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Pasanen N, Talala K, Remmers S, Tammela TLJ, Hugosson J, Roobol MJ, Taari K, Arnsrud Godtman R, Bangma C, Auvinen A. Which men benefit from prostate cancer screening? Prostate cancer mortality by subgroup in the European Randomised Study of Screening for Prostate Cancer. BJU Int 2024; 134:291-299. [PMID: 38725182 DOI: 10.1111/bju.16394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
OBJECTIVE To evaluate whether a subgroup of men can be identified that would benefit more from screening than others. MATERIALS AND METHODS This retrospective cohort study was based on three European Randomised Study of Screening for Prostate Cancer (ERSPC) centres, Finland, the Netherlands and Sweden. We identified 126 827 men aged 55-69 years in the study who were followed for maximum of 16 years after randomisation. The primary outcome was prostate cancer (PCa) mortality. We analysed three age groups 55-59, 60-64 and 65-69 years and PCa cases within four European Association of Urology (EAU) risk groups: low, intermediate, high risk, and advanced disease. RESULTS The hazard ratio (HR) for PCa mortality in the screening arm relative to the control arm for men aged 55-59 years was 0.96 (95% confidence interval [CI] 0.75-1.24) in Finland, 0.70 (95% CI 0.44-1.12) in the Netherlands and 0.42 (95% CI 0.24-0.73) in Sweden. The HR for men aged 60-64 years was 1.03 (95% CI 0.77-1.37) in Finland, 0.76 (95% CI 0.50-1.16) in the Netherlands and 0.97 (95% CI 0.64-1.48) in Sweden. The HR for men aged 65-69 years was 0.80 (95% CI 0.62-1.03) in Finland and 0.57 (95% CI 0.38-0.83) in the Netherlands, and this age group was absent in Sweden. In the EAU risk group analysis, PCa mortality rates were materially lower for men with advanced disease at diagnosis in all three countries: 0.67 (95% CI 0.56-0.82) in Finland, 0.28 (95% CI 0.18-0.44) in the Netherlands, and 0.48 (95% CI 0.30-0.78) in Sweden. CONCLUSION We were unable to unequivocally identify the optimal age group for screening, as mortality reduction differed among centres and age groups. Instead, the screening effect appears to depend on screening duration, and the number and frequency of screening rounds. PCa mortality reduction by screening is largely attributable to stage shift.
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Affiliation(s)
- Niko Pasanen
- Faculty of Social Sciences, Tampere University, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Sebastiaan Remmers
- Department of Urology, Erasmus University Medical Centre, Cancer Institute, Rotterdam, The Netherlands
| | - Teuvo L J Tammela
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Urology, Tampere University Hospital, Tampere, Finland
| | - Jonas Hugosson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Urology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Monique J Roobol
- Department of Urology, Erasmus University Medical Centre, Cancer Institute, Rotterdam, The Netherlands
| | - Kimmo Taari
- Department of Urology, Helsinki University Hospital, Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Rebecka Arnsrud Godtman
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Urology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Chris Bangma
- Department of Urology, Erasmus University Medical Centre, Cancer Institute, Rotterdam, The Netherlands
| | - Anssi Auvinen
- Faculty of Social Sciences, Tampere University, Tampere, Finland
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2
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Chen DM, Dong R, Kachuri L, Hoffmann TJ, Jiang Y, Berndt SI, Shelley JP, Schaffer KR, Machiela MJ, Freedman ND, Huang WY, Li SA, Lilja H, Justice AC, Madduri RK, Rodriguez AA, Van Den Eeden SK, Chanock SJ, Haiman CA, Conti DV, Klein RJ, Mosley JD, Witte JS, Graff RE. Transcriptome-wide association analysis identifies candidate susceptibility genes for prostate-specific antigen levels in men without prostate cancer. HGG ADVANCES 2024; 5:100315. [PMID: 38845201 PMCID: PMC11262184 DOI: 10.1016/j.xhgg.2024.100315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 05/31/2024] [Accepted: 06/03/2024] [Indexed: 06/18/2024] Open
Abstract
Deciphering the genetic basis of prostate-specific antigen (PSA) levels may improve their utility for prostate cancer (PCa) screening. Using genome-wide association study (GWAS) summary statistics from 95,768 PCa-free men, we conducted a transcriptome-wide association study (TWAS) to examine impacts of genetically predicted gene expression on PSA. Analyses identified 41 statistically significant (p < 0.05/12,192 = 4.10 × 10-6) associations in whole blood and 39 statistically significant (p < 0.05/13,844 = 3.61 × 10-6) associations in prostate tissue, with 18 genes associated in both tissues. Cross-tissue analyses identified 155 statistically significantly (p < 0.05/22,249 = 2.25 × 10-6) genes. Out of 173 unique PSA-associated genes across analyses, we replicated 151 (87.3%) in a TWAS of 209,318 PCa-free individuals from the Million Veteran Program. Based on conditional analyses, we found 20 genes (11 single tissue, nine cross-tissue) that were associated with PSA levels in the discovery TWAS that were not attributable to a lead variant from a GWAS. Ten of these 20 genes replicated, and two of the replicated genes had colocalization probability of >0.5: CCNA2 and HIST1H2BN. Six of the 20 identified genes are not known to impact PCa risk. Fine-mapping based on whole blood and prostate tissue revealed five protein-coding genes with evidence of causal relationships with PSA levels. Of these five genes, four exhibited evidence of colocalization and one was conditionally independent of previous GWAS findings. These results yield hypotheses that should be further explored to improve understanding of genetic factors underlying PSA levels.
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Affiliation(s)
- Dorothy M Chen
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Ruocheng Dong
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA 94305, USA
| | - Linda Kachuri
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA 94305, USA; Stanford Cancer Institute, Stanford University, Stanford, CA 94305, USA
| | - Thomas J Hoffmann
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA 94158, USA; Institute for Human Genetics, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Yu Jiang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA 94158, USA
| | - Sonja I Berndt
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD 20814, USA
| | - John P Shelley
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Kerry R Schaffer
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Mitchell J Machiela
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD 20814, USA
| | - Neal D Freedman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD 20814, USA
| | - Wen-Yi Huang
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD 20814, USA
| | - Shengchao A Li
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD 20814, USA
| | - Hans Lilja
- Departments of Pathology and Laboratory Medicine, Surgery, Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Department of Translational Medicine, Lund University, 21428 Malmö, Sweden
| | | | | | | | | | - Stephen J Chanock
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD 20814, USA
| | - Christopher A Haiman
- Center for Genetic Epidemiology, Department of Population and Preventive Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA 90032, USA; Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - David V Conti
- Center for Genetic Epidemiology, Department of Population and Preventive Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA 90032, USA; Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Robert J Klein
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Jonathan D Mosley
- Departments of Internal Medicine and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - John S Witte
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA 94158, USA; Department of Epidemiology and Population Health, Stanford University, Stanford, CA 94305, USA; Departments of Biomedical Data Science and Genetics (by courtesy), Stanford University, Stanford, CA 94305, USA.
| | - Rebecca E Graff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA 94158, USA.
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Gulati R, Jiao B, Al-Faouri R, Sharma V, Kaul S, Fleishman A, Wymer K, Boorjian SA, Olumi AF, Etzioni R, Gershman B. Lifetime Health and Economic Outcomes of Biparametric Magnetic Resonance Imaging as First-Line Screening for Prostate Cancer : A Decision Model Analysis. Ann Intern Med 2024; 177:871-881. [PMID: 38830219 PMCID: PMC11250625 DOI: 10.7326/m23-1504] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Contemporary prostate cancer (PCa) screening uses first-line prostate-specific antigen (PSA) testing, possibly followed by multiparametric magnetic resonance imaging (mpMRI) for men with elevated PSA levels. First-line biparametric MRI (bpMRI) screening has been proposed as an alternative. OBJECTIVE To evaluate the comparative effectiveness and cost-effectiveness of first-line bpMRI versus PSA-based screening. DESIGN Decision analysis using a microsimulation model. DATA SOURCES Surveillance, Epidemiology, and End Results database; randomized trials. TARGET POPULATION U.S. men aged 55 years with no prior screening or PCa diagnosis. TIME HORIZON Lifetime. PERSPECTIVE U.S. health care system. INTERVENTION Biennial screening to age 69 years using first-line PSA testing (test-positive threshold, 4 µg/L) with or without second-line mpMRI or first-line bpMRI (test-positive threshold, PI-RADS [Prostate Imaging Reporting and Data System] 3 to 5 or 4 to 5), followed by biopsy guided by MRI or MRI plus transrectal ultrasonography. OUTCOME MEASURES Screening tests, biopsies, diagnoses, overdiagnoses, treatments, PCa deaths, quality-adjusted and unadjusted life-years saved, and costs. RESULTS OF BASE-CASE ANALYSIS For 1000 men, first-line bpMRI versus first-line PSA testing prevented 2 to 3 PCa deaths and added 10 to 30 life-years (4 to 11 days per person) but increased the number of biopsies by 1506 to 4174 and the number of overdiagnoses by 38 to 124 depending on the biopsy imaging scheme. At conventional cost-effectiveness thresholds, first-line PSA testing with mpMRI followed by either biopsy approach for PI-RADS 4 to 5 produced the greatest net monetary benefits. RESULTS OF SENSITIVITY ANALYSIS First-line PSA testing remained more cost-effective even if bpMRI was free, all men with low-risk PCa underwent surveillance, or screening was quadrennial. LIMITATION Performance of first-line bpMRI was based on second-line mpMRI data. CONCLUSION Decision analysis suggests that comparative effectiveness and cost-effectiveness of PCa screening are driven by false-positive results and overdiagnoses, favoring first-line PSA testing with mpMRI over first-line bpMRI. PRIMARY FUNDING SOURCE National Cancer Institute.
