The National Cancer Data Base report on prostate cancer. American College of Surgeons Commission on Cancer and the American Cancer Society

African-American Men with Low-Risk Prostate Cancer: Modern Treatment and Outcome Trends

OBJECTIVE

To investigate the clinical characteristics and treatment patterns for African-American (AA) men with low-risk prostate cancer (PCa) using a national, population-based dataset.

METHODS

We conducted a retrospective review of the Surveillance Epidemiology and End Results database 2004-2008. AA men aged ≥40 years with low-risk PCa were identified. For comparison, white men were selected using the same selection criteria. We reviewed all recorded treatment modalities. Definitive treatment (DT) was defined as undergoing radiotherapy or prostatectomy.

RESULTS

Overall, 7246 AA men and 47,154 white men met the criteria. Most of the patients had PSA level between 4.1 and 6.9 ng/mL (56.2 %) and received DT (76 %). Black men were younger (mean age: 62(±8) vs. 65(±10) years), less likely to receive DT (adjusted odds ratio (AOR), 0.71 [0.67-0.76]), and of those receiving DT, less likely to undergo prostatectomy (AOR, 0.58 [0.54-0.62]). Patients receiving DT had lower crude cancer-specific and overall mortality (0.17 vs. 0.41 % and 2.9 vs. 7.8 %, p value < 0.001, respectively, among blacks). The difference in overall mortality was largest among ≥ 75 years (5.6 vs. 18.2 %). Across age groups, blacks had higher all-cause mortality (AOR, 1.45 [1.13-1.87] and 1.56[1.31-1.86] for <65 and ≥ 65 years, respectively).

CONCLUSION

Our study of a large modern cohort of men with low-risk PCa demonstrates significant lower receipt of DT, lower receipt of prostatectomy among those receiving DT, and lower survival for black men compared to their white counterparts. Older men were less likely to receive DT. Patients who received DT had better survival. The survival difference was most striking among the elderly.

Racial treatment trends in localized/regional prostate carcinoma: 1992-1999

BACKGROUND

African-American men have a greater incidence of and mortality from prostate carcinoma compared with white men, and they are less likely to receive definitive therapy (radical prostatectomy or external beam radiation therapy). During the 1990s, the use of brachytherapy increased; however, its influence on racial and ethnic prostate carcinoma treatment trends remains unclear. The objective of this study was to describe treatment trends over the period 1992-1999 for localized/regional prostate carcinoma among white, Hispanic, and African-American men.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) registry data from 1992 through 1999, logistic regression models were used to determine whether the odds of receiving a specific treatment modality differed by racial and ethnic group and whether the differences changed over time when the models were adjusted for age, marital status, tumor grade, and SEER site (geography).

RESULTS

The authors identified 142,340 men, including white men (81.6%), Hispanic men (6.4%), and African-American men (12.0%). Racial and ethnic differences in the rates of use of androgen-deprivation therapy/expectant management were noted; however, these differences appeared to lessen over time (P < 0.001). The rate of utilization of radical prostatectomy increased for Hispanic men, remained flat for African-American men, and decreased for white men. The utilization of brachytherapy and combination therapy increased for all three groups; however, the greatest increase in utilization was among white men.

CONCLUSIONS

Further research will be required to determine the patient-level and provider-level variables that influence racial and ethnic treatment differences in localized/regional prostate cancer.

Comparison of clinical and pathological features in African-American and Caucasian patients with localized prostate cancer

OBJECTIVE

To examine patient characteristics, prostate specific antigen (PSA) levels, and established preoperative and pathological prognostic factors to determine differences between Caucasian and African-American patients with localised prostate cancer, as it remains controversial whether African-American men present with more aggressive disease.

PATIENTS AND METHODS

One hundred consecutive patients (aged 53-76 years) undergoing radical retropubic prostatectomy (RRP) at an equal-access tertiary-care centre were retrospectively reviewed. All patients had preoperative PSA levels, a physical examination (including clinical staging), and sextant biopsy. Insurance information was also collected. The same urological oncologist determined clinical staging and performed all the RRPs, and the same genitourinary pathologist determined the Gleason grade for biopsies and surgical specimens, pathological stage, percentage of tumour involvement, and specimen weight. African-American and Caucasian patients were compared for PSA, clinical stage, pathological stage, biopsy and pathological Gleason grade, organ confinement, margin status and specimen weight. Using preoperative and pathological data, both groups were also compared for over- and under-staging and -grading. The Wilcoxon rank test with P < 0.05 was used to determine statistically significant differences.

RESULTS

African-American patients were more likely to be Medicaid or self-insured than Caucasian patients. Age, biopsy grade and clinical stage were not significantly different between the groups. African-American patients presented with a mean PSA level of 11.9 ng/mL and Caucasians with a mean of 8.5 ng/mL (P = 0.03). When clinical and biopsy data were compared with pathological data there were no differences between the groups in under/over-grading or under/over-staging. African-American patients had larger prostates per surgical specimen than their Caucasian counterparts (59.3 g vs 51.6 g, respectively; P = 0.04).

CONCLUSIONS

In a referred, equal-access system, African-American patients presented with higher serum PSA levels and had larger prostates in the surgical specimen. However, African-American patients did not present at an earlier age or with higher Gleason grade or clinical stage, nor were pathological grade and stages higher. Other pathological features were no different. African-American patients were not under- or over-staged or under- or over-graded more than their Caucasian counterparts. This retrospective study does not suggest that African-American men present with more aggressive disease.

Populations at high risk for prostate cancer

Although prostate cancer tends to be a slow-growing neoplasm affecting older men, there is clearly a subset of patients at high risk for developing early and possibly more aggressive disease. This group of high-risk patients includes men with a family history of prostate cancer and various histologic features such as PIN and ASAP identified on an initial biopsy. Black American men have a much higher risk of developing prostate cancer when compared with white men and especially Asian men. This finding may reflect both genetic and environmental factors. Screening men at increased risk of developing prostate cancer appears to be a logical strategy, especially in light of recent reports that suggest a benefit to aggressive treatment.

