Prostate cancer screening with prostate-specific antigen (PSA) test: a systematic review and meta-analysis

OBJECTIVE

To investigate the efficacy and safety of prostate-specific antigen (PSA) testing to screen for prostate cancer.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Electronic search of Cochrane Central Register of Controlled Trials, Web of Science, Embase, Scopus, OpenGrey, LILACS, and Medline, and search of scientific meeting abstracts and trial registers to April 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials comparing PSA screening with usual care in men without a diagnosis of prostate cancer.

DATA EXTRACTION

At least two reviewers screened studies, extracted data, and assessed the quality of eligible studies. A parallel guideline committee (BMJ Rapid Recommendation) provided input on the design and interpretation of the systematic review, including selection of outcomes important to patients. We used a random effects model to obtain pooled incidence rate ratios (IRR) and, when feasible, conducted subgroup analyses (defined a priori) based on age, frequency of screening, family history, ethnicity, and socioeconomic level, as well as a sensitivity analysis based on the risk of bias. The quality of the evidence was assessed with the GRADE approach.

RESULTS

Five randomised controlled trials, enrolling 721 718 men, were included. Studies varied with respect to screening frequency and intervals, PSA thresholds for biopsy, and risk of bias. When considering the whole body of evidence, screening probably has no effect on all-cause mortality (IRR 0.99, 95% CI 0.98 to 1.01; moderate certainty) and may have no effect on prostate-specific mortality (IRR 0.96, 0.85 to 1.08; low certainty). Sensitivity analysis of studies at lower risk of bias (n=1) also demonstrates that screening seems to have no effect on all-cause mortality (IRR 1.0, 0.98 to 1.02; moderate certainty) but may have a small effect on prostate-specific mortality (IRR 0.79, 0.69 to 0.91; moderate certainty). This corresponds to one less death from prostate cancer per 1000 men screened over 10 years. Direct comparative data on biopsy and treatment related complications from the included trials were limited. Using modelling, we estimated that for every 1000 men screened, approximately 1, 3, and 25 more men would be hospitalised for sepsis, require pads for urinary incontinence, and report erectile dysfunction, respectively.

CONCLUSIONS

At best, screening for prostate cancer leads to a small reduction in disease-specific mortality over 10 years but has does not affect overall mortality. Clinicians and patients considering PSA based screening need to weigh these benefits against the potential short and long term harms of screening, including complications from biopsies and subsequent treatment, as well as the risk of overdiagnosis and overtreatment.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42016042347.

Screening for prostate cancer

BACKGROUND

Any form of screening aims to reduce disease-specific and overall mortality, and to improve a person's future quality of life. Screening for prostate cancer has generated considerable debate within the medical and broader community, as demonstrated by the varying recommendations made by medical organizations and governed by national policies. To better inform individual patient decision-making and health policy decisions, we need to consider the entire body of data from randomised controlled trials (RCTs) on prostate cancer screening summarised in a systematic review. In 2006, our Cochrane review identified insufficient evidence to either support or refute the use of routine mass, selective, or opportunistic screening for prostate cancer. An update of the review in 2010 included three additional trials. Meta-analysis of the five studies included in the 2010 review concluded that screening did not significantly reduce prostate cancer-specific mortality. In the past two years, several updates to studies included in the 2010 review have been published thereby providing the rationale for this update of the 2010 systematic review.

OBJECTIVES

To determine whether screening for prostate cancer reduces prostate cancer-specific mortality or all-cause mortality and to assess its impact on quality of life and adverse events.

SEARCH METHODS

An updated search of electronic databases (PROSTATE register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CANCERLIT, and the NHS EED) was performed, in addition to handsearching of specific journals and bibliographies, in an effort to identify both published and unpublished trials.

SELECTION CRITERIA

All RCTs of screening versus no screening for prostate cancer were eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

The original search (2006) identified 99 potentially relevant articles that were selected for full-text review. From these citations, two RCTs were identified as meeting the inclusion criteria. The search for the 2010 version of the review identified a further 106 potentially relevant articles, from which three new RCTs were included in the review. A total of 31 articles were retrieved for full-text examination based on the updated search in 2012. Updated data on three studies were included in this review. Data from the trials were independently extracted by two authors.