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Affiliation(s)
- Roman Gulati
- Fred Hutchinson Cancer Center, Seattle, Washington
| | - Boshen Jiao
- Fred Hutchinson Cancer Center, Seattle, Washington
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, Washington
| | - Ra’ad Al-Faouri
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Sumedh Kaul
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Aaron Fleishman
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | - Aria F. Olumi
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ruth Etzioni
- Fred Hutchinson Cancer Center, Seattle, Washington
| | - Boris Gershman
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Martelin N, De Witt B, Chen B, Eschwège P. Development and validation of an imageless machine-learning algorithm for the initial screening of prostate cancer. Prostate 2024; 84:842-849. [PMID: 38571454 DOI: 10.1002/pros.24703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 06/02/2023] [Accepted: 03/20/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE Prostate specific antigen (PSA) testing is a low-cost screening method for prostate cancer (PCa). However, its accuracy is limited. While progress is being made using medical imaging for PCa screening, PSA testing can still be improved as an easily accessible first step in the screening process. We aimed to develop and validate a new model by further personalizing the analysis of PSA with demographic, medical history, lifestyle parameters, and digital rectal examination (DRE) results. METHODS Using data from 34,224 patients in the screening arm of the PLCO trial (22,188 for the training set and 12,036 for the validation set), we applied a gradient-boosting model whose features (Model 1) were one PSA value and the personal variables available in the PLCO trial except those that signaled an ex-ante assumption of PCa. A second algorithm (Model 2) included a DRE result. The primary outcome was the occurrence of PCa, while the aggressiveness of PCa was a secondary outcome. ROC analyses were used to compare both models to other initial screening tests. RESULTS The areas under the curve (AUC) for Model 2 was 0.894 overall and 0.908 for patients with a suspicious DRE, compared to 0.808 for PSA for patients with a suspicious DRE. The AUC for Model 1 was 0.814 compared to 0.821 for PSA. Model 2 predicted 58% more high-risk PCa than PSA ≥4 combined with an abnormal DRE and had a positive predictive value of 74.7% (vs. 50.6%). CONCLUSION Personalizing the interpretation of PSA values and DRE results with a gradient-boosting model showed promising results as a potential novel, low-cost method for the initial screening of PCa. The importance of DRE, when included in such a model, was also highlighted.
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Affiliation(s)
| | | | | | - Pascal Eschwège
- Urology Department, Nancy University Hospital, Vandœuvre-lès-Nancy, France
- Unité de Biologie des Tumeurs, CRAN UMR 7039 CNRS, Institut de cancérologie de Lorraine, Vandoeuvre-Lès-Nancy, France
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5
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Yang Z, Heijnsdijk EAM, Newcomb LF, Rizopoulos D, Erler NS. Exploring the relation of active surveillance schedules and prostate cancer mortality. Cancer Med 2024; 13:e6977. [PMID: 38491826 PMCID: PMC10943374 DOI: 10.1002/cam4.6977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 01/11/2024] [Accepted: 01/18/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Active surveillance (AS), where treatment is deferred until cancer progression is detected by a biopsy, is acknowledged as a way to reduce overtreatment in prostate cancer. However, a consensus on the frequency of taking biopsies while in AS is lacking. In former studies to optimize biopsy schedules, the delay in progression detection was taken as an evaluation indicator and believed to be associated with the long-term outcome, prostate cancer mortality. Nevertheless, this relation was never investigated in empirical data. Here, we use simulated data from a microsimulation model to fill this knowledge gap. METHODS In this study, the established MIcrosimulation SCreening Analysis model was extended with functionality to simulate the AS procedures. The biopsy sensitivity in the model was calibrated on the Canary Prostate Cancer Active Surveillance Study (PASS) data, and four (tri-yearly, bi-yearly, PASS, and yearly) AS programs were simulated. The relation between detection delay and prostate cancer mortality was investigated by Cox models. RESULTS The biopsy sensitivity of progression detection was found to be 50%. The Cox models show a positive relation between a longer detection delay and a higher risk of prostate cancer death. A 2-year delay resulted in a prostate cancer death risk of 2.46%-2.69% 5 years after progression detection and a 10-year risk of 5.75%-5.91%. A 4-year delay led to an approximately 8% greater 5-year risk and an approximately 25% greater 10-year risk. CONCLUSION The detection delay is confirmed as a surrogate for prostate cancer mortality. A cut-off for a "safe" detection delay could not be identified.
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Affiliation(s)
- Zhenwei Yang
- Department of BiostatisticsErasmus University Medical CenterRotterdamthe Netherlands
- Department of EpidemiologyErasmus University Medical CenterRotterdamthe Netherlands
| | | | - Lisa F. Newcomb
- Cancer Prevention Program, Public Health Sciences, Fred Hutchinson Cancer CenterSeattleWashingtonUSA
| | - Dimitris Rizopoulos
- Department of BiostatisticsErasmus University Medical CenterRotterdamthe Netherlands
- Department of EpidemiologyErasmus University Medical CenterRotterdamthe Netherlands
| | - Nicole S. Erler
- Department of BiostatisticsErasmus University Medical CenterRotterdamthe Netherlands
- Department of EpidemiologyErasmus University Medical CenterRotterdamthe Netherlands
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6
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Gulati R, Nyame YA, Lange JM, Shoag JE, Tsodikov A, Etzioni R. Racial disparities in prostate cancer mortality: a model-based decomposition of contributing factors. J Natl Cancer Inst Monogr 2023; 2023:212-218. [PMID: 37947332 PMCID: PMC10637024 DOI: 10.1093/jncimonographs/lgad018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/22/2023] [Accepted: 06/27/2023] [Indexed: 11/12/2023] Open
Abstract
To investigate the relative contributions of natural history and clinical interventions to racial disparities in prostate cancer mortality in the United States, we extended a model that was previously calibrated to Surveillance, Epidemiology, and End Results (SEER) incidence rates for the general population and for Black men. The extended model integrated SEER data on curative treatment frequencies and cancer-specific survival. Starting with the model for all men, we replaced up to 9 components with corresponding components for Black men, projecting age-standardized mortality rates for ages 40-84 years at each step. Based on projections in 2019, the increased frequency of developing disease, more aggressive tumor features, and worse cancer-specific survival in Black men diagnosed at local-regional and distant stages explained 38%, 34%, 22%, and 8% of the modeled disparity in mortality. Our results point to intensified screening and improved care in Black men as priority areas to achieve greater equity.
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Affiliation(s)
- Roman Gulati
- Division of Public Health Sciences, Biostatistics Program, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Yaw A Nyame
- Division of Public Health Sciences, Biostatistics Program, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA
| | - Jane M Lange
- Division of Public Health Sciences, Biostatistics Program, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Cancer Early Detection Advanced Research Center, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Jonathan E Shoag
- Department of Urology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Urology, Weill Cornell Medicine, New York, NY, USA
| | - Alex Tsodikov
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Ruth Etzioni
- Division of Public Health Sciences, Biostatistics Program, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Cancer Early Detection Advanced Research Center, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
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Padhani AR, Schoots IG. Prostate cancer screening-stepping forward with MRI. Eur Radiol 2023; 33:6670-6676. [PMID: 37154952 DOI: 10.1007/s00330-023-09673-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 03/22/2023] [Accepted: 04/10/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVE To comprehensively review the literature on the integration of MRI as a diagnostic tool in prostate cancer screening and offer practical recommendations for optimising its use. METHODS Existing research studies, clinical guidelines and expert opinions were reviewed to support the optimisation standards for MRI use in screening. Consolidated screening principles were used to make appropriate recommendations regarding the integration of MRI into the diagnostic pathway. RESULTS To strike a balance between the potential benefits of early detection on mortality and minimising the harm of over-diagnosing indolent cancers, it is necessary to have a clear understanding of the context of MRI use. The key to optimisation is patient selections and MRI-targeted biopsies. For men at higher-than-average risk, it is essential to use screening-specific MRI protocols and establish accuracy levels and interpretation criteria. Optimisation of readings by the automation of data acquisition, image quality monitoring, post-processing, radiologist certification and deep-learning computer-aided software is needed. The optimal utilisation of MRI involves its integration into a multistep diagnostic pathway, supported by a quality-assured and cost-effective infrastructure that ensures community-wide access to imaging. CONCLUSION MRI in the prostate cancer screening pathway can bring substantial diagnostic benefits. By carefully considering its advantages, limitations and safety concerns and integrating it into a multistep diagnostic pathway, clinicians can improve outcomes while minimising harm to screening participants. CLINICAL RELEVANCE STATEMENT The manuscript discusses the role of MRI in prostate cancer screening, highlighting its potential to improve accuracy and reduce overdiagnosis. It emphasises the importance of optimising protocols and integrating MRI into a multistep diagnostic pathway for successfully delivering screening benefits. KEY POINTS • Population screening for prostate cancer is a new indication for prostate MRI that allows the detection of high-risk cancers while reducing the need for biopsies and associated harm. • To optimise prostate cancer screening using MRI, it is essential to redefine MRI protocols; establish accuracy levels, reliability and interpretation criteria; and optimise reading (including post-processing, image quality, radiologist certification, and deep-learning computer-aided software). • The optimal utilisation of MRI for prostate cancer screening would involve its integration into a multistep diagnostic pathway, supported by a quality-assured and cost-effective infrastructure that ensures community-wide access to imaging.
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Affiliation(s)
- Anwar R Padhani
- Paul Strickland Scanner Centre, Mount Vernon Cancer Centre, Northwood, UK.
| | - Ivo G Schoots
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
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Chen DM, Dong R, Kachuri L, Hoffmann T, Jiang Y, Berndt SI, Shelley JP, Schaffer KR, Machiela MJ, Freedman ND, Huang WY, Li SA, Lilja H, Van Den Eeden SK, Chanock S, Haiman CA, Conti DV, Klein RJ, Mosley JD, Witte JS, Graff RE. Transcriptome-Wide Association Analysis Identifies Novel Candidate Susceptibility Genes for Prostate-Specific Antigen Levels in Men Without Prostate Cancer. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.04.23289526. [PMID: 37205487 PMCID: PMC10187439 DOI: 10.1101/2023.05.04.23289526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Deciphering the genetic basis of prostate-specific antigen (PSA) levels may improve their utility to screen for prostate cancer (PCa). We thus conducted a transcriptome-wide association study (TWAS) of PSA levels using genome-wide summary statistics from 95,768 PCa-free men, the MetaXcan framework, and gene prediction models trained in Genotype-Tissue Expression (GTEx) project data. Tissue-specific analyses identified 41 statistically significant (p < 0.05/12,192 = 4.10e-6) associations in whole blood and 39 statistically significant (p < 0.05/13,844 = 3.61e-6) associations in prostate tissue, with 18 genes associated in both tissues. Cross-tissue analyses that combined associations across 45 tissues identified 155 genes that were statistically significantly (p < 0.05/22,249 = 2.25e-6) associated with PSA levels. Based on conditional analyses that assessed whether TWAS associations were attributable to a lead GWAS variant, we found 20 novel genes (11 single-tissue, 9 cross-tissue) that were associated with PSA levels in the TWAS. Of these novel genes, five showed evidence of colocalization (colocalization probability > 0.5): EXOSC9, CCNA2, HIST1H2BN, RP11-182L21.6, and RP11-327J17.2. Six of the 20 novel genes are not known to impact PCa risk. These findings yield new hypotheses for genetic factors underlying PSA levels that should be further explored toward improving our understanding of PSA biology.
