SUMMARY The safety of active surveillance has been reinforced by recent reports. Accumulation of additional data on men with intermediate risk cancer and development and validation of new biomarkers of risk will allow refined and, likely, expanded use of this approach.
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Affiliation(s)
- Christopher J Welty
- Department of Urology and Hellen Diller Cancer Center, University of California, San Francisco, California, USA
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33
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Koerber F, Waidelich R, Stollenwerk B, Rogowski W. The cost-utility of open prostatectomy compared with active surveillance in early localised prostate cancer. BMC Health Serv Res 2014; 14:163. [PMID: 24721557 PMCID: PMC4022451 DOI: 10.1186/1472-6963-14-163] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Accepted: 03/25/2014] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND There is an on-going debate about whether to perform surgery on early stage localised prostate cancer and risk the common long term side effects such as urinary incontinence and erectile dysfunction. Alternatively these patients could be closely monitored and treated only in case of disease progression (active surveillance). The aim of this paper is to develop a decision-analytic model comparing the cost-utility of active surveillance (AS) and radical prostatectomy (PE) for a cohort of 65 year old men with newly diagnosed low risk prostate cancer. METHODS A Markov model comparing PE and AS over a lifetime horizon was programmed in TreeAge from a German societal perspective. Comparative disease specific mortality was obtained from the Scandinavian Prostate Cancer Group trial. Direct costs were identified via national treatment guidelines and expert interviews covering in-patient, out-patient, medication, aids and remedies as well as out of pocket payments. Utility values were used as factor weights for age specific quality of life values of the German population. Uncertainty was assessed deterministically and probabilistically. RESULTS With quality adjustment, AS was the dominant strategy compared with initial treatment. In the base case, it was associated with an additional 0.04 quality adjusted life years (7.60 QALYs vs. 7.56 QALYs) and a cost reduction of €6,883 per patient (2011 prices). Considering only life-years gained, PE was more effective with an incremental cost-effectiveness ratio of €96,420/life year gained. Sensitivity analysis showed that the probability of developing metastases under AS and utility weights under AS are a major sources of uncertainty. A Monte Carlo simulation revealed that AS was more likely to be cost-effective even under very high willingness to pay thresholds. CONCLUSION AS is likely to be a cost-saving treatment strategy for some patients with early stage localised prostate cancer. However, cost-effectiveness is dependent on patients' valuation of health states. Better predictability of tumour progression and modified reimbursement practice would support widespread use of AS in the context of the German health care system. More research is necessary in order to reliably quantify the health benefits compared with initial treatment and account for patient preferences.
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Affiliation(s)
- Florian Koerber
- Institute for Health Economics and Health Care Management, Helmholtz Zentrum Munich, German Research Center for Environmental Health (GmbH), Ingolstädter Landstrasse 1, 85764 Neuherberg, Germany
| | - Raphaela Waidelich
- Department of Urology, University of Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Björn Stollenwerk
- Institute for Health Economics and Health Care Management, Helmholtz Zentrum Munich, German Research Center for Environmental Health (GmbH), Ingolstädter Landstrasse 1, 85764 Neuherberg, Germany
| | - Wolf Rogowski
- Institute for Health Economics and Health Care Management, Helmholtz Zentrum Munich, German Research Center for Environmental Health (GmbH), Ingolstädter Landstrasse 1, 85764 Neuherberg, Germany
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University of Munich, Ziemssenstraße 1, 80336 Munich, Germany
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Haffner MC, De Marzo AM, Yegnasubramanian S, Epstein JI, Carter HB. Diagnostic challenges of clonal heterogeneity in prostate cancer. J Clin Oncol 2014; 33:e38-40. [PMID: 24638011 DOI: 10.1200/jco.2013.50.3540] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Michael C Haffner
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Angelo M De Marzo
- Sidney Kimmel Comprehensive Cancer Center; and Brady Urological Institute, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Jonathan I Epstein
- Sidney Kimmel Comprehensive Cancer Center; and Brady Urological Institute, Johns Hopkins School of Medicine, Baltimore, MD
| | - H Ballentine Carter
- Sidney Kimmel Comprehensive Cancer Center; and Brady Urological Institute, Johns Hopkins School of Medicine, Baltimore, MD
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35
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Welty CJ, Carroll PR. The ongoing need for improved risk stratification and monitoring for those on active surveillance for early stage prostate cancer. Eur Urol 2014; 65:1032-3. [PMID: 24636678 DOI: 10.1016/j.eururo.2014.02.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 02/17/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Christopher J Welty
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA.