Prostate carcinoma presentation, diagnosis, and staging: an update form the National Cancer Data Base

BACKGROUND

Based on the 1998 Patient Care Evaluation (PCE) from the American College of Surgeons National Cancer Data Base (NCDB), the authors described contemporary nationwide patterns of prostate carcinoma presentation, diagnosis, and staging.

METHODS

The authors reviewed 54,212 cases from the 1998 PCE. Demographics, presenting signs and symptoms, tumor characteristics, prostate biopsy techniques, and use of staging modalities were evaluated.

RESULTS

The mean age of patients in the sample was 68 years. Among patients with available data, 87.5% had a prostate specific antigen (PSA) level of 4 ng/mL or higher, 83.1% had American Joint Committee on Cancer (AJCC) Stage I-II lesions, 80.2% had well or moderately differentiated cancers, and 68.7% of newly diagnosed patients were asymptomatic. Compared with symptomatic patients, asymptomatic patients were more likely to have localized disease (84.6% vs. 78.2%, P < 0.01) and well or moderately differentiated tumors (82.2% vs. 74.6%, P < 0.01). Transrectal ultrasound-guided prostate biopsy was the most common method of tissue confirmation (45.4%). Radionuclide bone scintigraphy was the most frequently employed staging modality (48.7%). Use of various staging evaluations was more frequent among patients at increased risk for disseminated disease (PSA > 10 ng/mL and/or high-grade tumors) versus patients at lower risk (PSA < or = 10 and low to moderate-grade tumors) for metastatic disease (P < 0.005).

CONCLUSIONS

Most newly diagnosed patients with prostate carcinoma are asymptomatic and have moderately differentiated and organ-confined disease. Compared with symptomatic patients, tumors in asymptomatic men are associated with lower pretreatment PSA levels, AJCC stage, and tumor grade. Selective use of staging evaluations, based on risk of metastatic disease, may be relatively uncommon. The NCDB remains a unique and rich source of novel patient care information and serves as a national point of reference for prostate carcinoma presentation, diagnosis, and staging.

Race independently predicts prostate specific antigen testing frequency following a prostate carcinoma diagnosis

BACKGROUND

The goals of the current study were to describe patterns of prostate specific antigen (PSA) surveillance for prostate carcinoma progression in a community-based cohort of patients and to identify independent clinical and sociodemographic factors that predict the frequency of surveillance.

METHODS

Patients diagnosed with localized prostate carcinoma from October 1, 1991 to December 31, 1992 in New Haven and Hartford, Connecticut, were identified. Data were collected through standardized outpatient medical record review. Multivariate statistical methods were used to determine the factors that independently predicted the frequency of surveillance.

RESULTS

Six hundred fifty-eight men with localized prostate carcinoma were included in the cohort. Forty-five percent of all patients were tested at least once annually, and 69% were tested at least once every 2 years. Multivariate models indicated that African American men were half as likely as Caucasian men to receive annual testing (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.24-0.97). Men diagnosed at age 70 years or older were 38% less likely to have annual testing than men diagnosed between the ages of 65 and 69 (OR, 0.62; 95% CI, 0.41-0.94). A higher Gleason score and PSA at presentation also were associated independently with higher rates of annual PSA surveillance.

CONCLUSIONS

Postdiagnosis PSA surveillance is common, although not universal. African American men were at significantly greater risk for receiving less frequent testing compared with Caucasian men. This disparity in access to care may explain, in part, previously observed racial differences in survival in prostate carcinoma. Further research is needed to identify the reasons for the racial disparity in PSA surveillance and to design interventions to lessen these differences.

Effect of race on biochemical disease-free outcome in patients with prostate cancer treated with definitive radiation therapy in an equal-access health care system: radiation oncology report of the Department of Defense Center for Prostate Disease Research

PURPOSE

To report on the first collaboration of the Department of Defense Center for Prostate Disease Research concerned with the relationship between African American race and biochemical disease-free outcomes after definitive radiation therapy.

MATERIALS AND METHODS

Information from the medical records of 1,806 patients (1,349 white, 343 African American, 42 of "other" races, and 72 of "unknown" races) treated with definitive radiation therapy between 1973 and 2000 was reviewed. Patients receiving adjuvant hormonal therapy or postoperative adjuvant or salvage radiation therapy were excluded. Biochemical failure was calculated in over 96% of cases by using ASTRO criteria; patients with fewer than three follow-up visits were considered to have biochemical failure with a prostate-specific antigen (PSA) value more than 10-fold the previous value or with any value greater than 50.0 ng/mL. Median radiation therapy doses were similar. The median follow-up was 58.4 months. Kaplan-Meier tests, Cox proportional hazards regression analysis, and log-rank tests were used for data analysis.

RESULTS

There was no statistically significant difference in biochemical disease-free survival according to race when patients were stratified according to T stage. African American race conferred a negative prognosis for patients with lesions of Gleason biopsy score 7 (P =.004) but not for patients with lesions of Gleason score 2-4 (P =.14), 5-6 (P =.79), or 8-10 (P =.86). Similarly, African American race conferred a negative prognosis in patients with PSA values of 20.1-50.0 ng/mL (P =.01) at presentation but not in patients with PSA values less than or equal to 4.0 ng/mL (P =.84), 4.1-10.0 ng/mL (P =.71), 10.1-20.0 ng/mL (P =.75), or above 50.0 ng/mL (P =.15) at presentation. At multivariate analysis, race was not a statistically significant predictor of outcome.

CONCLUSION

In the equal-access health care system of the Department of Defense, African American race is not associated with a consistently negative prognosis in patients treated with definitive radiation therapy for prostate cancer. Race appears to confer a negative prognosis only in patients with advanced disease at presentation.

Prognostic significance of race on biochemical control in patients with localized prostate cancer treated with permanent brachytherapy: multivariate and matched-pair analyses

PURPOSE

To compare PSA relapse-free survival (PSA-RFS) between African-American (AA) and white American (WA) males treated with permanent prostate brachytherapy (PPB) for clinically localized prostate cancer.