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Affiliation(s)
- Dorothy M. Chen
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, 94158, USA
| | - Ruocheng Dong
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, 94305, USA
| | - Linda Kachuri
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, 94305, USA
- Stanford Cancer Institute, Stanford University, Stanford, CA, 94305, USA
| | - Thomas Hoffmann
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, 94158, USA
- Institute for Human Genetics, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Yu Jiang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, 94158, USA
| | - Sonja I. Berndt
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, 20814, USA
| | - John P. Shelley
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Kerry R. Schaffer
- Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
- Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Mitchell J. Machiela
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, 20814, USA
| | - Neal D. Freedman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, 20814, USA
| | - Wen-Yi Huang
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, 20814, USA
| | - Shengchao A. Li
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, 20814, USA
| | - Hans Lilja
- Departments of Pathology and Laboratory Medicine, Surgery, Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
- Department of Translational Medicine, Lund University, Malmö, 21428, Sweden
| | | | - Stephen Chanock
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, 20814, USA
| | - Christopher A. Haiman
- Center for Genetic Epidemiology, Department of Population and Preventive Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90032, USA
- Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - David V. Conti
- Center for Genetic Epidemiology, Department of Population and Preventive Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90032, USA
- Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Robert J. Klein
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Jonathan D. Mosley
- Departments of Internal Medicine and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - John S. Witte
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, 94158, USA
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, 94305, USA
- Departments of Biomedical Data Science and Genetics (by courtesy), Stanford University, Stanford, CA, 94305, USA
| | - Rebecca E. Graff
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, 94158, USA
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Ola IO, Talala K, Tammela T, Taari K, Murtola T, Kujala P, Raitanen J, Auvinen A. Prostate cancer incidence in men with prostate-specific antigen below 3 ng/mL: The Finnish Randomized Study of Screening for Prostate Cancer. Int J Cancer 2023; 152:672-678. [PMID: 36056577 PMCID: PMC10087780 DOI: 10.1002/ijc.34274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/04/2022] [Accepted: 08/08/2022] [Indexed: 02/01/2023]
Abstract
Prostate-specific antigen (PSA)-based screening for prostate cancer (PCa) can reduce PCa mortality, but also involves overdetection of low-risk disease with potential adverse effects. We evaluated PCa incidence among men with PSA below 3 ng/mL and no PCa diagnosis at the first screening round of the Finnish Randomized Study of Screening for PCa. Follow-up started at the first screening attendance and ended at PCa diagnosis, emigration, death or the common closing date (December 2016), whichever came first. Cox regression analysis was used to estimate hazard ratios and their confidence intervals (CI). Among men with PSA <3 ng/mL, cumulative PCa incidence was 9.1% after 17.6 years median follow-up. Cumulative incidence was 3.6% among men with baseline PSA 0 to 0.99 ng/mL, 11.5% in those with PSA 1.0 to 1.99 ng/mL and 25.7% among men with PSA 2 to 2.99 ng/mL (hazard ratio 9.0, 95% CI: 7.9-10.2 for the latter). The differences by PSA level were most striking for low-risk disease based on Gleason score and EAU risk group. PSA values <1 ng/mL indicate a very low 20-year risk, while at PSA 2 to 2.99 ng/mL risks are materially higher, with 4- to 5-fold risk for aggressive disease. Using risk-stratification and appropriate rescreening intervals will reduce screening intensity and overdetection. Using cumulative incidence of clinically significant PCa (csPCa) as the criterion, rescreening intervals could range from approximately 3 years for men with initial PSA 2 to 2.99 ng/mL, 6 years for men with PSA 1 to 1.99 ng/mL to 10 years for men with PSA <1 ng/mL.
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Affiliation(s)
- Idris Olasunmbo Ola
- Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | | | - Teuvo Tammela
- Department of Urology, TAYS Cancer Center, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Kimmo Taari
- Department of Urology, Helsinki University Hospital, Helsinki, Finland.,Medical Faculty, University of Helsinki, Helsinki, Finland
| | - Teemu Murtola
- Department of Urology, TAYS Cancer Center, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Paula Kujala
- Department of Pathology, Fimlab Laboratories, Tampere, Finland
| | - Jani Raitanen
- Faculty of Social Sciences, Tampere University, Tampere, Finland.,UKK Institute for Health Promotion Research, Tampere, Finland
| | - Anssi Auvinen
- Faculty of Social Sciences, Tampere University, Tampere, Finland
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10
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Kim EH, Andriole GL. Should men undergo MRI before prostate biopsy - CON. Urol Oncol 2023; 41:92-95. [PMID: 34602360 DOI: 10.1016/j.urolonc.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/06/2021] [Indexed: 10/20/2022]
Abstract
Prostate magnetic resonance imaging (MRI) is increasingly used prior to biopsy in response to the overdiagnosis and overtreatment of prostate cancer (CaP) associated with prostate-specific antigen (PSA) based screening. However, technical limitations in the conventional diffusion-weighted imaging (DWI) sequences as well as the high degree of radiologist-to-radiologist variability in interpreting prostate MRI result in inadequate accuracy. Specifically, the insufficient negative predictive value (NPV) of prostate MRI (76%-87%) does not allow biopsy to be omitted in the negative MRI setting. Additionally, the variable, and relatively low positive predictive value (PPV) of MRI (27%-44%) provides only an incremental improvement in risk prediction compared to readily available clinical tools such as the Prostate Cancer Prevention Trial risk calculator. This small benefit is likely confined to the minority of patients with positive MRI findings in a typically under-sampled region of the prostate (e.g., anterior lesions), which may be obviated by newer biopsy approaches and tools such as transperineal prostate biopsy and micro-ultrasound technology. With these considerations in mind, pre-biopsy prostate MRI in its current form is unlikely to provide a clinically significant benefit, and should not be considered as routine practice until its accuracy is sufficiently improved.
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Affiliation(s)
- Eric H Kim
- Division of Urologic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Gerald L Andriole
- Division of Urologic Surgery, Washington University School of Medicine, St. Louis, MO.
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11
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Li FP, Zhang MX, Wang LJ, Zhu XL, Sun LX, Chen ZX, Chen WY, Liu DY, Li HP, Jiang YY, Tung TH. Design and Implementation of Taizhou Integrated Prostate Screening. Am J Mens Health 2022; 16:15579883221138192. [PMID: 36412060 PMCID: PMC9703546 DOI: 10.1177/15579883221138192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A community-based prostate cancer screening program was conducted to assess the morbidity and associated factors for prostate cancer among the subpopulation of men aged ≥50 years in Taizhou, China. Taizhou Integrated Prostate Screening (TIPS) is a large, observational, population-based study of prostate cancer screening data based on serum prostate-specific antigen (PSA) concentrations. A pilot census of all male residents aged 50 years or older was conducted in Luqiao District, one of the field sites of the TIPS cohort in the city of Taizhou, Zhejiang. The interviewer-administered questionnaire evaluated demographic characteristics and environmental exposure factors. A total of 1,806 out of 3,516 participants completed the questionnaire. The overall prevalence of PSA ≥4 ng/mL was 11.5%, and included participants at low risk (9.2%), moderate risk (1.7%), and high risk (0.6%). Participants aged 60-69, 70-79, and ≥80 years had a 2.7-fold, 4.2-fold, and 6.5-fold higher risk of elevated PSA, respectively, in comparison with those aged 50 to 59 years (p < .001). Eighteen patients were diagnosed with prostate cancer, of whom 11 (61.1%) underwent radical surgery. This community-based PSA screening program indicated the results for early detection of prostate cancer among men aged ≥50 years. Early screening and appropriate clinical therapy for the management of prostate cancer are essential in this subpopulation.
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Affiliation(s)
- Fei-Ping Li
- Department of Urology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Enze Hospital, Taizhou Enze Medical Center (Group), Taizhou, China
| | - Mei-Xian Zhang
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Li-Jun Wang
- Department of Urology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Enze Hospital, Taizhou Enze Medical Center (Group), Taizhou, China
| | - Xiao-Liang Zhu
- Department of Urology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Enze Hospital, Taizhou Enze Medical Center (Group), Taizhou, China
| | - Liang-Xue Sun
- Department of Urology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Enze Hospital, Taizhou Enze Medical Center (Group), Taizhou, China
| | - Zhi-Xia Chen
- Department of Urology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Enze Hospital, Taizhou Enze Medical Center (Group), Taizhou, China
| | - Wei-Ying Chen
- Department of Urology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Enze Hospital, Taizhou Enze Medical Center (Group), Taizhou, China
| | - Ding-Yi Liu
- Department of Urology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Enze Hospital, Taizhou Enze Medical Center (Group), Taizhou, China
| | - Hai-Ping Li
- Department of Urology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Enze Hospital, Taizhou Enze Medical Center (Group), Taizhou, China
| | - Yu-Ying Jiang
- Department of Urology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Enze Hospital, Taizhou Enze Medical Center (Group), Taizhou, China
| | - Tao-Hsin Tung
- Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China,Tao-Hsin Tung, Evidence-Based Medicine Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, Zhejiang 317000, China.