| | - Peter R Carroll
- Department of Urology, University of California, San Francisco, San Francisco, CA, USA
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Pataky R, Gulati R, Etzioni R, Black P, Chi KN, Coldman AJ, Pickles T, Tyldesley S, Peacock S. Is prostate cancer screening cost-effective? A microsimulation model of prostate-specific antigen-based screening for British Columbia, Canada. Int J Cancer 2014; 135:939-47. [PMID: 24443367 DOI: 10.1002/ijc.28732] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 12/30/2013] [Indexed: 11/06/2022]
Abstract
Prostate-specific antigen (PSA) screening for prostate cancer may reduce mortality, but it incurs considerable risk of over diagnosis and potential harm to quality of life. Our objective was to evaluate the cost-effectiveness of PSA screening, with and without adjustment for quality of life, for the British Columbia (BC) population. We adapted an existing natural history model using BC incidence, treatment, cost and mortality patterns. The modeled mortality benefit of screening derives from a stage-shift mechanism, assuming mortality reduction consistent with the European Study of Randomized Screening for Prostate Cancer. The model projected outcomes for 40-year-old men under 14 combinations of screening ages and frequencies. Cost and utility estimates were explored with deterministic sensitivity analysis. The incremental cost-effectiveness of regular screening ranged from $36,300/LYG, for screening every four years from ages 55 to 69 years, to $588,300/LYG, for screening every two years from ages 40 to 74 years. The marginal benefits of increasing screening frequency to 2 years or starting screening at age 40 years were small and came at significant cost. After utility adjustment, all screening strategies resulted in a loss of quality-adjusted life years (QALYs); however, this result was very sensitive to utility estimates. Plausible outcomes under a range of screening strategies inform discussion of prostate cancer screening policy in BC and similar jurisdictions. Screening may be cost-effective, but the sensitivity of results to utility values suggests individual preferences for quality versus quantity of life should be a key consideration.
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Affiliation(s)
- Reka Pataky
- Cancer Control Research, BC Cancer Agency, Vancouver, BC, Canada; Canadian Centre for Applied Research in Cancer Control, Vancouver, BC, Canada
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Overdiagnosis and overtreatment of prostate cancer. Eur Urol 2014; 65:1046-55. [PMID: 24439788 DOI: 10.1016/j.eururo.2013.12.062] [Citation(s) in RCA: 630] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 12/27/2013] [Indexed: 12/16/2022]
Abstract
CONTEXT Although prostate cancer (PCa) screening reduces the incidence of advanced disease and mortality, trade-offs include overdiagnosis and resultant overtreatment. OBJECTIVE To review primary data on PCa overdiagnosis and overtreatment. EVIDENCE ACQUISITION Electronic searches were conducted in Cochrane Central Register of Controlled Trials, PubMed, and Embase from inception to July 2013 for original articles on PCa overdiagnosis and overtreatment. Supplemental articles were identified through hand searches. EVIDENCE SYNTHESIS The lead-time and excess-incidence approaches are the main ways used to estimate overdiagnosis in epidemiological studies, with estimates varying widely. The estimated number of PCa cases needed to be diagnosed to save a life has ranged from 48 down to 5 with increasing follow-up. In clinical studies, generally lower rates of overdiagnosis have been reported based on the frequency of low-grade minimal tumors at radical prostatectomy (1.7-46.8%). Autopsy studies have reported PCa in 18.5-38.5%, although not all are low grade or low volume. Factors influencing overdiagnosis include the study population, screening protocol, and background incidence, limiting generalizability between settings. Reported rates of overtreatment vary widely in the literature, although contemporary international studies suggest increasing use of conservative management. CONCLUSIONS Epidemiological, clinical, and autopsy studies have been used to examine PCa overdiagnosis, with estimates ranging widely from 1.7% to 67%. Correspondingly, estimates of overtreatment vary widely based on patient features and may be declining internationally. Careful patient selection for screening and reducing overtreatment are important to preserve the benefits and reduce the downstream harms of prostate-specific antigen testing. Because all of these estimates are extremely population and context specific, this must be considered when using these data to inform policy. PATIENT SUMMARY Screening reduces spread and death from prostate cancer (PCa) but overdiagnoses some low-risk tumors that may not have caused harm. Because treatment has potential side effects, it is critical that not all patients with PCa receive aggressive treatment.