MAIN RESULTS

Five RCTs with a total of 341,342 participants were included in this review. All involved prostate-specific antigen (PSA) testing, with or without digital rectal examination (DRE), though the interval and threshold for further evaluation varied across trials. The age of participants ranged from 45 to 80 years and duration of follow-up from 7 to 20 years. Our meta-analysis of the five included studies indicated no statistically significant difference in prostate cancer-specific mortality between men randomised to the screening and control groups (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.86 to 1.17). The methodological quality of three of the studies was assessed as posing a high risk of bias. The European Randomized Study of Screening for Prostate Cancer (ERSPC) and the US Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial were assessed as posing a low risk of bias, but provided contradicting results. The ERSPC study reported a significant reduction in prostate cancer-specific mortality (RR 0.84, 95% CI 0.73 to 0.95), whilst the PLCO study concluded no significant benefit (RR 1.15, 95% CI 0.86 to 1.54). The ERSPC was the only study of the five included in this review that reported a significant reduction in prostate cancer-specific mortality, in a pre-specified subgroup of men aged 55 to 69 years of age. Sensitivity analysis for overall risk of bias indicated no significant difference in prostate cancer-specific mortality when referring to the meta analysis of only the ERSPC and PLCO trial data (RR 0.96, 95% CI 0.70 to 1.30). Subgroup analyses indicated that prostate cancer-specific mortality was not affected by the age at which participants were screened. Meta-analysis of four studies investigating all-cause mortality did not determine any significant differences between men randomised to screening or control (RR 1.00, 95% CI 0.96 to 1.03). A diagnosis of prostate cancer was significantly greater in men randomised to screening compared to those randomised to control (RR 1.30, 95% CI 1.02 to 1.65). Localised prostate cancer was more commonly diagnosed in men randomised to screening (RR 1.79, 95% CI 1.19 to 2.70), whilst the proportion of men diagnosed with advanced prostate cancer was significantly lower in the screening group compared to the men serving as controls (RR 0.80, 95% CI 0.73 to 0.87). Screening resulted in a range of harms that can be considered minor to major in severity and duration. Common minor harms from screening include bleeding, bruising and short-term anxiety. Common major harms include overdiagnosis and overtreatment, including infection, blood loss requiring transfusion, pneumonia, erectile dysfunction, and incontinence. Harms of screening included false-positive results for the PSA test and overdiagnosis (up to 50% in the ERSPC study). Adverse events associated with transrectal ultrasound (TRUS)-guided biopsies included infection, bleeding and pain. No deaths were attributed to any biopsy procedure. None of the studies provided detailed assessment of the effect of screening on quality of life or provided a comprehensive assessment of resource utilization associated with screening (although preliminary analyses were reported).

AUTHORS' CONCLUSIONS

Prostate cancer screening did not significantly decrease prostate cancer-specific mortality in a combined meta-analysis of five RCTs. Only one study (ERSPC) reported a 21% significant reduction of prostate cancer-specific mortality in a pre-specified subgroup of men aged 55 to 69 years. Pooled data currently demonstrates no significant reduction in prostate cancer-specific and overall mortality. Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity. Overdiagnosis and overtreatment are common and are associated with treatment-related harms. Men should be informed of this and the demonstrated adverse effects when they are deciding whether or not to undertake screening for prostate cancer. Any reduction in prostate cancer-specific mortality may take up to 10 years to accrue; therefore, men who have a life expectancy less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial. No studies examined the independent role of screening by DRE.

Screening for prostate cancer: systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To examine the evidence on the benefits and harms of screening for prostate cancer.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Electronic databases including Medline, Embase, CENTRAL, abstract proceedings, and reference lists up to July 2010. Review methods Included studies were randomised controlled trials comparing screening by prostate specific antigen with or without digital rectal examination versus no screening. Data abstraction and assessment of methodological quality with the GRADE approach was assessed by two independent reviewers and verified by the primary investigator. Mantel-Haenszel and inverse variance estimates were calculated and pooled under a random effects model expressing data as relative risks and 95% confidence intervals.