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12
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Van Poppel H, Albreht T, Basu P, Hogenhout R, Collen S, Roobol M. Serum PSA-based early detection of prostate cancer in Europe and globally: past, present and future. Nat Rev Urol 2022; 19:562-572. [PMID: 35974245 DOI: 10.1038/s41585-022-00638-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 12/14/2022]
Abstract
In the pre-PSA-detection era, a large proportion of men were diagnosed with metastatic prostate cancer and died of the disease; after the introduction of the serum PSA test, randomized controlled prostate cancer screening trials in the USA and Europe were conducted to assess the effect of PSA screening on prostate cancer mortality. Contradictory outcomes of the trials and the accompanying overdiagnosis resulted in recommendations against prostate cancer screening by organizations such as the United States Preventive Services Task Force. These recommendations were followed by a decline in PSA testing and a rise in late-stage diagnosis and prostate cancer mortality. Re-evaluation of the randomized trials, which accounted for contamination, showed that PSA-based screening does indeed reduce prostate cancer mortality; however, the debate about whether to screen or not to screen continues because of the considerable overdiagnosis that occurs using PSA-based screening. Meanwhile, awareness among the population of prostate cancer as a potentially lethal disease stimulates opportunistic screening practices that further increase overdiagnosis without the benefit of mortality reduction. However, in the past decade, new screening tools have been developed that make the classic PSA-only-based screening an outdated strategy. With improved use of PSA, in combination with age, prostate volume and with the application of prostate cancer risk calculators, a risk-adapted strategy enables improved stratification of men with prostate cancer and avoidance of unnecessary diagnostic procedures. This combination used with advanced detection techniques (such as MRI and targeted biopsy), can reduce overdiagnosis. Moreover, new biomarkers are becoming available and will enable further improvements in risk stratification.
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Affiliation(s)
| | - Tit Albreht
- National Institute of Public Health, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Partha Basu
- International Agency for Research on Cancer, Lyon, France
| | - Renée Hogenhout
- Erasmus University Medical Center, Cancer Institute, Rotterdam, Netherlands
| | - Sarah Collen
- European Association of Urology, Arnhem, Netherlands
| | - Monique Roobol
- Erasmus University Medical Center, Cancer Institute, Rotterdam, Netherlands
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13
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Abstract
PURPOSE Our goal was to analyze results from 22 years of followup in the Göteborg randomized prostate cancer (PC) screening trial. MATERIALS AND METHODS In December 1994, 20,000 men born 1930-1944 were randomly extracted from the Swedish population register and were randomized (1:1) into either a screening group (SG) or to a control group (CG). Men in the SG were repeatedly invited for biennial prostate specific antigen testing up to an average age of 69 years. Main endpoints were PC incidence and mortality (intention-to-screen principle). RESULTS After 22 years, 1,528 men in the SG and 1,124 men in the CG had been diagnosed with PC. In total, 112 PC deaths occurred in the SG and 158 in the CG. Compared with the CG, the SG showed a PC incidence rate ratio (RR) of 1.42 (95% CI, 1.31-1.53) and a PC mortality RR of 0.71 (95% CI, 0.55-0.91). The 22-year cumulative PC mortality rate was 1.55% (95% CI, 1.29-1.86) in the SG and 2.13% (95% CI, 1.83-2.49) in the CG. Correction for nonattendance (Cuzick method) yielded a RR of PC mortality of 0.59 (95% CI, 0.43-0.80). Number needed to invite and number needed to diagnose was estimated to 221 and 9, respectively. PC death risk was increased in the following groups: nontesting men, men entering the program after age 60 and men with >10 years of followup after screening termination. CONCLUSIONS Prostate specific antigen-based screening substantially decreases PC mortality. However, not attending, starting after age 60 and stopping at age 70 seem to be major pitfalls regarding PC death risk.
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14
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Improved Harm/Benefit Ratio and Cost-effectiveness of Prostate Cancer Screening Using New Technologies. Eur Urol 2022; 82:20-21. [DOI: 10.1016/j.eururo.2022.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 01/20/2022] [Indexed: 11/17/2022]
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15
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Karunasinghe N, Minas TZ, Bao BY, Lee A, Wang A, Zhu S, Masters J, Goudie M, Huang SP, Jenkins FJ, Ferguson LR. Assessment of factors associated with PSA level in prostate cancer cases and controls from three geographical regions. Sci Rep 2022; 12:55. [PMID: 34997089 PMCID: PMC8742081 DOI: 10.1038/s41598-021-04116-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 12/15/2021] [Indexed: 11/22/2022] Open
Abstract
It is being debated whether prostate-specific antigen (PSA)-based screening effectively reduces prostate cancer mortality. Some of the uncertainty could be related to deficiencies in the age-based PSA cut-off thresholds used in screening. Current study considered 2779 men with prostate cancer and 1606 men without a cancer diagnosis, recruited for various studies in New Zealand, US, and Taiwan. Association of PSA with demographic, lifestyle, clinical characteristics (for cases), and the aldo–keto reductase 1C3 (AKR1C3) rs12529 genetic polymorphisms were analysed using multiple linear regression and univariate modelling. Pooled multivariable analysis of cases showed that PSA was significantly associated with demographic, lifestyle, and clinical data with an interaction between ethnicity and age further modifying the association. Pooled multivariable analysis of controls data also showed that demographic and lifestyle are significantly associated with PSA level. Independent case and control analyses indicated that factors associated with PSA were specific for each cohort. Univariate analyses showed a significant age and PSA correlation among all cases and controls except for the US-European cases while genetic stratification in cases showed variability of correlation. Data suggests that unique PSA cut-off thresholds factorized with demographics, lifestyle and genetics may be more appropriate for prostate cancer screening.
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Affiliation(s)
- Nishi Karunasinghe
- Auckland Cancer Society Research Centre, Faculty of Medical and Health Sciences (FMHS), University of Auckland, Private Bag 92019, Auckland, New Zealand.
| | - Tsion Zewdu Minas
- Molecular Epidemiology Section, Laboratory of Human Carcinogenesis, National Cancer Institute, NIH, Bethesda, MD, 20892, USA
| | - Bo-Ying Bao
- Department of Pharmacy, China Medical University, Taichung, 404, Taiwan
| | - Arier Lee
- Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Alice Wang
- Auckland Cancer Society Research Centre, Faculty of Medical and Health Sciences (FMHS), University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Shuotun Zhu
- Auckland Cancer Society Research Centre, Faculty of Medical and Health Sciences (FMHS), University of Auckland, Private Bag 92019, Auckland, New Zealand
| | | | - Megan Goudie
- Urology Department, Auckland City Hospital, Auckland, New Zealand
| | - Shu-Pin Huang
- Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, 807, Taiwan.,Center for Cancer Research, Kaohsiung Medical University, Kaohsiung, 807, Taiwan
| | - Frank J Jenkins
- Infectious Diseases and Microbiology and Clinical and Translational Science Institute, The University of Pittsburgh Medical Center, Hillman Cancer Center, Pittsburgh, PA, USA
| | - Lynnette R Ferguson
- Emeritus Professor, FMHS, University of Auckland, Private Bag 92019, Auckland, New Zealand
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16
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Mansi R, Nock BA, Dalm SU, Busstra MB, van Weerden WM, Maina T. Radiolabeled Bombesin Analogs. Cancers (Basel) 2021; 13:cancers13225766. [PMID: 34830920 PMCID: PMC8616220 DOI: 10.3390/cancers13225766] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/13/2021] [Accepted: 11/15/2021] [Indexed: 12/16/2022] Open
Abstract
Simple Summary Recent medical advancements have strived for a personalized medicine approach to patients, aimed at optimizing therapy outcomes with minimum toxicity. In this respect, nuclear medicine methodologies have been playing increasingly important roles. For example, the overexpression of peptide receptors, such as the gastrin-releasing peptide receptor (GRPR), on tumor cells as opposed to their lack of expression in healthy surrounding tissues can be elegantly exploited with the aid of “smart” peptide carriers, such as the analogs of the amphibian 14-peptide bombesin (BBN). These molecules can bring clinically attractive radionuclides to malignant lesions in prostate, breast, and other human cancers, sparing healthy tissues. Depending upon the radionuclide in question, diagnostic imaging with single-photon emission computed tomography (SPECT) or positron emission tomography (PET) has been pursued, identifying patients who are eligible for peptide radionuclide receptor therapy (PRRT) in an integrated “theranostic” approach. In the present review, we (i) discuss the major steps taken in the development of anti-GRPR theranostic radioligands, with a focus on those selected for clinical testing; (ii) comment on the present status in this field of research; and (iii) reflect on the current limitations as well as on new opportunities for their broader and more successful clinical applications. Abstract The gastrin-releasing peptide receptor (GRPR) is expressed in high numbers in a variety of human tumors, including the frequently occurring prostate and breast cancers, and therefore provides the rationale for directing diagnostic or therapeutic radionuclides on cancer lesions after administration of anti-GRPR peptide analogs. This concept has been initially explored with analogs of the frog 14-peptide bombesin, suitably modified at the N-terminus with a number of radiometal chelates. Radiotracers that were selected for clinical testing revealed inherent problems associated with these GRPR agonists, related to low metabolic stability, unfavorable abdominal accumulation, and adverse effects. A shift toward GRPR antagonists soon followed, with safer analogs becoming available, whereby, metabolic stability and background clearance issues were gradually improved. Clinical testing of three main major antagonist types led to promising outcomes, but at the same time brought to light several limitations of this concept, partly related to the variation of GRPR expression levels across cancer types, stages, previous treatments, and other factors. Currently, these parameters are being rigorously addressed by cell biologists, chemists, nuclear medicine physicians, and other discipline practitioners in a common effort to make available more effective and safe state-of-the-art molecular tools to combat GRPR-positive tumors. In the present review, we present the background, current status, and future perspectives of this endeavor.