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Salomon L, Bastide C, Beuzeboc P, Cormier L, Fromont G, Hennequin C, Mongiat-Artus P, Peyromaure M, Ploussard G, Renard-Penna R, Rozet F, Azria D, Coloby P, Molinié V, Ravery V, Rebillard X, Richaud P, Villers A, Soulié M. Recommandations en onco-urologie 2013 du CCAFU : Cancer de la prostate. Prog Urol 2013; 23 Suppl 2:S69-101. [DOI: 10.1016/s1166-7087(13)70048-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Abstract
PURPOSE OF REVIEW To give insight into recent literature (during the past 12-18 months) reporting on oncologic outcomes of men on active surveillance. RECENT FINDINGS From recent published trials comparing radical prostatectomy vs. watchful waiting, we learn that radical treatment only benefits a small proportion of men and that a substantial part of men is overtreated. Therefore, active surveillance should aim at postponing treatment for most, but still generate the same disease-specific mortality as radical prostatectomy by treating only those who benefit. In this review some recent published data on prostate cancer-specific mortality under active surveillance as well as intermediate outcomes are described. SUMMARY Prostate cancer-specific mortality under active surveillance is very low; however, longer follow-up is warranted. When deferred radical treatment and immediate radical treatment are compared, results seem to be quite similar, suggesting that postponing treatment does not affect the outcomes of men under active surveillance. Furthermore, in the majority of men active treatment could be avoided completely, without compromising oncologic outcome.
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Bratt O, Carlsson S, Holmberg E, Holmberg L, Johansson E, Josefsson A, Nilsson A, Nyberg M, Robinsson D, Sandberg J, Sandblom D, Stattin P. The Study of Active Monitoring in Sweden (SAMS): a randomized study comparing two different follow-up schedules for active surveillance of low-risk prostate cancer. Scand J Urol 2013; 47:347-55. [PMID: 23883427 PMCID: PMC3810035 DOI: 10.3109/21681805.2013.813962] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Only a minority of patients with low-risk prostate cancer needs treatment, but the methods for optimal selection of patients for treatment are not established. This article describes the Study of Active Monitoring in Sweden (SAMS), which aims to improve those methods. MATERIAL AND METHODS SAMS is a prospective, multicentre study of active surveillance for low-risk prostate cancer. It consists of a randomized part comparing standard rebiopsy and follow-up with an extensive initial rebiopsy coupled with less intensive follow-up and no further scheduled biopsies (SAMS-FU), as well as an observational part (SAMS-ObsQoL). Quality of life is assessed with questionnaires and compared with patients receiving primary curative treatment. SAMS-FU is planned to randomize 500 patients and SAMS-ObsQoL to include at least 500 patients during 5 years. The primary endpoint is conversion to active treatment. The secondary endpoints include symptoms, distant metastases and mortality. All patients will be followed for 10-15 years. RESULTS Inclusion started in October 2011. In March 2013, 148 patients were included at 13 Swedish urological centres. CONCLUSIONS It is hoped that the results of SAMS will contribute to fewer patients with indolent, low-risk prostate cancer receiving unnecessary treatment and more patients on active surveillance who need treatment receiving it when the disease is still curable. The less intensive investigational follow-up in the SAMS-FU trial would reduce the healthcare resources allocated to this large group of patients if it replaced the present standard schedule.