METHODS AND MATERIALS

One thousand eighty-one consecutive patients, including 246 African-Americans, underwent PPB with 103Pd or 125I, alone or with external beam radiation therapy between September 1992 and September 1999. Computer-generated matching was performed to create two identical cohorts of WA and AA males, based on the use of neoadjuvant androgen ablation (NAAD), pretreatment PSA, and Gleason score. Presenting characteristics were used to define risk groups, as follows: Low risk had PSA <or=10 and Gleason score <or=6, intermediate risk had PSA >10 or Gleason score >or=7, and high risk had PSA >10 and Gleason score >or=7. PSA-RFS was calculated using the Kattan modification of the ASTRO definition, and the log-rank test was used to compare Kaplan-Meier PSA-RFS curves. Univariate and multivariate analyses were performed to determine predictors of PSA-RFS.

RESULTS

Overall, univariate analysis revealed that AA males at presentation had lower disease stage (p = 0.01), had lower Gleason scores (p = 0.017), were younger (p = 0.001), and were more likely to receive NAAD (p = 0.001) than their WA counterparts. There were no differences in pretreatment PSA, isotope selection, use of external beam radiation therapy, median follow-up, or risk group classification between AA and WA males. Pretreatment PSA and Gleason score were significant predictors of PSA-RFS in multivariate analysis, and race was not significant. There was no significant difference between the 5-year PSA-RFS for AA males (84.0%) and the matched cohort of WA males (81.2%) (p = 0.384). Race was not a predictor of 5-year PSA-RFS among patients treated with or without NAAD and within low-, intermediate-, and high-risk groups.

CONCLUSION

Race is not an independent predictor of 5-year PSA-RFS in patients with localized prostate cancer treated with PPB. This result is consistent with other studies that also show that race does not contribute to differences in outcome after definitive therapies for localized prostate cancer.

Prospective study of cancer detection in black and white men with normal digital rectal examination but prostate specific antigen equal or greater than 4.0 ng/mL

BACKGROUND

The serum prostate specific antigen (PSA) concentration with no clinical evidence of prostate carcinoma is higher and more variable in black than in white American men. The influence of this phenomenon on relations between race, PSA, and cancer detection in men with a PSA greater than or equal to 4.0 ng/mL has not been investigated.

METHODS

Between January 1992 and December 2000, 451 black and 480 white men with a normal digital rectal examination and a PSA greater than or equal to 4.0 ng/mL had an initial prostate biopsy at one medical center. The histology of the biopsy specimens and the Gleason score of malignant specimens was determined by one uropathologist.

RESULTS

Cancer was detected in 207 (46%) black and 167 (35%) white men (P = 0.0006). When adjusted for PSA, cancer detection was also greater in the black than the white men, but the difference did not achieve statistical significance (relative risk, 1.30; 95% confidence interval [CI], 0.99-1.71; P = 0.06). Gleason score 7-10 cancer was detected in 88 (20%) black and 45 (9%) white men (P = 0.0001), and the difference remained significant when adjusted for PSA (relative risk, 1.73; 95% CI, 1.16-2.61; P = 0.0008). In the intermediate PSA range of 4.0-9.9 ng/mL, cancer detection and Gleason score 7-10 cancer detection was greater in black than in white men younger than 60, 60-69, and 70 years of age or older, but the difference was significant only for Gleason score 7-10 cancer detection among men 60-69 years of age (P = 0.006).

CONCLUSIONS

There is a direct correlation between Gleason score and cause specific survival with local stage prostate carcinoma. The authors' study indicates that prostate carcinomas with established malignant potential are more likely to be identified in black than in white men with PSA elevation as the only indication of malignancy and raises the possibility that a PSA threshold less than 4.0 ng/mL in black men younger than 70 years of age may reduce racial disparities in prostate carcinoma morbidity and mortality.

Clinical stage T1c prostate cancer: pathologic outcomes following radical prostatectomy in black and white men

BACKGROUND

The incidence of prostate cancer in black men is 50% to 70% higher than among age-matched white men. Black men have a twofold higher mortality rate and overall tend to have higher serum prostate-specific antigen (PSA) levels than white men. To determine whether racial differences exist in men whose prostate cancer was diagnosed based solely on an elevated serum PSA level, we compared clinical and pathologic features in black and white men undergoing radical prostatectomy (RP) for clinical stage T1c prostate cancer.

METHODS

We used a prospectively collected database to identify all men undergoing RP for clinical T1c prostate cancer between July 1995 and October 2000. A total of 129 consecutive men (56 black men and 73 white men) were compared for age at diagnosis, serum PSA level, biopsy Gleason score, pathologic stage, RP specimen Gleason score, incidence of lymph node metastasis, and incidence of positive surgical margins.

RESULTS

Statistically significant differences were not found by race in patients' ages, serum PSA levels, biopsy Gleason score, pathologic stage, incidence of lymph node metastases, or incidence of positive surgical margins. The RP specimen Gleason score was more heterogeneous in black men than white men (P=0.02).

CONCLUSIONS

Racial differences in the incidence and mortality rate of prostate cancer are well known, but differences in the clinical and pathologic features between black and white men with prostate cancer identified solely based on an elevated serum PSA level with negative results on digital rectal examination (clinical stage T1c ) have been poorly studied. Our results suggest that men with clinical stage T1c prostate cancer have similar clinical and pathologic findings regardless of race. These results suggest that early-detection programs using serum PSA testing for prostate cancer in black men potentially can result in improvements in prostate cancer outcomes in this high-risk group.

Racial differences in prostate carcinogenesis. Histologic and clinical observations

Racial differences in the prevalence of HGPIN and in the Gleason score of local stage cancers indicate that clinically observed racial differences in cancer incidence and stage at diagnosis reflect racial variability in prostate carcinogenesis. Exploration of genetic, hormonal, nutritional, and behavioral differences in black and white men may provide insight into the fundamental mechanisms of prostatic carcinogenesis and cancer progression.