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Affiliation(s)
- Rosalba Mansi
- Division of Radiopharmaceutical Chemistry, Clinic of Radiology and Nuclear Medicine University Hospital Basel, 4031 Basel, Switzerland;
| | - Berthold A. Nock
- Molecular Radiopharmacy, INRaSTES, NCSR “Demokritos”, 15310 Athens, Greece;
| | - Simone U. Dalm
- Erasmus Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (S.U.D.); (M.B.B.); (W.M.v.W.)
| | - Martijn B. Busstra
- Erasmus Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (S.U.D.); (M.B.B.); (W.M.v.W.)
| | - Wytske M. van Weerden
- Erasmus Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (S.U.D.); (M.B.B.); (W.M.v.W.)
| | - Theodosia Maina
- Molecular Radiopharmacy, INRaSTES, NCSR “Demokritos”, 15310 Athens, Greece;
- Correspondence: ; Tel.: +30-650-3908/3891
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17
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Hendrix N, Gulati R, Jiao B, Kader AK, Ryan ST, Etzioni R. Clarifying the Trade-Offs of Risk-Stratified Screening for Prostate Cancer: A Cost-Effectiveness Study. Am J Epidemiol 2021; 190:2064-2074. [PMID: 34023874 DOI: 10.1093/aje/kwab155] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 05/13/2021] [Accepted: 05/18/2021] [Indexed: 12/18/2022] Open
Abstract
Cancer risk prediction is necessary for precision early detection, which matches screening intensity to risk. However, practical steps for translating risk predictions to risk-stratified screening policies are not well established. We used a validated population prostate-cancer model to simulate the outcomes of strategies that increase intensity for men at high risk and reduce intensity for men at low risk. We defined risk by the Prompt Prostate Genetic Score (PGS) (Stratify Genomics, San Diego, California), a germline genetic test. We first recalibrated the model to reflect the disease incidence observed within risk strata using data from a large prevention trial where some participants were tested with Prompt PGS. We then simulated risk-stratified strategies in a population with the same risk distribution as the trial and evaluated the cost-effectiveness of risk-stratified screening versus universal (risk-agnostic) screening. Prompt PGS risk-adapted screening was more cost-effective when universal screening was conservative. Risk-stratified strategies improved outcomes at a cost of less than $100,000 per quality-adjusted life year compared with biennial screening starting at age 55 years, but risk stratification was not cost-effective compared with biennial screening starting at age 45. Heterogeneity of risk and fraction of the population within each stratum were also important determinants of cost-effectiveness.
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18
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Scailteux LM, Capelle V, Balusson F, Oger E, Vincendeau S, Mathieu R, Chapron A. Changes in prostate cancer screening practice by blood PSA testing between 2011 and 2017, a French population-based study. Curr Med Res Opin 2021; 37:1435-1441. [PMID: 34134580 DOI: 10.1080/03007995.2021.1944075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of the study was to determine the trend of first blood prostate-specific antigen (PSA) test prescription in France between 2011 and 2017, based on the assumption that prostate cancer (PCa) screening is expected to decline over the years. METHOD Using a representative sample of the French population from the French Health Insurance database, we identified 50-52-year-old men without PCa and without any blood PSA test in the five years before 2011, 2014 and 2017 (January 1-December 31 of each year). For each of these three years, the primary outcome was the first reimbursement of a blood PSA test. We used a logistic regression model with first blood PSA test as the outcome and year as the main explanatory variable. As secondary objectives, we also identified the prescriber's specialty, the urological consultation frequency, and the number of prostate biopsies in the year after the first blood PSA test reimbursement (only for 2011 and 2014). RESULTS In 2011, 2014 and 2017, 5 275, 5 792 and 5 887 50-52-year-old men, respectively, were included. The percentage of patients with a first blood PSA test prescription decreased linearly from 2011 to 2017: 15.7% in 2011, 13.2% in 2014, and 12.4% in 2017 (p < .001). Blood PSA testing was mainly prescribed by general practitioners (>95%). The median interval between PSA tests was 13 months in 2011 and 14 months in 2014. Fewer than 10% of men had ≥1 consultation with an urologist during the year after the first blood PSA test. After the first blood PSA test, eight prostate biopsies were performed in 2011 and two in 2014. CONCLUSION Our results suggest that in France, PCa screening is a primary care issue. Although PCa screening remains controversial and confusion exists about the best practice, our study showed a linear decrease of blood PSA test prescriptions for 50-52-year-old men between 2011 and 2017, although the reason for screening was unknown. As clinical information was not available, additional evidence is needed to determine the real impact of this decrease on the cancer-specific and overall mortality.
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Affiliation(s)
- Lucie-Marie Scailteux
- Pharmacovigilance, Pharmacoepidemiology and Drug Information Center, Rennes University Hospital, Rennes, France
- Univ Rennes, CHU Rennes, REPERES [Pharmacoepidemiology and Heath Services Research], Rennes, France
| | | | - Frédéric Balusson
- Univ Rennes, CHU Rennes, REPERES [Pharmacoepidemiology and Heath Services Research], Rennes, France
| | - Emmanuel Oger
- Pharmacovigilance, Pharmacoepidemiology and Drug Information Center, Rennes University Hospital, Rennes, France
- Univ Rennes, CHU Rennes, REPERES [Pharmacoepidemiology and Heath Services Research], Rennes, France
| | | | - Romain Mathieu
- Urology Department, Rennes University Hospital, Rennes
- Univ Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
| | - Anthony Chapron
- Département de Médecine Générale, Univ Rennes, Rennes, France
- Univ Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), Rennes, France
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19
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Jiao B, Gulati R, Hendrix N, Gore JL, Rais-Bahrami S, Morgan TM, Etzioni R. Economic Evaluation of Urine-Based or Magnetic Resonance Imaging Reflex Tests in Men With Intermediate Prostate-Specific Antigen Levels in the United States. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1111-1117. [PMID: 34372976 PMCID: PMC8358184 DOI: 10.1016/j.jval.2021.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 02/03/2021] [Accepted: 02/28/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES For men with intermediate prostate-specific antigen (PSA) levels (4-10 ng/mL), urine-based biomarkers and multiparametric magnetic resonance imaging (MRI) are increasingly used as reflex tests before prostate biopsy. We assessed the cost effectiveness of these reflex tests in the United States. METHODS We used an existing microsimulation model of prostate cancer (PCa) progression and survival to predict lifetime outcomes for a hypothetical cohort of 55-year-old men with intermediate PSA levels. Urine-based biomarkers-PCa antigen (PCA3), TMPRSS2:ERG gene fusion (T2:ERG), and the MyProstateScore (MPS) for any PCa and for high-grade (Gleason score ≥7) PCa (MPShg)-were generated using biomarker data from 1112 men presenting for biopsy at 10 United States institutions. MRI results were based on published sensitivity and specificity for high-grade PCa. Costs and utilities were sourced from literature and Medicare reimbursement schedules. Outcome measures included life years, quality-adjusted life years (QALYs), and lifetime medical costs per patient. Incremental cost-effectiveness ratios were empirically calculated on the basis of simulated life histories under different reflex testing strategies. RESULTS Biopsying all men provided the most life years and QALYs, followed by reflex testing using MPShg, MPS, MRI, T2:ERG, PCA3, and biopsying no men (QALY range across strategies 15.98-16.09). Accounting for costs, MRI and MPShg were dominated by other strategies. PCA3, T2:ERG, and MPS were likely to be the most cost-effective strategy at willingness-to-pay thresholds of $100 000/QALY, $125 000/QALY, and $150 000/QALY, respectively. CONCLUSIONS Using PCA3, T2:ERG, or MPS as reflex tests has greater economic value than MRI, biopsying all men, or biopsying no men with intermediate PSA levels.
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Affiliation(s)
- Boshen Jiao
- Division of Public Health Science, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA
| | - Roman Gulati
- Division of Public Health Science, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
| | - Nathaniel Hendrix
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA
| | - John L Gore
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Soroush Rais-Bahrami
- Department of Urology, Department of Radiology, and O'Neal Comprehensive Cancer Center at UAB, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Todd M Morgan
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Ruth Etzioni
- Division of Public Health Science, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Chiam K, Bang A, Patel MI, Nair-Shalliker V, O'Connell DL, Smith DP. Characteristics Associated with the Use of Diagnostic Prostate Biopsy and Biopsy Outcomes in Australian Men. Cancer Epidemiol Biomarkers Prev 2021; 30:1735-1743. [PMID: 34155065 DOI: 10.1158/1055-9965.epi-20-1571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/28/2021] [Accepted: 06/04/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Population characteristics associated with the use of prostate biopsy are poorly understood. We described the use of diagnostic prostate biopsy and subsequent biopsy outcomes in a population-based Australian cohort. METHODS A total of 91,764 men from the Sax Institute's 45 and Up Study (New South Wales, Australia) recruited during 2006 to 2009 were included. Self-completed baseline questionnaires and linked administrative health data were used. Study period was from the date of recruitment to December 2013. Cox regression and logistic regression identified factors associated with receipt of biopsy and subsequent prostate cancer diagnosis. RESULTS During the study period, 5,089 participants had a diagnostic prostate biopsy, and 2,805 men (55.1% of those biopsied) received a cancer diagnosis. Men with a family history of prostate cancer (HR 1.55; 95% confidence interval (CI), 1.43-1.68), severe lower urinary tract symptoms (HR 1.62; 95% CI, 1.41-1.86), or a record of medication for benign prostatic hyperplasia (HR 1.34; 95% CI, 1.23-1.47) had increased risks of receiving a biopsy. Men with a family history of prostate cancer had increased odds of a positive biopsy (OR 1.21; 95% CI, 1.01-1.43). High alcohol consumption (≥21 drinks per week compared with 1-6 drinks per week) was associated with decreased risk of biopsy (HR 0.88; 95% CI, 0.80-0.96) but increased odds of a positive biopsy (OR 1.63; 95% CI, 1.32-2.02). CONCLUSIONS Certain characteristics are associated with both undertaking diagnostic prostate biopsy and positive biopsy outcomes. IMPACT This highlights the need to improve management of specific groups of men, especially those with clinical symptoms that overlap with prostate cancer, in their investigation for prostate cancer.