RESULTS

Six randomised controlled trials with a total of 387 286 participants that met inclusion criteria were analysed. Screening was associated with an increased probability of receiving a diagnosis of prostate cancer (relative risk 1.46, 95% confidence interval 1.21 to 1.77; P<0.001) and stage I prostate cancer (1.95, 1.22 to 3.13; P=0.005). There was no significant effect of screening on death from prostate cancer (0.88, 0.71 to 1.09; P=0.25) or overall mortality (0.99, 0.97 to 1.01; P=0.44). All trials had one or more substantial methodological limitations. None provided data on the effects of screening on participants' quality of life. Little information was provided about potential harms associated with screening.

CONCLUSIONS

The existing evidence from randomised controlled trials does not support the routine use of screening for prostate cancer with prostate specific antigen with or without digital rectal examination.

Clinicopathologic predictors of sentinel lymph node metastasis in thin melanoma

PURPOSE

Indications for sentinel lymph node biopsy (SLNB) for thin melanoma are continually evolving. We present a large multi-institutional study to determine factors predictive of sentinel lymph node (SLN) metastasis in thin melanoma.

PATIENTS AND METHODS

Retrospective review of the Sentinel Lymph Node Working Group database from 1994 to 2012 identified 1,250 patients who had an SLNB and thin melanomas (≤ 1 mm). Clinicopathologic characteristics were correlated with SLN status and outcome.

RESULTS

SLN metastases were detected in 65 (5.2%) of 1,250 patients. On univariable analysis, rates of Breslow thickness ≥ 0.75 mm, Clark level ≥ IV, ulceration, and absence of regression differed significantly between positive and negative SLN groups (all P < .05). These four variables and mitotic rate were used in multivariable analysis, which demonstrated that Breslow thickness ≥ 0.75 mm (P = .03), Clark level ≥ IV (P = .05), and ulceration (P = .01) significantly predicted SLN metastasis with 6.3%, 7.0%, and 11.6% of the patients with these respective characteristics having SLN disease. Melanomas < 0.75 mm had positive SLN rates of < 5% regardless of Clark level and ulceration status. Median follow-up was 2.6 years. Melanoma-specific survival was significantly worse for patients with positive versus negative SLNs (P = .001).

CONCLUSION

Breslow thickness ≥ 0.75 mm, Clark level ≥ IV, and ulceration significantly predict SLN disease in thin melanoma. Most SLN metastases (86.2%) occur in melanomas ≥ 0.75 mm, with 6.3% of these patients having SLN disease, whereas in melanomas < 0.75 mm, SLN metastasis rates are < 5%. By using a 5% metastasis risk threshold, SLNB is indicated for melanomas ≥ 0.75 mm, but further study is needed to define indications for SLNB in melanomas < 0.75 mm.

Thinking Styles and Regret in Physicians

BACKGROUND

Decision-making relies on both analytical and emotional thinking. Cognitive reasoning styles (e.g. maximizing and satisficing tendencies) heavily influence analytical processes, while affective processes are often dependent on regret. The relationship between regret and cognitive reasoning styles has not been well studied in physicians, and is the focus of this paper.

METHODS

A regret questionnaire and 6 scales measuring individual differences in cognitive styles (maximizing-satisficing tendencies; analytical vs. intuitive reasoning; need for cognition; intolerance toward ambiguity; objectivism; and cognitive reflection) were administered through a web-based survey to physicians of the University of South Florida. Bonferroni's adjustment was applied to the overall correlation analysis. The correlation analysis was also performed without Bonferroni's correction, given the strong theoretical rationale indicating the need for a separate hypothesis. We also conducted a multivariate regression analysis to identify the unique influence of predictors on regret.