Equivalent racial outcome after conformal radiotherapy for prostate cancer: a single departmental experience

PURPOSE

African-American (AA) men with prostate cancer present with advanced disease, relative to white (W) men. This report summarizes our clinical and biochemical control (bNED) rates after conformal radiotherapy (RT). In particular, we aim to characterize any race-based outcome differences seen after comparable treatment.

PATIENTS AND METHODS

We reviewed 893 patients (418 AA and 475 W) with clinically localized prostate cancer treated between 1988 and 1997. Neoadjuvant hormonal blockade was used in 22.5% of cases, and all patients received conformal RT to a median dose of 68 Gy (range, 60 to 74.8 Gy). Biochemical failure was defined according to the American Society of Therapeutic Radiology and Oncology consensus definition. Median follow-up was 24 months (range, 1 to 114 months).

RESULTS

The 5-year actuarial survival, disease-free survival, and bNED rates for the entire population were 80.5%, 70.0%, and 57.6%, respectively. When classified by prognostic risk category, the 5-year actuarial bNED rates were 78.7% for favorable, 57.7% for intermediate, and 39.8% for unfavorable category patients. AA men presented at younger ages and with more advanced disease. Controlled for prognostic risk category, AA and W men had similar 5-year actuarial bNED rates in favorable (78% v 79%, P: = .91), intermediate (52% v 62%, P: =.44), and unfavorable categories (36% v 45%, P: = .09). Race was not an independent prognostic factor (P: = .36).

CONCLUSION

Conformal RT is equally effective for AA and W patients. More research is needed in order to understand and correct the advanced presentations in AA men. These data suggest a need for early screening in AA populations.

Trends in the curative treatment of localized prostate cancer after the introduction of prostate-specific antigen: data from the Rotterdam Cancer Registry

OBJECTIVE

To investigate changes in the incidence and treatment of prostate cancer over the period in which new diagnostic tools were introduced and the attitude towards treatment was changing.

PATIENTS AND METHODS

Information on the extent of disease and treatment of patients diagnosed with prostate cancer within the Rotterdam region was retrieved from the Rotterdam Cancer Registry.

RESULTS

In the period 1989-95, 4344 patients were diagnosed with prostate cancer and the age-standardized incidence increased from 62 to 125 per 100 000 men. This increase mainly comprised tumours localized to the prostate, while the incidence of advanced cancers remained stable. The proportion of poorly differentiated tumours decreased from 33% in 1989 to 24% in 1995. In the same period the number of patients receiving radiotherapy increased from 80 to 258, while the annual number of radical prostatectomies rose from 17 to 159. Radiotherapy was the preferred type of treatment in patients over 70 years of age, whereas radical prostatectomy was used more frequently in younger patients with localized tumours.

CONCLUSION

While the value of screening for prostate cancer remains in debate, incidence and treatment patterns are changing rapidly. Information on patterns of care is needed to interpret future mortality data and to plan resources for adequate health care.

Race and cause specific survival with prostate cancer: influence of clinical stage, Gleason score, age and treatment

PURPOSE

We assess the influence of race on stage stratified cause specific survival of men with prostate cancer, and Gleason score, age at diagnosis and treatment on potential racial differences in survival.

MATERIALS AND METHODS

A total of 524 black and 396 white men were diagnosed with prostate cancer at a Veterans Affairs Medical Center between January 1982 and December 1992. Clinical stage was determined by retrospective review of the medical records and Gleason score of biopsy material as assigned by a single uropathologist. Of 611 patients who died the cause of death was determined by retrospective or prospective review of hospital records in 493 and by review of the death certificates in 102. In 16 cases the cause of death was indeterminate. Median potential followup was 112 months (range 60 to 182) and median period of observation was 61 months (range 1 to 182).

RESULTS

Cause specific survival with stage T1b-2 cancer was lower in 231 black than in 264 white men of all ages (p = 0.02) and lower in 110 black than in 170 white men younger than in 70 years at diagnosis (p = 0.04). Gleason 7 to 10 cancer, which was associated with a less favorable cause specific survival compared to Gleason 2 to 6 cancer (p <0.0001), was more common in black than in white men with stage T1b-2 cancer of all ages (p = 0.01) and younger than 70 years at diagnosis (p = 0.04). No or unknown treatment status, which was associated with a less favorable cause specific survival compared to treatment (p = 0.05), was more common in black than in white men with stage T1b-2 cancer of all ages (p = 0.0005) but not significantly different when stratified by age. In men of all ages racial differences in cause specific survival were not significant when adjusted for age and Gleason score (p = 0.14) or age, Gleason score and treatment status (p = 0.17). In men younger than 70 years racial differences in cause specific survival were not significant when adjusted for age and Gleason score (p = 0.22). There were no significant racial differences in overall or age stratified all cause survival of men with stage T1b-2 cancer. There were no significant differences in overall or age stratified cause specific or all cause survival of 112 black and 58 white men with stage T3-4 cancer, or 181 and 74, respectively, with metastatic cancer.

CONCLUSIONS

Our data indicate that local stage prostate cancer is more lethal in black than in white men and the difference is most pronounced in men younger than 70 years. The survival disadvantage of black men with local stage cancer is due in part to a propensity for development of less differentiated and more aggressive malignancies.

The impact of race on biochemical disease-free survival in early-stage prostate cancer patients treated with surgery or radiation therapy

PURPOSE

To assess the impact of race on biochemical freedom from recurrence in patients with early-stage prostate cancer treated either by radical prostatectomy or radiation therapy.