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Affiliation(s)
- Karen Chiam
- Daffodil Centre, The University of Sydney, a joint venture with Cancer Council New South Wales, New South Wales, Australia.
| | - Albert Bang
- Daffodil Centre, The University of Sydney, a joint venture with Cancer Council New South Wales, New South Wales, Australia
| | - Manish I Patel
- Department of Urology, Westmead Hospital, New South Wales, Australia
- Discipline of Surgery, Sydney Medical School, University of Sydney, New South Wales, Australia
| | - Visalini Nair-Shalliker
- Daffodil Centre, The University of Sydney, a joint venture with Cancer Council New South Wales, New South Wales, Australia
- Department of Clinical Medicine, Macquarie University, New South Wales, Australia
| | - Dianne L O'Connell
- Daffodil Centre, The University of Sydney, a joint venture with Cancer Council New South Wales, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, New South Wales, Australia
| | - David P Smith
- Daffodil Centre, The University of Sydney, a joint venture with Cancer Council New South Wales, New South Wales, Australia
- Menzies Health Institute, Griffith University, Queensland, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Kappen S, Jürgens V, Freitag MH, Winter A. Attitudes Toward and Use of Prostate-Specific Antigen Testing Among Urologists and General Practitioners in Germany: A Survey. Front Oncol 2021; 11:691197. [PMID: 34150662 PMCID: PMC8213068 DOI: 10.3389/fonc.2021.691197] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/18/2021] [Indexed: 11/21/2022] Open
Abstract
Background In 2020, around 1.4 million new prostate cancer (PCa) cases were recorded worldwide. Early detection of PCa by prostate-specific antigen (PSA) screening remains debated, leading to different specialist-specific recommendations in PCa guidelines. This study aimed to assess attitudes toward and use of PSA testing among urologists in Germany and general practitioners (GPs) in Lower Saxony (Germany). Methods A nationwide questionnaire was sent to urologists via the mailing lists of the Professional Association of German Urologists and the German Urological Society. A version of the questionnaire for GPs was sent to email addresses via the Association of Statutory Health Insurance Physicians Lower Saxony. The online questionnaires covered use of PSA testing, information communication, handling of test results, and handling of/knowledge about national and international guidelines and recommendations on early detection of PCa. Statistical analysis was performed at a descriptive level. Results In total, 432 of 6,568 urologists (6.6%) and 96 of 1,579 GPs (6.1%) participated in this survey. Urologists and GPs differed in their attitudes and approaches toward PSA testing. Most urologists (86.8%, n=375) judged the test as “very meaningful” or “meaningful”, compared with 52.1% (n=50) of GPs. Almost two-thirds of the urologists (64.4%, n=278) viewed the PCa mortality reduction by PSA testing as proven, compared with one-fifth of GPs (20.8%, n=20). Almost 80% of male urologists (79.9%, n=291) indicated that they would undergo a PSA test in the future (again), compared with 55.1% of male GPs (n=38). In addition, 56.3% (n=243) of urologists stated that “considerably more than half” or “almost all” men aged 45 years or older received a PSA test, compared with 19.8% (n=19) of GPs. Conclusions Urologists are more convinced about the PSA test than GPs. PSA testing is therefore used more often in urological settings, although the preselected patient population must be considered. In accordance with specialist-specific recommendations, GPs show a more reserved approach toward PSA testing. Instead of focusing on different attitudes and recommendations on PSA testing, the exchange between specialist groups should be improved to achieve a consistent approach to PSA testing.
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Affiliation(s)
- Sanny Kappen
- Division of Epidemiology and Biometry, Department of Health Services Research, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Verena Jürgens
- Division of Epidemiology and Biometry, Department of Health Services Research, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Michael H Freitag
- Division of General Practice, Department of Health Services Research, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Alexander Winter
- University Hospital for Urology, Klinikum Oldenburg, Department of Human Medicine, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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22
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Kappen S, de Bock GH, Sirri E, Vohmann C, Kieschke J, Winter A. Differences in Prostate Cancer Incidence and Mortality in Lower Saxony (Germany) and Groningen Province (Netherlands): Potential Impact of Prostate-Specific Antigen Testing. Front Oncol 2021; 11:681006. [PMID: 34123851 PMCID: PMC8194402 DOI: 10.3389/fonc.2021.681006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/30/2021] [Indexed: 12/12/2022] Open
Abstract
Background Prostate cancer (PCa) is the most frequent cancer among men in Europe. Differences in PCa incidence around the world can be partly explained by variations in recommendations for prostate-specific antigen (PSA), particularly for early detection. For example, the PSA testing policy is more conservative in the Netherlands than in Germany. To better understand the relationship between PSA testing recommendations and PCa incidence, stage distribution, and mortality, we compared these variables over time between Lower Saxony in northwestern Germany and the neighboring province of Groningen in the Netherlands. Methods Population data, tumor stage- and age group-specific PCa incidence (ICD-10 C61) and mortality rates for Lower Saxony and Groningen were obtained from the Lower Saxony Epidemiological Cancer Registry, the Netherlands Comprehensive Cancer Organization, and Statistics Netherlands for 2003–2012. Incidence and mortality rates per 100,000 person-years were age-standardized (ASR, old European standard). Trends in age-standardized incidence rates (ASIR) and mortality rates (ASMR) for specific age groups were assessed using joinpoint regression. Results The mean annual PCa ASIR between 2003 and 2012 was on average 19.9% higher in Lower Saxony than in Groningen (120.5 vs. 100.5 per 100,000), while the mean annual ASMR was on average 24.3% lower in Lower Saxony than in Groningen (21.5 vs. 28.4 per 100,000). Between 2003 and 2012, the average annual percentage change (AAPC) in PCa incidence rates did not change significantly in either Lower Saxony (−1.8%, 95% CI −3.5, 0.0) or Groningen (0.2%, 95% CI −5.0, 5.7). In contrast, the AAPC in mortality rate decreased significantly during the same time period in Lower Saxony (−2.5%, 95% CI −3.0, −2.0) but not in Groningen (0.1%, 95% CI −2.4, 2.6). Conclusions Higher PCa incidence and lower PCa-related mortality was detected in Lower Saxony than in Groningen. Although recommendations on PSA testing may play a role, the assessed data could not offer obvious explanations to the observed differences. Therefore, further investigations including data on the actual use of PSA testing, other influences (e.g., dietary and ethnic factors), and better data quality are needed to explain differences between the regions.
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Affiliation(s)
- Sanny Kappen
- Division of Epidemiology and Biometry, Department of Health Services Research, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Geertruida H de Bock
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Eunice Sirri
- Lower Saxony Epidemiological Cancer Registry, Oldenburg, Germany
| | - Claudia Vohmann
- Lower Saxony Epidemiological Cancer Registry, Oldenburg, Germany
| | - Joachim Kieschke
- Lower Saxony Epidemiological Cancer Registry, Oldenburg, Germany
| | - Alexander Winter
- University Hospital for Urology, Klinikum Oldenburg, Department of Human Medicine, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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23
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Park SG, Shim KH, Choo SH, Kim SJ, Kim SI. The presence of prostate-specific antigen checked more than 1 year before diagnostic biopsy is an independent prognostic factor in patients undergoing radical prostatectomy. Investig Clin Urol 2021; 62:438-446. [PMID: 34085793 PMCID: PMC8246017 DOI: 10.4111/icu.20200545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/23/2020] [Accepted: 02/14/2021] [Indexed: 11/18/2022] Open
Abstract
PURPOSE In large scale prospective studies, prostate-specific antigen (PSA)-screening not only decreased prostate cancer mortality, but also reduced biochemical recurrence (BCR) in patients undergoing radical prostatectomy (RP). We investigated the independent effect of the presence of PSA checked more than 1 year before diagnostic biopsy on the prognosis of patients undergoing RP in a real world setting without PSA-screening. MATERIALS AND METHODS We reviewed the database of patients undergoing RP at Ajou University Hospital from March 1999 to May 2018. Clinicopathological features assessed were age, presence of lower urinary tract symptoms at presentation, presence of PSA checked over 1 year before biopsy, presence of PSA checked within 4 to 1 years of biopsy, last pre-biopsy PSA (pPSA), biopsy grade group (bGG), cT, cN, percentage of positive biopsy cores (PPBC), pathological GG (pGG), pT, pN, surgical margin, and index tumor diameter. The primary endpoint was BCR-free survival (BCRFS). RESULTS Of 598 patients enrolled, 211 experienced BCR at the mean follow-up of 64±37 months. The 5-year and 10-year BCRFS were 62.8% and 53.9%, respectively. In multivariate analyses including clinical variables only, pPSA, bGG, cT, PPBC, and PSA within 4 to 1 years of biopsy independently affected BCRFS. In multivariate analyses including pathological variables only, pPSA, pGG, pT, pN, PSA checked over 1 year before biopsy and PSA checked within 4 to 1 years of biopsy independently affected BCRFS. CONCLUSIONS Patients who has checked PSA at least once beyond 1 year before diagnosis of prostate cancer show better BCRFS regardless of other factors.
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Affiliation(s)
- Sung Gon Park
- Department of Urology, Ajou University School of Medicine, Suwon, Korea
| | - Kang Hee Shim
- Department of Urology, Ajou University School of Medicine, Suwon, Korea
| | - Seol Ho Choo
- Department of Urology, Ajou University School of Medicine, Suwon, Korea
| | - Se Joong Kim
- Department of Urology, Ajou University School of Medicine, Suwon, Korea
| | - Sun Il Kim
- Department of Urology, Ajou University School of Medicine, Suwon, Korea.