RESULTS

165 trainees and 56 attending physicians (age range 25 to 69) participated in the survey. After bivariate analysis we found that maximizing tendency positively correlated with regret with respect to both decision difficulty (r=0.673; p<0.001) and alternate search strategy (r=0.239; p=0.002). When Bonferroni's correction was not applied, we also found a negative relationship between satisficing tendency and regret (r=-0.156; p=0.021). In trainees, but not faculty, regret negatively correlated with rational-analytical thinking (r=-0.422; p<0.001), need for cognition (r=-0.340; p<0.001), and objectivism (r=-0.309; p=0.003) and positively correlated with ambiguity intolerance (r=0.285; p=0.012). However, after conducting a multivariate regression analysis, we found that regret was positively associated with maximizing only with respect to decision difficulty (r=0.791; p<0.001), while it was negatively associated with satisficing (r=-0.257; p=0.020) and objectivism (r=-0.267; p=0.034). We found no statistically significant relationship between regret and overall accuracy on conditional inferential tasks.

CONCLUSION

Regret in physicians is strongly associated with their tendency to maximize; i.e. the tendency to consider more choices among abundant options leads to more regret. However, physicians who exhibit satisficing tendency - the inclination to accept a "good enough" solution - feel less regret. Our observation that objectivism is a negative predictor of regret indicates that the tendency to seek and use empirical data in decision-making leads to less regret. Therefore, promotion of evidence-based reasoning may lead to lower regret.

Changes in Functional Status and Health-Related Quality of Life in Older Adults After Surgical, Interventional, or Medical Management of Acute Myocardial Infarction

Functional status and health-related quality of life (HRQoL) are important outcomes, particularly among older patients. However, data on such patient-centered outcomes after cardiac surgery are limited. We evaluated the incidence and predictors of decline in functional status and HRQoL among older patients hospitalized for acute myocardial infarction (AMI). Participants were age 75 years or older hospitalized for AMI at 94 US sites. We examined decline in functional status (defined as decline in 1 or more activities of daily living, ADLs), as well as mental (MCS) and physical component scales (PCS) of the SF-12 to assess HRQoL (5-point decline or greater in each scale) between 1 month prior to the hospitalization and 6 months after. Multivariable model compared the risk of decline after coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI) and medical management. Among 3041 patients (1708 PCI, 362 CABG, and 971 medical management), 1525 (50.2%) experienced decline in 1 or more domain: 633 (20.8%) declined in ADLs, 786 (25.9%) declined in the MCS, and 1078 (35.5%) declined in the PCS. The unadjusted incidence of ADL decline was the lowest among patients who underwent CABG (n = 50, 13.8%) compared with PCI (n = 271, 15.9%) or medical management (n = 312, 32.1%). Patients who underwent CABG and PCI had lower adjusted risk of decline in functional and HRQoL compared with those who received medical therapy. The risks after CABG and PCI were not significantly different. Over half of older patients significantly declined in function or HRQoL after AMI. Compared with medical management, risk of decline was lower in those who underwent revascularization.

The Patient Care Ownership Scale: Development of an Instrument to Measure Patient Care Ownership Among Internal Medicine Trainees

BACKGROUND

Patient care ownership is essential to delivering high-quality medical care but appears to be eroding among trainees. The lack of an objective measure has limited the study of ownership in physicians.

OBJECTIVE

To develop an instrument to measure psychological ownership of patient care.

DESIGN

Cross-sectional study.

PARTICIPANTS

Internal medicine trainees in a large, academic hospital completing an inpatient rotation.

MAIN MEASURES

Our scale prototype adapted an existing ownership scale (developed in the non-medical setting) based on themes identified in qualitative studies of patient care ownership. We conducted cognitive interviews to determine face validity of the scale items. Our finalized scale measures ownership's key constructs: advocacy, responsibility, accountability, follow-through, knowledge, communication, initiative, continuity of care, autonomy, and perceived ownership. We distributed an online, anonymous, 46-question survey to 219 residents; 192 residents completed the survey; and 166 responses were included in the analysis. We calculated Cronbach's α to determine the scale's internal consistency. Exploratory factor analysis was used to explore possible subscales. We examined construct validity using bivariate and correlational analysis.