METHODS

Between July 1989 and December 1994, 693 patients with early-stage prostate cancer were treated with radiation (302 patients) or by radical prostatectomy (391 patients) at Barbara Ann Karmanos Cancer Institute/Wayne State University. Stage, Gleason score, race, pretreatment PSA, and follow-up PSA values were abstracted. There were 387 Caucasian males (CM) and 306 African-American males (AAM). None of the patients received hormone therapy. Radiation therapy was delivered using photon irradiation (249 patients, median dose 69 Gy) or mixed neutron/photon irradiation (53 patients, median dose 10 NGy + 38 PGy). Median follow-up was 36 months (range 2-70) for CM and 35 months (range 1-70) for AAM.

RESULTS

Thirty-seven percent of patients treated surgically were AAM, compared to 53% in the radiation group (p = 0001). AAM had a higher median prostate-specific antigen (PSA) than CM (9.78 ng/ml vs. 8.0 ng/ml, p = 0.01). Thirty-three percent of AAM had a pretreatment PSA greater than 15 ng/ml compared to 20% of CM (p = 0.00001). Disease-free survival (DFS) by race was equivalent at 36 months, 81% for CM and 77% for AAM (p = NS). For patients with PSA < or =15, DFS rates were 87% and 85% for CM and AAM, respectively. DFS rates for patients with PSA >15 were 61% for CM and 64% for AAM (p = NS). Significant prognostic factors on multivariate analysis included pretreatment PSA (p = 0.0001) and Gleason score (p = 0.0001).

CONCLUSION

Race does not appear to adversely affect biochemical disease-free survival in males treated for early-stage prostate cancer. African-American males with early-stage prostate cancer should expect similar biochemical disease-free survival rates to those seen in Caucasian males.

Effects of health insurance and race on early detection of cancer

BACKGROUND

The presence and type of health insurance may be an important determinant of cancer stage at diagnosis. To determine whether previously observed racial differences in stage of cancer at diagnosis may be explained partly by differences in insurance coverage, we studied all patients with incident cases of melanoma or colorectal, breast, or prostate cancer in Florida in 1994 for whom the stage at diagnosis and insurance status were known.

METHODS

The effects of insurance and race on the odds of a late stage (regional or distant) diagnosis were examined by adjusting for an individual's age, sex, marital status, education, income, and comorbidity. All P values are two-sided.

RESULTS

Data from 28 237 patients were analyzed. Persons who were uninsured were more likely diagnosed at a late stage (colorectal cancer odds ratio [OR] = 1.67, P =.004; melanoma OR = 2.59, P =.004; breast cancer OR = 1.43, P =.001; prostate cancer OR = 1.47, P =.02) than were persons with commercial indemnity insurance. Patients insured by Medicaid were more likely diagnosed at a late stage of breast cancer (OR = 1.87, P<.001) and melanoma (OR = 4.69, P<.001). Non-Hispanic African-American patients were more likely diagnosed with late stage breast and prostate cancers than were non-Hispanic whites. Hispanic patients were more likely to be diagnosed with late stage breast cancer but less likely to be diagnosed with late stage prostate cancer.

CONCLUSIONS

Persons lacking health insurance and persons insured by Medicaid are more likely diagnosed with late stage cancer at diverse sites, and efforts to improve access to cancer-screening services are warranted for these groups. Racial differences in stage at diagnosis are not explained by insurance coverage or socioeconomic status.

Urinary symptoms as a predictor for participation in prostate cancer screening among African American men

BACKGROUND

There are minimal data on the influence of urinary symptoms and participation in prostate cancer screening in African American men.

METHODS

This correlational study examined the influence of urinary symptoms on 1) participation in a free prostate cancer screening program and 2) abnormal screening results. The 1,402 African American men in the South Carolina Prostate Cancer Project (SCPCP), mean age of 50 years, completed a survey that included self-reported urinary symptoms, participated in a prostate cancer educational program, and received a free prostate cancer screening consisting of a digital rectal examination (DRE) and prostate-specific antigen (PSA) from their personal physician.

RESULTS

One in 5 men reported the presence of urinary symptoms. Over 60% of the 1,402 men participated in the free CaP screening. Among the 852 men who participated in the free prostate cancer screening, 73 (8.6%) had abnormal screening results as classified by abnormal DRE and/or PSA >4.0 ng/ml. Urinary symptoms were significant predictors, both of participation in screening (OR = 1.30, CI = 1.00, 1.70) and of obtaining an abnormal screening result (OR = 1.78, CI = 1.17, 2.72).

CONCLUSIONS

Prostate cancer health education needs to include the fact that prostate cancer, in its early stages, has no urinary symptoms.

Novel staging tool for localized prostate cancer: a pilot study using genetic adaptive neural networks

PURPOSE

An estimated $1.5 billion is spent annually for direct medical expenses and an additional $2.5 billion for indirect costs for the management of prostate cancer. Today there are several procedures for staging prostate cancer, including lymph node dissection. Despite these procedures, the accuracy of predicting extracapsular disease remains low (range 37 to 63, mean 45%). Use of multiple staging procedures adds significantly to the costs of managing prostate cancer. Recently artificial intelligence based neural networks have become available for medical applications. Unlike traditional statistical methods, these networks do not assume linearity or homogeneity of variance and, thus, they are more accurate for clinical data. We applied this concept to staging localized prostate cancer and devised an algorithm that can be used for prostate cancer staging.

MATERIALS AND METHODS

Our study comprised 1,200 men with clinically organ confined prostate cancer who underwent preoperative staging using serum prostate specific antigen, systematic biopsy and Gleason scoring before radical prostatectomy and lymphadenectomy. The performance of the neural network was validated for a subset of patients and network predictions were compared with actual pathological stage. Mean patient age was 62.9 years, mean serum prostate specific antigen 8.1 ng./ml. and mean biopsy Gleason 6. Of the patients 55% had organ confined disease, 27% positive margins, 8% seminal vesicle involvement and 7% lymph node disease. Of margin positive patients 30% also had seminal vesicle involvement, while of seminal vesicle positive patients 50% also had positive margins.