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24
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Getaneh AM, Heijnsdijk EA, de Koning HJ. Cost-effectiveness of multiparametric magnetic resonance imaging and MRI-guided biopsy in a population-based prostate cancer screening setting using a micro-simulation model. Cancer Med 2021; 10:4046-4053. [PMID: 33991077 PMCID: PMC8209626 DOI: 10.1002/cam4.3932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/29/2021] [Accepted: 04/12/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The introduction of multiparametric magnetic resonance imaging (mpMRI) and MRI-guided biopsy has improved the diagnosis of prostate cancer. However, it remains uncertain whether it is cost-effective, especially in a population-based screening strategy. METHODS We used a micro-simulation model to assess the cost-effectiveness of an MRI-based prostate cancer screening in comparison to the classical prostate-specific antigen (PSA) screening, at a population level. The test sensitivity parameters for the mpMRI and MRI-guided biopsy, grade misclassification rates, utility estimates, and the unit costs of different interventions were obtained from literature. We assumed the same screening attendance rate and biopsy compliance rate for both strategies. A probabilistic sensitivity analysis, consisting of 1000 model runs, was performed to estimate a mean incremental cost-effectiveness ratio (ICER) and assess uncertainty. A €20,000 willingness-to-pay (WTP) threshold per quality-adjusted life year (QALY) gained, and a discounting rate of 3.5% was considered in the analysis. RESULTS The MRI-based screening improved the life-years (LY) and QALYs gained by 3.5 and 3, respectively, in comparison to the classical screening pathway. Based on the probabilistic sensitivity analyses, the MRI screening pathway leads to total discounted mean incremental costs of €15,413 (95% confidence interval (CI) of €14,556-€16,272) compared to the classical screening pathway. The corresponding discounted mean incremental QALYs gained was 1.36 (95% CI of 1.31-1.40), resulting in a mean ICER of €11,355 per QALY gained. At a WTP threshold of €20,000, the MRI screening pathway has about 84% chance to be more cost-effective than the classical screening pathway. CONCLUSIONS For triennial screening from age 55-64, incorporation of mpMRI as a reflex test after a positive PSA test result with a subsequent MRI-guided biopsy has a high probability to be more cost-effective as compared with the classical prostate cancer screening pathway.
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Affiliation(s)
- Abraham M Getaneh
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Eveline Am Heijnsdijk
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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25
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Heijnsdijk EAM, Gulati R, Tsodikov A, Lange JM, Mariotto AB, Vickers AJ, Carlsson SV, Etzioni R. Lifetime Benefits and Harms of Prostate-Specific Antigen-Based Risk-Stratified Screening for Prostate Cancer. J Natl Cancer Inst 2021; 112:1013-1020. [PMID: 32067047 PMCID: PMC7566340 DOI: 10.1093/jnci/djaa001] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/03/2019] [Accepted: 12/12/2019] [Indexed: 12/23/2022] Open
Abstract
Background Studies conducted in Swedish populations have shown that men with lowest prostate-specific antigen (PSA) levels at ages 44–50 years and 60 years have very low risk of future distant metastasis or death from prostate cancer. This study investigates benefits and harms of screening strategies stratified by PSA levels. Methods PSA levels and diagnosis patterns from two microsimulation models of prostate cancer progression, detection, and mortality were compared against results of the Malmö Preventive Project, which stored serum and tracked subsequent prostate cancer diagnoses for 25 years. The models predicted the harms (tests and overdiagnoses) and benefits (lives saved and life-years gained) of PSA-stratified screening strategies compared with biennial screening from age 45 years to age 69 years. Results Compared with biennial screening for ages 45–69 years, lengthening screening intervals for men with PSA less than 1.0 ng/mL at age 45 years led to 46.8–47.0% fewer tests (range between models), 0.9–2.1% fewer overdiagnoses, and 3.1–3.8% fewer lives saved. Stopping screening when PSA was less than 1.0 ng/mL at age 60 years and older led to 12.8–16.0% fewer tests, 5.0–24.0% fewer overdiagnoses, and 5.0–13.1% fewer lives saved. Differences in model results can be partially explained by differences in assumptions about the link between PSA growth and the risk of disease progression. Conclusion Relative to a biennial screening strategy, PSA-stratified screening strategies investigated in this study substantially reduced the testing burden and modestly reduced overdiagnosis while preserving most lives saved. Further research is needed to clarify the link between PSA growth and disease progression.
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Affiliation(s)
- Eveline A M Heijnsdijk
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Institute, Seattle, WA, USA
| | - Alex Tsodikov
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Jane M Lange
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Institute, Seattle, WA, USA
| | - Angela B Mariotto
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sigrid V Carlsson
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Institute, Seattle, WA, USA
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26
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Duffy MJ. Biomarkers for prostate cancer: prostate-specific antigen and beyond. Clin Chem Lab Med 2021; 58:326-339. [PMID: 31714881 DOI: 10.1515/cclm-2019-0693] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/19/2019] [Indexed: 12/21/2022]
Abstract
In recent years, several new biomarkers supplementing the role of prostate-specific antigen (PSA) have become available for men with prostate cancer. Although widely used in an ad hoc manner, the role of PSA in screening asymptomatic men for prostate cancer is controversial. Several expert panels, however, have recently recommended limited PSA screening following informed consent in average-risk men, aged 55-69 years. As a screening test for prostate cancer however, PSA has limited specificity and leads to overdiagnosis which in turn results in overtreatment. To increase specificity and reduce the number of unnecessary biopsies, biomarkers such as percent free PSA, prostate health index (PHI) or the 4K score may be used, while Progensa PCA3 may be measured to reduce the number of repeat biopsies in men with a previously negative biopsy. In addition to its role in screening, PSA is also widely used in the management of patients with diagnosed prostate cancer such as in surveillance following diagnosis, monitoring response to therapy and in combination with both clinical and histological criteria in risk stratification for recurrence. For determining aggressiveness and predicting outcome, especially in low- or intermediate-risk men, tissue-based multigene tests such as Decipher, Oncotype DX (Prostate), Prolaris and ProMark, may be used. Emerging therapy predictive biomarkers include AR-V7 for predicting lack of response to specific anti-androgens (enzalutamide, abiraterone), BRAC1/2 mutations for predicting benefit from PARP inhibitor and PORTOS for predicting benefit from radiotherapy. With the increased availability of multiple biomarkers, personalised treatment for men with prostate cancer is finally on the horizon.
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Affiliation(s)
- Michael J Duffy
- UCD Clinical Research Centre, St. Vincent's University Hospital, Dublin 4, Ireland.,UCD School of Medicine, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, Ireland
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27
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Lange J, Remmers S, Gulati R, Bill-Axelson A, Johansson JE, Kwiatkowski M, Auvinen A, Hugosson J, Hu JC, Roobol MJ, Carlsson SV, Etzioni R. Impact of cancer screening on metastasis: A prostate cancer case study. J Med Screen 2021; 28:480-487. [PMID: 33563084 DOI: 10.1177/0969141321989738] [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: 11/17/2022]
Abstract
BACKGROUND Trials of cancer screening present results in terms of deaths prevented, but metastasis is also a key endpoint that screening seeks to prevent. We developed a framework for projecting overall (de novo and progressive) metastases prevented in a screening trial using prostate cancer screening as a case study. METHODS Mechanistic simulation model in which screening shifts a fraction of cases that would be metastatic at diagnosis to being non-metastatic. This shift increases the incidence of non-overdiagnosed, organ-confined cases. We use estimates of the risk of metastatic progression for these cases to project how many progress to metastasis after diagnosis and tally the projected de novo and progressive metastatic cases with and without screening. We use data on stage shift from the European Randomized Study of Screening for Prostate Cancer (ERSPC) and data on the risk of metastatic progression from the Scandinavian Prostate Cancer Group-4 trial. We estimate the relative risk and absolute risk reductions in metastatic disease at diagnosis and compare these with reductions in overall metastases. RESULTS Assuming no effect of screening beyond initial stage shift at diagnosis, the model projects a 43% reduction in metastasis at diagnosis but a 22% reduction in the cumulative probability of metastasis over 12 years in favor of screening. These results are consistent with the empirical findings from the ERSPC. CONCLUSION Any reduction in metastatic disease at diagnosis under screening is likely to be an overly optimistic predictor of the impact of screening on overall metastasis and disease-specific mortality.
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Affiliation(s)
- Jane Lange
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Sebastiaan Remmers
- Department of Urology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Anna Bill-Axelson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Jan-Erik Johansson
- Department of Urology, The School of Health and Medical Sciences Örebro, Örebro, Sweden.,Department of Urology, Örebro University Hospital, Örebro, Sweden
| | - Maciej Kwiatkowski
- Department of Urology, Cantonal Hospital Aarau, Aarau, Switzerland.,Medical Faculty, University of Basel, Basel, Switzerland.,Department of Urology, Academic Hospital Braunschweig, Braunschweig, Germany
| | - Anssi Auvinen
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Jonas Hugosson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Jim C Hu
- Department of Urology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Monique J Roobol
- Department of Urology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Sigrid V Carlsson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Departments of Surgery (Urology Service) and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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28
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Getaneh AM, Heijnsdijk EAM, de Koning HJ. The comparative effectiveness of mpMRI and MRI-guided biopsy vs regular biopsy in a population-based PSA testing: a modeling study. Sci Rep 2021; 11:1801. [PMID: 33469144 PMCID: PMC7815791 DOI: 10.1038/s41598-021-81459-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/05/2021] [Indexed: 11/09/2022] Open
Abstract
The benefit of prostate cancer screening is counterbalanced by the risk of overdiagnosis and overtreatment. The use of a multi-parametric magnetic resonance imaging (mpMRI) test after a positive prostate-specific antigen (PSA) test followed by magnetic resonance imaging-guided biopsy (MRIGB) may reduce these harms. The aim of this study was to determine the effects of mpMRI and MRIGB vs the regular screening pathway in a population-based prostate cancer screening setting. A micro-simulation model was used to predict the effects of regular PSA screening (men with elevated PSA followed by TRUSGB) and MRI based screening (men with elevated PSA followed by mpMRI and MRIGB). We predicted reduction of overdiagnosis, harm-benefit ratio (overdiagnosis per cancer death averted), reduction in number of biopsies, detection of clinically significant cancer, prostate cancer death averted, life-years gained (LYG), and quality adjusted life years (QALYs) gained for both strategies. A univariate sensitivity analysis and threshold analysis were performed to assess uncertainty around the test sensitivity parameters used in the MRI strategy.In the MRI pathway, we predicted a 43% reduction in the risk of overdiagnosis, compared to the regular pathway. Similarly a lower harm-benefit ratio (overdiagnosis per cancer death averted) was predicted for this strategy compared to the regular screening pathway (1.0 vs 1.8 respectively). Prostate cancer mortality reduction, LY and QALYs gained were also slightly increased in the MRI pathway than the regular screening pathway. Furthermore, 30% of men with a positive PSA test could avoid a biopsy as compared to the regular screening pathway. Compared to regular PSA screening, the use of mpMRI as a triage test followed by MRIGB can substantially reduce the risk of overdiagnosis and improve the harm-benefit balance, while maximizing prostate cancer mortality reduction and QALYs gained.