KEY RESULTS

The 15-item ownership scale demonstrated good internal consistency (Cronbach's α = 0.89). We identified three possible subscales corresponding to assertiveness, being the "go-to" person, and diligence. Training level and prior intensive care unit experience significantly predicted ownership (p < 0.01). There was no significant relationship between ownership and age, gender, inpatient service type, call schedule, patient turnover, or supervisory experience of the attending physician. We found a significant negative correlation between ownership and perceived degree of burnout (r = - 0.33), depression (r = - 0.24), detachment (r = - 0.35), and frustration (r = - 0.31) and a significant positive association between ownership and fulfillment (r = 0.37) and happiness (r = 0.36).

CONCLUSION

We developed an instrument to quantify patient care ownership in residents. Our scale demonstrates good internal consistency and preliminary evidence of validity. With further validation, we expect this to be a valuable tool to evaluate interventions aimed at improving ownership.

Which patients with unprovoked venous thromboembolism should receive extended anticoagulation with direct oral anticoagulants? A systematic review, network meta-analysis, and decision analysis

INTRODUCTION

Direct oral anticoagulants (DOACs) effectively prevent recurrent venous thromboembolism (VTE). However, it is unknown which agents should be used to prevent recurrent VTE and which patients with unprovoked VTE should receive extended anticoagulation. We therefore sought to compare the efficacy and safety among DOACs for secondary prevention of VTE. We also determined a risk-adapted threshold for initiating extended anticoagulation based on the likelihood of VTE recurrence (without treatment) and bleeding (with treatment) in patients with unprovoked VTE.

METHODS

Our systematic review of randomized controlled trials compares extended anticoagulation with DOACs to another DOAC, aspirin, or placebo for the prevention of recurrent VTE. We searched PubMed, EMBASE, and Cochrane Registry of Controlled Trials (CENTRAL) in October 2018. Our outcomes of interest were VTE recurrence, major bleeding, and all clinically relevant bleeding. We used network meta-analysis to make indirect comparisons among DOACs. We populated the threshold decision-analytic model with data from our meta-analysis to determine the risk of VTE recurrence above which the benefits of extended anticoagulation outweigh the harms compared with no treatment.

RESULTS

We included four, high-quality, randomized trials comprising 8386 participants. Low-dose apixaban, full-dose apixaban, low-dose rivaroxaban, full-dose rivaroxaban, and dabigatran reduce VTE recurrence compared with placebo (RR = 0.19, 95% CI, 0.12-0.31; RR = 0.20, 95% CI, 0.12-0.32; RR = 0.08, 95% CI, 0.03-0.27; RR = 0.14, 95% CI, 0.06-0.35; RR = 0.19, 95% CI, 0.09-0.40, respectively). No DOACs increased major bleeding risk compared with placebo. A VTE recurrence risk above 0.3% to 0.4% at approximately 1 year is the threshold to treat a patient with unprovoked VTE with extended anticoagulation (with any DOAC).

CONCLUSIONS

All DOACs exhibit comparable efficacy for the prevention of recurrent VTE. Given that the risk of VTE recurrence is much higher than the calculated threshold for treatment, extended thromboprophylaxis should be considered in all patients with unprovoked VTE who do not have increased bleeding risk.

Translating and validating a Japanese version of the Patient Care Ownership Scale: a multicenter cross-sectional study

BACKGROUND

Patient care ownership (PCO) is an essential component in medical professionalism and is crucial for delivering high-quality care. The 15-item PCO Scale (PCOS) is a validated questionnaire for quantifying PCO in residents; however, no corresponding tool for assessing PCO in Japan exists. This study aimed to develop a Japanese version of the PCOS (J-PCOS) and validate it among Japanese medical trainees.

METHODS

We performed a multicenter cross-sectional survey to test the validity and reliability of the J-PCOS. The study sample was trainees of postgraduate years 1-5 in Japan. The participants completed the J-PCOS questionnaire. Construct validity was assessed through exploratory and confirmatory factor analyses. Internal consistency reliability was examined by calculating Cronbach's alpha coefficients and inter-item correlations.