RESULTS

The sensitivity of the network was 81 to 100%, and specificity was 72 to 75% for various predictions of margin, seminal vesicle and lymph node involvement. The negative predictive values tended to be relatively high for all 3 features (range 92 to 100%). The neural network missed only 8% of patients with margin positive disease, and 2% with lymph node and 0% with seminal vesicle involvement.

CONCLUSIONS

Our study suggests that neural networks may be useful as an initial staging tool for detection of extracapsular extension in patients with clinically organ confined prostate cancer. These networks preclude unnecessary staging tests for 63% of patients with clinically organ confined prostate cancer.

Ultrasonically guided interstitial brachytherapy for prostate cancer: care of the patient in ambulatory surgery

The diagnosis of prostate cancer at any age can strike fear in a man and his family. One treatment for early stage prostate cancer that is gaining renewed popularity is ultrasonically guided permanent iodine-125 or palladium-103 interstitial brachytherapy or seed implantation. This procedure permits concentrated, accurate radiation to the prostate while reducing the probability of radiation injury to adjacent tissue. A well-tolerated outpatient procedure, it is associated with negligible complications, and is the most overall cost-effective treatment option for early stage prostate cancer today. Nurses who are knowledgeable about the treatment plan and procedure play a pivotal role in teaching, preparing, and caring for patients during all phases of the treatment process. Their care and reassurance help reduce anxiety for patients and families during a difficult time in their lives.

Changes in patterns of prostate cancer care in the United States: results of American College of Surgeons Commission on Cancer studies, 1974-1993

BACKGROUND

Advances in medical and public health practice have led to many changes in patterns of prostate cancer care. Data from several studies of prostate cancer by the Commission on Cancer of the American College of Surgeons provide information on the directions, magnitudes, and consequences of these changes.

METHODS

The Commission on Cancer conducts patient care evaluation (PCE) studies based on the voluntary participation of hospital cancer programs and their tumor registries. PCE studies have been conducted repeatedly for prostate cancer covering patients diagnosed as early as 1974 and as recently as 1990. In addition, the National Cancer Data Base of the Commission on Cancer collects data for all forms of cancer from throughout the country. The Commission on Cancer, the American Cancer Society, and the American Urologic Association also has conducted a focused survey of radical prostatectomy outcomes. In aggregate, these multiple studies have accrued 179,366 reports on treatment of prostate cancer patients.

RESULTS

Predominant among practice changes are new techniques of prostate cancer detection and initial evaluation which have led to shifts in disease stage at the time of initial therapy. The proportion of prostate cancer that is localized at the time of detection has increased. Use of radiation therapy and radical prostatectomy has increased as the selection of hormone treatment and no cancer-directed treatment have decreased. Five-year prostate cancer survival has improved for every stage of disease.

CONCLUSIONS

The multiple studies by the Commission on Cancer provide data that are not available from other sources. Continued monitoring of prostate cancer patterns of care may be useful in measuring progress in control of this common disease.

Comparison of serum prostate specific membrane antigen, prostate specific antigen, and free prostate specific antigen levels in radical prostatectomy patients

BACKGROUND

Higher preoperative prostate specific antigen (PSA) levels are associated with higher pathologic stage and grade in patients undergoing radical prostatectomy (RP). In earlier studies, serum prostate specific membrane antigen (PSMA) elevations were associated with clinical progression and hormone-refractory carcinoma. The goal of this study was to evaluate the serum markers PSMA, free PSA (FPSA), free:total PSA ratio (F:TPSA), and total PSA (PSA) in men undergoing RP.

METHODS

Serum was obtained from 63 patients undergoing RP for clinically localized (T1c, T2) prostate carcinoma. Serum PSA and FPSA were determined by Hybritech Tandem-E(R) and Tandem-R(R), respectively, and PSMA was determined by Western blot analysis. Serum values for these markers were compared with the pathologic stage, surgical margin status, Gleason sum, prostate size (as calculated via reconstruction and transrectal ultrasound), tumor size based on pathologic assessment of the whole mount, and World Health Organization (WHO) grade of the prostatectomy specimen. Markers were also compared against demographic information and the patients' age and race.

RESULTS

There was a weak correlation between serum PSA and positive surgical margins, higher Gleason sum, and WHO grade (P < 0.05). Receiver operating characteristic curve (ROC) analysis comparing sensitivity and specificity of the markers to positive and negative margins as well as seminal vesicle invasion demonstrated PSA and FPSA predictive ability for seminal vesicle invasion. The area under the curve for PSA and FPSA in this case was 0.7318 and 0.7432, respectively. There was also a weak correlation between the FPSA level and margins, with a low ROC area under the curve of 0.6789. The FPSA cannot distinguish the more advanced stage of disease. There was no significant correlation between F:TPSA and PSMA with regard to the study variables in predicting organ confinement. High PSMA levels only correlated with higher stage and were maximal in pT4a classified disease.

CONCLUSIONS

Higher PSA and FPSA levels are likely to be associated with more locally advanced disease. Total PSA was the best marker. However, the cutoff values necessary for significant accuracy between PSA and FPSA are not of clinical usefulness due to the lack of specificity and sensitivity of the markers at those cutoffs. F:TPSA and PSMA levels as currently measured are of limited value in discriminating more aggressive disease in patients with clinically localized CaP.

Abnormal p53 expression is rare in clinically localized human prostate cancer: comparison between immunohistochemical and molecular detection of p53 mutations

BACKGROUND

We assessed the frequency and molecular basis of p53 mutations in clinically localized prostatic adenocarcinoma.

METHODS

Prostate specimens were examined from 100 patients with clinically localized prostatic adenocarcinoma and 13 patients with benign prostatic hyperplasia (BPH). Mutations producing nuclear accumulation of p53 were detected immunohistochemically. Exon-specific mutations were analyzed by polymerase chain reaction amplification and single strand conformation polymorphism (PCR-SSCP) and sequenced.

RESULTS

p53 accumulation was detected in 5 tumors using antibody DO-1, and in 4 of these using antibody PAb 1801, but not in BPH. PCR-SSCP detected mutations in all 5 tumors, with alterations in exon 5 for 1 tumor, exon 6 for 3 tumors, and exon 7 for 1 tumor. An exon 6 mutation was also found in a tumor with no anti-p53 staining.