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Affiliation(s)
- Ola Bratt
- Department of Urology, Helsingborg Hospital, Lund University , Sweden
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Hayes JH, Ollendorf DA, Pearson SD, Barry MJ, Kantoff PW, Lee PA, McMahon PM. Observation versus initial treatment for men with localized, low-risk prostate cancer: a cost-effectiveness analysis. Ann Intern Med 2013; 158:853-60. [PMID: 23778902 PMCID: PMC4487888 DOI: 10.7326/0003-4819-158-12-201306180-00002] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Observation is underutilized among men with localized, low-risk prostate cancer. OBJECTIVE To assess the costs and benefits of observation versus initial treatment. DESIGN Decision analysis simulating treatment or observation. DATA SOURCES Medicare schedules, published literature. TARGET POPULATION Men aged 65 and 75 years who had newly diagnosed low-risk prostate cancer (prostate-specific antigen level <10 µg/L, stage ≤T2a, Gleason score ≤3 + 3). TIME HORIZON Lifetime. PERSPECTIVE Societal. INTERVENTION Treatment (brachytherapy, intensity-modulated radiation therapy, or radical prostatectomy) or observation (active surveillance [AS] or watchful waiting [WW]). OUTCOME MEASURES Quality-adjusted life expectancy and costs. RESULTS OF BASE-CASE ANALYSIS Observation was more effective and less costly than initial treatment. Compared with AS, WW provided 2 additional months of quality-adjusted life expectancy (9.02 vs. 8.85 years) at a savings of $15,374 ($24,520 vs. $39,894) in men aged 65 years and 2 additional months (6.14 vs. 5.98 years) at a savings of $11,746 ($18,302 vs. $30,048) in men aged 75 years. Brachytherapy was the most effective and least expensive initial treatment. RESULTS OF SENSITIVITY ANALYSIS Treatment became more effective than observation when it led to more dramatic reductions in prostate cancer death (hazard ratio, 0.47 vs. WW and 0.64 vs. AS). Active surveillance became as effective as WW in men aged 65 years when the probability of progressing to treatment on AS decreased below 63% or when the quality of life with AS versus WW was 4% higher in men aged 65 years or 1% higher in men aged 75 years. Watchful waiting remained least expensive in all analyses. LIMITATION Results depend on outcomes reported in the published literature, which is limited. CONCLUSION Among these men, observation is more effective and costs less than initial treatment, and WW is most effective and least expensive under a wide range of clinical scenarios. PRIMARY FUNDING SOURCE National Cancer Institute, U.S. Department of Defense, Prostate Cancer Foundation, and Institute for Clinical and Economic Review.
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Affiliation(s)
- Julia H Hayes
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Institute for Clinical and Economic Review, Institute for Technology Assessment, Boston, MA 02115, USA.
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Ahmed HU. Multiparametric magnetic resonance imaging findings in men with low-risk prostate cancer followed using active surveillance. BJU Int 2013. [DOI: 10.1111/j.1464-410x.2012.11786.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Hashim U. Ahmed
- MRC Clinician Scientist and Clinical Lecturer in Urology; Division of Surgery and Interventional Science; University College London; London UK
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Age remains the major predictor of curative treatment non-receipt for localised prostate cancer: a population-based study. Br J Cancer 2013; 109:272-9. [PMID: 23722470 PMCID: PMC3708581 DOI: 10.1038/bjc.2013.268] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 05/01/2013] [Accepted: 05/10/2013] [Indexed: 11/25/2022] Open
Abstract
Background: Geriatric oncology guidelines state that fit older men with prostate cancer should receive curative treatment. In a population-based study, we investigated associations between age and non-receipt of curative treatment in men with localised prostate cancer, and the effect of clinical variables on this in different age groups. Methods: Clinically localised prostate cancers (T1–T2N0M0) diagnosed from 2002 to 2008 among men aged ⩾40 years, with hospital in-patient episode(s) within 1 year post-diagnosis, were included (n=5456). Clinical and socio-demographic variables were obtained from cancer registrations. Comorbidity was determined from hospital episode data. Logistic regression was used to investigate associations between age and non-receipt of treatment, adjusting for confounders; the outcome was non-receipt of curative treatment (radical prostatectomy or radiotherapy). Results: The percentage who did not receive curative treatment was 9.2%, 14.3%, 48.2% and 91.7% for men aged 40–59, 60–69, 70–79 and 80+ years, respectively. After adjusting for clinical and socio-demographic factors, age remained the main determinant of treatment non-receipt. Men aged 70–79 had a significant five-fold increased risk of not having curative treatment compared with men aged 60–69 (odds ratio (OR)=5.5; 95% confidence interval 4.7, 6.5). In age-stratified analyses, clinical factors had a higher weight for men aged 60–69 than in other age strata. Over time, non-receipt of curative treatment increased among men aged 40–59 and decreased among men aged 70–79. Conclusion: Age remains the dominant factor in determining non-receipt of curative treatment. There have been some changes in clinical practice over time, but whether these will impact on prostate cancer mortality remains to be established.