RESULTS

During the survey period, 437 trainees at 48 hospitals completed the questionnaire. Exploratory factor analysis of the J-PCOS extracted four factors: assertiveness, sense of ownership, diligence, and being the "go-to" person. The second factor had not been identified in the original PCOS, which may be related to a unique cultural feature of Japan, namely, a historical code of personal conduct. Confirmatory factor analysis supported this four-factor model, revealing good model fit indices. The analysis results of Cronbach's alpha coefficients and inter-item correlations indicated adequate internal consistency reliability.

CONCLUSIONS

We developed the J-PCOS and examined its validity and reliability. This tool can be used in studies on postgraduate medical education. Further studies should confirm its robustness and usefulness for improving PCO.

Safety and Efficacy of Teclistamab in Patients With Relapsed or Refractory AL Amyloidosis

INTRODUCTION

Teclistamab has demonstrated deep responses in patients with multiple myeloma in the MajesTEC-1 study. However, the safety and efficacy of teclistamab in patients with AL amyloidosis are unknown.

METHODS

We retrospectively analyzed patients with biopsy-proven relapsed/refractory AL amyloidosis who were treated with teclistamab from December 2022 to February 2024 at the University of Pennsylvania. The data cutoff was 2/29/24. Adverse events (AE) were extracted from the electronic medical record. Patients were assessed for hematologic and organ response per consensus guidelines.

RESULTS

Eight patients were included in this case series: median age 63 (range 59-67), 75% female, 88% White. All eight patients achieved at least very good partial response (VGPR) and had normalization of free light chains (FLC), and six (75%) patients achieved undetectable FLC levels. Of the six patients with immunofixation completed, all six (100%) achieved hematologic complete response (hCR). The median time to hematologic VGPR and hCR was 13 days (range 12-18 days) and 88 days (range 32-150 days), respectively. The median duration of follow-up was 8.5 months (range 1-14 months). Of the five patients with cardiac involvement, four (80%) achieved a cardiac response. Of the seven patients with renal involvement, two patients already achieved renal response prior to teclistamab, and of the remaining five, three (60%) achieved renal response. Six patients (75%) developed low-grade cytokine release syndrome (CRS). No patients developed ICANS. Neutropenia and AKI both occurred in 25% of patients, respectively.

CONCLUSIONS

In this series of patients, teclistamab showed outstanding depth of response and was well-tolerated. Teclistamab shows promise in treating patients with relapsed AL amyloidosis.

Associations between hospitalist physician workload, length of stay, and return to the hospital

BACKGROUND

Hospitalist physicians' workload-the total number of patients they care for daily-is rising in the U.S. Hospitalists report that increased workload negatively affects patients care.

OBJECTIVE

Measure the associations between hospitalist physicians' workload and clinical outcomes.

DESIGN, SETTINGS, AND PARTICIPANTS

Observational study, using electronic health record (EHR) data, of adults hospitalized on the hospitalist service at Yale-New Haven Hospital from 2015-2018.

MAIN OUTCOME AND MEASURES

We defined hospitalists' workload as the number of patients they cared for on the first full hospital day of a given patient's encounter. We used multilevel Poisson and logistic regression to examine associations between workload and length of stay (LOS), return to the Emergency Department (ED), and readmission. We adjusted for sociodemographic factors, patient complexity and severity of illness, and weekend admission (for LOS) or discharge (for ED visits or readmission).

RESULTS

We analyzed 38,141 hospitalizations. Median patient age was 64 years (IQR 51-78 years), 53% were female, and 34% were nonwhite. Mean workload was 15 patients (SD 3 patients; range 10-34 patients). LOS was prolonged by 0.05 days (95% CI 0.02, 0.08; p(0.001) when comparing the 75th workload percentile (16 patients) to the 25th workload percentile (13 patients). There were no associations between workload and ED visits or readmission within 7 and 30 days.

CONCLUSIONS

There was a statistically significant but modest relationship between workload and LOS; workload was not associated with ED visits or readmissions.Given clinical reports of the deleterious effects of increased hospitalist workload, there is a need for prospective research assessing a range of outcomes, beyond those measurable in contemporary EHR data.