CONCLUSIONS

p53 mutations are uncommon in clinically localized prostatic adenocarcinoma and absent from BPH. 5 of the 6 mutations were derived from locally invasive, prostate carcinomas, supporting the hypothesis that mutation of p53 is a late event in prostate carcinoma progression.

Bladder carcinoma and other second malignancies after radiotherapy for prostate carcinoma

BACKGROUND

Radiation therapy (RT) to the pelvis has been associated with an increased risk of bladder carcinoma, as well as other malignancies. However, no controlled studies have previously explored the risk of second malignancies after RT for prostate carcinoma.

METHODS

A retrospective cohort study was conducted utilizing data from the Surveillance, Epidemiology, and End Results Program (SEER) of the U. S. National Cancer Institute from 1973-1990. The standardized incidence ratio (SIR), adjusted for age, was calculated as an estimate of the relative risk (RR) of developing a second malignancy after prostate carcinoma for radiated and nonradiated prostate carcinoma patients separately.

RESULTS

The cohort was comprised of 34,889 prostate carcinoma patients who had undergone RT, and 106,872 who had not. After 8 years, the risk of bladder carcinoma was elevated for the RT group (RR 1.5; 95% confidence interval [CI], 1.1-2.0) but not for the non-RT group (RR 1.0; 95% CI, 0.7-1.2). There was an elevated risk of bladder carcinoma for the RT group at 5-8 years as well (RR 1.3; 95% CI, 1.0-1.7). No elevations in risk were observed for rectal carcinoma, acute nonlymphocytic leukemia, or chronic lymphocytic leukemia for either RT patients or non-RT patients.

CONCLUSIONS

The risk of bladder carcinoma is elevated several years after RT for prostate carcinoma, but this elevation is not dramatic. There is no increased risk of rectal carcinoma or leukemia after this type of radiation exposure.

The National Cancer Data Base report on patterns of hospital reporting

BACKGROUND

Previous Commission on Cancer data from the National Cancer Data Base (NCDB) have examined time trends in stage of disease, treatment patterns, and survival for selected cancers. The most current (1993) data are described here.

METHODS

Five calls for data have yielded a total of 3,700,000 cases for the years 1985 through 1993, including 477,679 cases for 1988, and 608,593 cases for 1993, from hospital cancer registries across the U.S.

RESULTS

The most recent call for data for 1993 comprised 52% of the estimated new cases of cancer in the U.S. The country was comprised of 6 regions, with the Mountain and Southeast regions having the highest regional reporting of new cases of cancer (69% and 55%, respectively) and the Northeast and Pacific regions having the lowest (47% each). Approximately 96% of patients received their treatment at the reporting hospital. The 4 most common carcinomas were breast (15.7%), lung (14.6%), prostate (14.2%), and colon (7.5%) and comprised the majority of new cases. Trends in patterns of care for breast carcinoma were analyzed for possible bias in the 1988 and 1993 periods. When hospitals reporting only in 1988 or in 1993 were compared with hospitals reporting at both time points, the only differences were small differences in ethnic participation. These differences were less than 1.5% in the proportion of African Americans reported in the different time periods. There were no significant differences in the downstaging of breast carcinoma, or the role of conservative surgery or adjuvant radiation therapy.

CONCLUSIONS

The NCDB is a cancer management and outcomes data base for health care organizations that presently comprises 52% of the estimated new cases in the U.S. This will increase to 80% as the approved hospitals of the Commission on Cancer are required to report to the NCDB. Comparison of breast carcinoma findings at two time periods appeared similar regardless of hospital reporting set (i.e., set of hospitals reporting for one period versus both periods).

Trends in the stage specific incidence of prostate carcinoma in the Detroit metropolitan area, 1973-1994

BACKGROUND

Much of the recent increase in prostate carcinoma incidence has been attributed to screening with prostate specific antigen (PSA). Controversy exists as to whether this screening will ultimately impact prostate carcinoma mortality. Until adequate time elapses since PSA screening became widespread, or a randomized trial of PSA screening is completed, the effect of PSA screening on prostate carcinoma mortality cannot be determined. In the interim, stage specific prostate carcinoma incidence rates may provide an indication of the effect of PSA screening.

METHODS

Annual stage specific age-adjusted prostate carcinoma incidence rates for the years 1973 through 1994 were obtained from the Metropolitan Detroit Cancer Surveillance System (MDCSS), a member of the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program. These incidence rates were analyzed for trends using Poisson regression analysis.

RESULTS

There were 10,801 cases of prostate carcinoma in black men and 31,501 in white men during the 22-year period. Incidence rates for stages of local and regional prostate carcinoma reached a maximum in 1992 and 1993. Distant stage prostate carcinoma incidence has steadily declined since 1989 (P < 0.001), the year in which the increasing trend in the incidence rates for local and regional stage prostate carcinoma were first noted.

CONCLUSIONS

These findings suggest that a substantial proportion of early stage prostate carcinoma detected by PSA is in fact clinically important and that early detection of these carcinomas has resulted in a continuous decline in the stage of metastatic prostate carcinoma since 1989.