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Reese AC, Landis P, Han M, Epstein JI, Carter HB. Expanded criteria to identify men eligible for active surveillance of low risk prostate cancer at Johns Hopkins: a preliminary analysis. J Urol 2013; 190:2033-8. [PMID: 23680308 DOI: 10.1016/j.juro.2013.05.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE At our institution the eligibility criteria used to enroll patients in active surveillance are clinical stage T1, prostate specific antigen density less than 0.15 ng/ml, biopsy Gleason score 6 or less, 2 or fewer positive biopsy cores and 50% or less involvement of any biopsy core. We hypothesized that these criteria may be excessively strict, precluding many men from active surveillance. MATERIALS AND METHODS We studied pathological outcomes in men treated with radical prostatectomy between 1995 and 2012 who met 4 or more of the 5 active surveillance criteria. Outcomes included a definition of significant tumor (pathological Gleason 7 or greater, or nonorgan confined). We compared adverse pathology rates between men who met all 5 vs 4 of 5 active surveillance criteria. RESULTS Of 8,261 men 1,890 (22.9%) met all active surveillance eligibility criteria and 2,133 (25.8%) met 4. Men with values exceeding prostate specific antigen density and biopsy Gleason criteria were at increased risk for adverse pathological outcomes. Clinical stage greater than T1 was not associated with adverse pathological findings. The risk of significant tumors in men with clinical stage T2 lesions, 3 or fewer positive biopsy cores and less than 60% core involvement was comparable to that of men who met all active surveillance criteria. CONCLUSIONS Prostate specific antigen density greater than 0.15 ng/ml and biopsy Gleason score 7 or greater are strongly associated with adverse pathological findings at radical prostatectomy. Our findings suggest that active surveillance criteria should be expanded to include men with clinical stage T2 lesions and a greater number of positive biopsy cores of low grade. Based on these preliminary findings, we are in the process of reassessing active surveillance eligibility criteria using more detailed pathological analysis.
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Affiliation(s)
- Adam C Reese
- James Buchanan Brady Urological Institute, Johns Hopkins University, Baltimore, Maryland.
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Tosoian JJ, JohnBull E, Trock BJ, Landis P, Epstein JI, Partin AW, Walsh PC, Carter HB. Pathological outcomes in men with low risk and very low risk prostate cancer: implications on the practice of active surveillance. J Urol 2013; 190:1218-22. [PMID: 23643603 DOI: 10.1016/j.juro.2013.04.071] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2013] [Indexed: 02/06/2023]
Abstract
PURPOSE We assessed oncologic outcomes at surgery in men with low risk and very low risk prostate cancer who were candidates for active surveillance. MATERIALS AND METHODS In a prospectively collected institutional database, we identified 7,486 subjects eligible for active surveillance who underwent radical retropubic prostatectomy. Candidates were designated as being at low risk (stage T1c/T2a, prostate specific antigen 10 ng/ml or less, and Gleason score 6 or less) or very low risk (stage T1c, prostate specific antigen density 0.15 or less, Gleason score 6 or less, 2 or fewer positive biopsy cores, 50% or less cancer involvement per core) based on preoperative data. Adverse findings were Gleason score upgrade (score 7 or greater) and nonorgan confined cancer on surgical pathology. The relative risk of adverse findings in men at low risk with very low risk disease was evaluated in a multivariate model using Poisson regression. RESULTS A total of 7,333 subjects met the criteria for low risk disease and 153 had very low risk disease. The proportion of subjects at low risk found to have Gleason score upgrade or nonorgan confined cancer on final pathology was 21.8% and 23.1%, respectively. Corresponding values in those at very low risk were 13.1% and 8.5%, respectively. After adjusting for age, race, year of surgery, body mass index, and prostate specific antigen at diagnosis, the relative risk of Gleason score upgrade in men with low risk vs very low risk disease was 1.89 (95% CI 1.21-2.95). The relative risk of nonorgan confined cancer was 2.06 (95% CI 1.19-3.57). CONCLUSIONS Men with very low risk prostate cancer were at significantly lower risk for adverse findings at surgery compared to those with low risk disease. These data support the stratification of low risk cancer when selecting and counseling men who may be appropriate for active surveillance.