Histopathology of the frozen prostate. The microscopic bases of prostatic carcinoma cryoablation

In the last few years percutaneous cryoablation surgery of the prostate has been re-introduced as an alternative means to treat prostatic carcinoma. Advantages of the technique include local effectiveness in eradicating tumors, minimal morbidity rate and lower costs when compared to radical surgery. We report a study documenting the histopathological changes seen in 317 biopsy specimens obtained from 30 patients (age range 59-83 years, median 73 years) treated with cryosurgical ablation for prostate cancer. Pre- and postoperatory assessment was inclusive of plain clinical, laboratory and instrumental data (digital rectal examination, transrectal ultrasound scan, serum prostatic specific antigen concentration) and systematic biopsies obtained from conventional and modified prostate sextants. Fifteen patients had tumors extending through the prostate capsule (pT3 and pT4). Six patients had stage PT1 tumors and 9 had stage pT2. Tissues were sampled at 3, 6 and between 12-18 months postoperatively. The histologic findings, in decreasing order of frequency, were: full core fibrosis, necrosis, granulation tissue, basal cell hyperplasia, cell swelling, hemosiderin deposits, chronic inflammation, thick nerves and prostatic hyperplasia. Necrosis was of the coagulative type, sometimes associated with nuclear debris, and seen at relatively short interval from cryotherapy. Fibrosis with hyaline qualities was seen especially at 12-18 month interval. The presence of necrosis, as well as granulation tissue, hemosiderin deposits and cell swelling, strongly correlate to intervals from cryosurgical ablation. Residual tumor tissue was focal (0.5-1 mm) and recognizable in 9 cores from 4 patients (13.3%) sampled especially from the prostatic apex. Incipient tumor necrosis was seen in 11 cores, without particular distribution. These findings indicate that cryosurgery results in distinctive changes in both tumoral and non-tumoral prostate tissue. Knowledge of the histopathologic patterns is important since it provides the clinicians with information on treatment efficacy or failure, and could assist in the selection of larger groups of patients eligible to cryosurgical ablation.

Does brachytherapy have a role in the treatment of prostate cancer?

The goal of radiation therapy is to deliver a high dose to the tumor while preserving normal surrounding tissue. For early-stage prostate cancer, the ultimate conformal irradiation is to place radioactive sources directly into the gland either as permanent or temporary seeds. Permanent seed implantation is capable of delivering two times the radiobiologically equivalent dose of external beam irradiation to the prostate and tumor. In the past, the results of prostate brachytherapy were likely poor owing to the technical difficulty in accurately placing the radioactive seeds uniformly throughout the prostate. The use of low-dose-rate I-125 to treat high-grade cancers probably also contributed to the poorer results as compared with external beam irradiation. Over the last 10 years, however, technologic advances in transrectal ultrasonography, computer dosimetry, and template-based transperineal techniques have dramatically improved the accuracy and consistency of the brachytherapist to place radioactive sources directly into the prostate gland. Transperineal ultrasound or CT directed seed implantation has replaced the older retropubic method. Brachytherapists are now able to accurately map out the gland prior to the implant and carefully evaluate preoperatively seed placement. The availability of such radioactive sources as iodine-125, palladium-103, and iridium-192 has also given the brachytherapist isotopes that can be more carefully matched to the biology and stage of the tumor. More sensitive definitions of failure have prompted radiation oncologists and urologists to carefully evaluate the efficacy of external beam irradiation and surgery. Accurate comparison of the efficacy of brachytherapy to surgery and to external beam radiation requires a randomized study. Comparisons of retrospective studies are fraught with the problems of the heterogeneous nature of early-stage prostate cancer. Imbalances in stage, grade, initial PSA extraprostatic disease, and nodal status of patient groups make comparisons difficult. Most of the long-term data for permanent seed implantation are the result of work at a single institution. These results will need to be repeated at other institutions treating patients in a similar manner. Because techniques vary from institution to institution, permanent implant results will need to be carefully evaluated for technique as well as stratified for pretreatment variables. Pretreatment PSA and grade appear to be more sensitive variables than stage in predicting failure after radiation. As more patients are diagnosed with very early and nonpalpable disease, future studies will need to stratify patients based on these pretreatment factors. Patients with early-stage disease but identified as high risk for extraprostatic disease will require more intensive regimens. The treatment outcomes based on biopsy results are inconclusive. A lack of consensus on the definition of a truly positive biopsy remains forthcoming. The value of a positive prostate biopsy as an outcome predictor for clinical failure is still unclear. The use of prostate nuclear cell antigen staining may help clarify the issue. Comparison of treatment outcome based on absolute PSA is also difficult. The Seattle series suggest that brachytherapy by permanent seed implantation is as efficacious as external beam irradiation for early-stage disease in patients with a low PSA (< 10 ng/mL). As the PSA value rises above 10 ng/mL, the probability of failure after external beam rises substantially. Results from the Seattle series suggest an advantage to seed implant alone or the judicious application of seed implant boost to external beam radiation for these patients with more advanced cancer. The most sensitive measurement of therapeutic outcome is progression-free survival. Few studies to date have evaluated progression-free survival.

The National Cancer Data Base report on longitudinal observations on prostate cancer

BACKGROUND

Data on 349,154 prostate cancer cases diagnosed since 1986 have been entered to the American College of Surgeons National Cancer Data Base (NCDB). Previous annual reports have examined subsets of these data. The present report highlights major trends in the presentation and treatment of prostate cancer in the United States evident from longitudinal analyses of the entire data.

METHODS

NCDB data are collected following a computerized, standard format. Hospital participation is voluntary.

RESULTS

Since the first year of data collection, the number of participating hospitals has increased from 496 to 996 and the number of prostate cancer patients reported to the NCDB increased from 19,531 to 84,408. The proportion of men diagnosed at ages younger than 70 years increased from 37.8% in 1986 to 46.9% in 1993. Completeness of reporting stage of disease and tumor grade has improved. The proportions of both the earliest (American joint Committee an Cancer [AJCC] Stage Groups 0 and I) and the most advanced (AJCC++ Stage Group IV) stages declined. The proportion of Grade 2 (moderately differentiated) tumors increased from 38.6% in 1986 to 57.5% in 1993. The proportion of AJCC Stage II prostate cancer increased from 19% in 1986 to 48.4% in 1993. The proportion of patients treated by prostatectomy increased from 9.9% in 1986 to 29.2% in 1993. The proportion of patients receiving no cancer directed treatment declined from 41.8% in 1986 to 21.6% in 1993. Less change was observed in the use of radiation and hormonal treatments.

CONCLUSIONS

These data show that the clinical patterns of prostate cancer have changed markedly in recent years.