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Affiliation(s)
- Jeffrey J Tosoian
- Department of Urology, The Johns Hopkins University School of Medicine, The James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, Maryland
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van den Bergh RCN, Albertsen PC, Bangma CH, Freedland SJ, Graefen M, Vickers A, van der Poel HG. Timing of curative treatment for prostate cancer: a systematic review. Eur Urol 2013; 64:204-15. [PMID: 23453419 DOI: 10.1016/j.eururo.2013.02.024] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 02/12/2013] [Indexed: 10/27/2022]
Abstract
CONTEXT Delaying definitive therapy unfavourably affects outcomes in many malignancies. Diagnostic, psychological, and logistical reasons but also active surveillance (AS) strategies can lead to treatment delay, an increase in the interval between the diagnosis and treatment of prostate cancer (PCa). OBJECTIVE To review and summarise the current literature on the impact of treatment delay on PCa oncologic outcomes. EVIDENCE ACQUISITION A comprehensive search of PubMed and Embase databases until 30 September 2012 was performed. Studies comparing pathologic, biochemical recurrence (BCR), and mortality outcomes between patients receiving direct and delayed curative treatment were included. Studies presenting single-arm results following AS were excluded. EVIDENCE SYNTHESIS Seventeen studies were included: 13 on radical prostatectomy, 3 on radiation therapy, and 1 combined both. A total of 34 517 PCa patients receiving radical local therapy between 1981 and 2009 were described. Some studies included low-risk PCa only; others included a wider spectrum of disease. Four studies found a significant effect of treatment delay on outcomes in multivariate analysis. Two included low-risk patients only, but it was unknown whether AS was applied or repeat biopsy triggered active therapy during AS. The two other studies found a negative effect on BCR rates of 2.5-9 mo delay in higher risk patients (respectively defined as any with T ≥ 2b, prostate-specific antigen >10, Gleason score >6, >34-50% positive cores; or D'Amico intermediate risk-group). All studies were retrospective and nonrandomised. Reasons for delay were not always clear, and time-to-event analyses may be subject to bias. CONCLUSIONS Treatment delay of several months or even years does not appear to affect outcomes of men with low-risk PCa. Limited data suggest treatment delay may have an impact on men with non-low-risk PCa. Most AS protocols suggest a confirmatory biopsy to avoid delaying treatment in those who harbour higher risk disease that was initially misclassified.
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Affiliation(s)
- Roderick C N van den Bergh
- University Medical Centre Utrecht, Utrecht, The Netherlands; Netherlands Cancer Institute, Amsterdam, The Netherlands.
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Bellardita L, Rancati T, Alvisi MF, Villani D, Magnani T, Marenghi C, Nicolai N, Procopio G, Villa S, Salvioni R, Valdagni R. Predictors of health-related quality of life and adjustment to prostate cancer during active surveillance. Eur Urol 2013; 64:30-6. [PMID: 23357351 DOI: 10.1016/j.eururo.2013.01.009] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 01/07/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Active surveillance (AS) is emerging as an alternative approach to limit the risk of overtreatment and impairment of quality of life (QoL) in patients with low-risk localised prostate cancer. Although most patients report high levels of QoL, some men may be distressed by the idea of living with untreated cancer. OBJECTIVE To identify factors associated with poor QoL during AS. DESIGN, SETTING, AND PARTICIPANTS Between September 2007 and March 2012, 103 patients participated in the Prostate Cancer Research International Active Surveillance (PRIAS) QoL study. Mental health (Symptom Checklist-90), demographic, clinical, and decisional data were assessed at entrance in AS. Health-related QoL (HRQoL) Functional Assessment of Cancer Therapy-Prostate version and Mini-Mental Adjustment to Cancer outcomes were assessed after 10 mo of AS. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Multivariate logistic regression models were used to identify predictors of low (<25th percentile) HRQoL, adjustment to cancer, and a global QoL index at 10 mo after enrollment. RESULTS AND LIMITATIONS The mean age of the study patients was 67 yr (standard deviation: ±7 yr). Lack of partner (odds ratio [OR]: 0.08; p=0.009) and impaired mental health (OR: 1.2, p=0.1) were associated with low HRQoL (p=0.006; area under the curve [AUC]: 0.72). The maladaptive adjustment to cancer (p=0.047; AUC: 0.60) could be predicted by recent diagnosis (OR: 3.3; p=0.072). Poor global QoL (overall p=0.02; AUC: 0.85) was predicted by impaired mental health (OR: 1.16; p=0.070) and time from diagnosis to enrollment in AS <5 mo (OR: 5.52; p=0.009). Influence of different physicians on the choice of AS (OR: 0.17; p=0.044), presence of a partner (OR: 0.22; p=0.065), and diagnostic biopsy with >18 core specimens (OR: 0.89; p=0.029) were predictors of better QoL. Limitations of this study were the small sample size and the lack of a control group. CONCLUSIONS Factors predicting poor QoL were lack of a partner, impaired mental health, recent diagnosis, influence of clinicians and lower number of core samples taken at diagnostic biopsy. Educational support from physicians and emotional/social support should be promoted in some cases to prevent poor QoL.
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Affiliation(s)
- Lara Bellardita
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
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