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Affiliation(s)
- Abraham M Getaneh
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Eveline A M Heijnsdijk
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
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29
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Prostate-specific antigen testing and opportunistic prostate cancer screening: a cohort study in England, 1998-2017. Br J Gen Pract 2021; 71:e157-e165. [PMID: 33431381 PMCID: PMC7805413 DOI: 10.3399/bjgp20x713957] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/10/2020] [Indexed: 01/08/2023] Open
Abstract
Background Prostate cancer is a leading cause of cancer- related death. Interpreting the results from trials of screening with prostate-specific antigen (PSA) is complex in terms of defining optimal prostate cancer screening policy. Aim To assess the rates of, and factors associated with, the uptake of PSA testing and opportunistic screening (that is, a PSA test in the absence of any symptoms) in England between 1998 and 2017, and to estimate the likely rates of pre-randomisation screening and contamination (that is, unscheduled screening in the ‘control’ arm) of the UK-based Cluster Randomised Trial of PSA Testing for Prostate Cancer (CAP). Design and setting Open cohort study of men in England aged 40–75 years at cohort entry (1998–2017), undertaken using the QResearch database. Method Eligible men were followed for up to 19 years. Rates of PSA testing and opportunistic PSA screening were calculated; Cox regression was used to estimate associations. Results The cohort comprised 2 808 477 men, of whom 631 426 had a total of 1 720 855 PSA tests. The authors identified that 410 724 men had opportunistic PSA screening. Cumulative proportions of uptake of opportunistic screening in the cohort were 9.96% at 5 years’, 22.71% at 10 years’, and 44.13% at 19 years’ follow-up. The potential rate of contamination in the CAP control arm was estimated at 24.50%. Conclusion A substantial number of men in England opt in to opportunistic prostate cancer screening, despite uncertainty regarding its efficacy and harms. The rate of opportunistic prostate cancer screening in the population is likely to have contaminated the CAP trial, making it difficult to interpret the results.
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30
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Kappen S, Koops L, Jürgens V, Freitag MH, Blanker MH, Timmer A, de Bock GH. General practitioners' approaches to prostate-specific antigen testing in the north-east of the Netherlands. BMC FAMILY PRACTICE 2020; 21:270. [PMID: 33334312 PMCID: PMC7747401 DOI: 10.1186/s12875-020-01350-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 12/08/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND There is wide variation in clinical practice for the early detection of prostate cancer, not least because of the ongoing debate about the benefits of prostate-specific antigen (PSA) testing. In this study, we aimed to assess the approaches, attitudes, and knowledge of general practitioners (GPs) regarding PSA testing in primary care in the Netherlands, particularly regarding recommendations for prostate cancer. METHODS Questionnaire surveys were sent to 179 GPs in the north-east of the Netherlands, of which 65 (36%) were completed and returned. We also surveyed 23 GPs attending a postgraduate train-the-trainer day (100%). In addition to demographic data and practice characteristics, the 31-item questionnaire covered the attitudes, clinical practice, adherence to PSA screening recommendations, and knowledge concerning the recommendations for prostate cancer early detection. Statistical analysis was limited to the descriptive level. RESULTS Most GPs (95%; n = 82) stated that they had at least read the Dutch GP guideline, but just half (50%; n = 43) also stated that they knew the content. Almost half (46%; n = 39) stated they would offer detailed counseling before ordering a PSA test to an asymptomatic man requesting a test. Overall, prostate cancer screening was reported to be of minor importance compared to other types of cancer screening. CONCLUSIONS Clinical PSA testing in primary care in this region of the Netherlands seems generally to be consistent with the relevant guideline for Dutch GPs that is restrictive to PSA testing. The next step will be to further evaluate the effects of the several PSA testing strategies.
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Affiliation(s)
- Sanny Kappen
- Division of Epidemiology and Biometry, Department of Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany.
| | - Lisa Koops
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Verena Jürgens
- Division of Epidemiology and Biometry, Department of Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Michael H Freitag
- Division of General Practice, Department of Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Marco H Blanker
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Antje Timmer
- Division of Epidemiology and Biometry, Department of Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Geertruida H de Bock
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Olver IN. Prostate cancer treatment in private and public health services. Med J Aust 2020; 213:408-409. [DOI: 10.5694/mja2.50819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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32
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Pakarainen T, Nevalainen J, Talala K, Taari K, Raitanen J, Kujala P, Stenman UH, Tammela TLJ, Auvinen A. Number of screening rounds attended and incidence of high-risk prostate cancer in the Finnish Randomized Study of Screening for Prostate Cancer (FinRSPC). Cancer 2020; 127:188-192. [PMID: 33048394 DOI: 10.1002/cncr.33254] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/21/2020] [Accepted: 08/31/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND The European Randomized Study of Screening for Prostate Cancer has shown a 20% reduction in prostate cancer (PC) mortality by prostate-specific antigen-based screening. In addition, screening has been shown to reduce the risk of advanced PC. The objective of the current study was to analyze the impact of screening participation on the incidence of PC by risk group. METHODS The participants in the screening arm of the Finnish trial (31,867 men) were classified according to screening attendance in a time-dependent fashion. Initially, all men in the screening arm were regarded as nonattenders until the first screening attendance; they then remained in the once-screened group until the second screen and similarly for the possible third round. The control arm formed the reference group. Follow-up started at randomization and ended at the time of diagnosis of PC, emigration, or the end of 2015. PC cases were divided into risk groups according to European Association of Urology definitions. RESULTS The incidence of low-risk PC increased with the number of screens, whereas no clear relation with participation was noted in the intermediate-risk and high-risk cases. For patients with advanced PC, attending screening at least twice was associated with a lower risk. CONCLUSIONS Screening reduces the risk of advanced PC after only 2 screening cycles. A single screen demonstrated no benefit in terms of PC incidence. Repeated screening is necessary to achieve screening advantages.
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Affiliation(s)
- Tomi Pakarainen
- Department of Urology, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jaakko Nevalainen
- Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | | | - Kimmo Taari
- Department of Urology, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Jani Raitanen
- Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland.,UKK Institute for Health Promotion, Tampere, Finland
| | - Paula Kujala
- Department of Pathology, FimLab Laboratories, Tampere University Hospital, Tampere, Finland
| | - Ulf-Håkan Stenman
- Department of Clinical Chemistry, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Teuvo L J Tammela
- Department of Urology, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Anssi Auvinen
- Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
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33
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Gulati R, Morgan TM, A'mar T, Psutka SP, Tosoian JJ, Etzioni R. Overdiagnosis and Lives Saved by Reflex Testing Men With Intermediate Prostate-Specific Antigen Levels. J Natl Cancer Inst 2020; 112:384-390. [PMID: 31225597 DOI: 10.1093/jnci/djz127] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/30/2019] [Accepted: 06/13/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Several prostate cancer (PCa) early-detection biomarkers are available for reflex testing in men with intermediate prostate-specific antigen (PSA) levels. Studies of these biomarkers typically provide information about diagnostic performance but not about overdiagnosis and lives saved, the primary drivers of associated harm and benefit. METHODS We projected overdiagnoses and lives saved using an established microsimulation model of PCa incidence and mortality with screening and treatment efficacy based on randomized trials. We used this framework to evaluate four urinary reflex biomarkers (measured in 1112 men presenting for prostate biopsy at 10 US academic or community clinics) and two hypothetical ideal biomarkers (with 100% sensitivity or specificity for any or for high-grade PCa) at one-time screening tests at ages 55 and 65 years. RESULTS Compared with biopsying all men with elevated PSA, reflex testing reduced overdiagnoses (range across ages and biomarkers = 8.8-60.6%) but also reduced lives saved (by 7.3-64.9%), producing similar overdiagnoses per life saved. The ideal biomarker for high-grade disease improved this ratio (by 35.2% at age 55 years and 42.0% at age 65 years). Results were similar under continued screening for men not diagnosed at age 55 years, but the ideal biomarker for high-grade disease produced smaller incremental improvement. CONCLUSIONS Modeling is a useful tool for projecting the implications of using reflex biomarkers for long-term PCa outcomes. Under simplified conditions, reflex testing with urinary biomarkers is expected to reduce overdiagnoses but also produce commensurate reductions in lives saved. Reflex testing that accurately identifies high-grade PCa could improve the net benefit of screening.
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Affiliation(s)
- Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Teresa A'mar
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA.,Department of Urology, University of Michigan, Ann Arbor, MI
| | - Sarah P Psutka
- Department of Urology, University of Washington, Seattle, WA
| | | | - Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
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Getaneh AM, Heijnsdijk EAM, Roobol MJ, de Koning HJ. Assessment of harms, benefits, and cost-effectiveness of prostate cancer screening: A micro-simulation study of 230 scenarios. Cancer Med 2020; 9:7742-7750. [PMID: 32813910 PMCID: PMC7571827 DOI: 10.1002/cam4.3395] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/30/2020] [Accepted: 07/31/2020] [Indexed: 12/15/2022] Open
Abstract
Background Prostate cancer screening incurs a high risk of overdiagnosis and overtreatment. An organized and age‐targeted screening strategy may reduce the associated harms while retaining or enhancing the benefits. Methods Using a micro‐simulation analysis (MISCAN) model, we assessed the harms, benefits, and cost‐effectiveness of 230 prostate‐specific antigen (PSA) screening strategies in a Dutch population. Screening strategies were varied by screening start age (50, 51, 52, 53, 54, and 55), stop age (51‐69), and intervals (1, 2, 3, 4, 8, and single test). Costs and effects of each screening strategy were compared with a no‐screening scenario. Results The most optimum strategy would be screening with 3‐year intervals at ages 55–64 resulting in an incremental cost‐effectiveness ratio (ICER) of €19 733 per QALY. This strategy predicted a 27% prostate cancer mortality reduction and 28 life years gained (LYG) per 1000 men; 36% of screen‐detected men were overdiagnosed. Sensitivity analyses did not substantially alter the optimal screening strategy. Conclusions PSA screening beyond age 64 is not cost‐effective and associated with a higher risk of overdiagnosis. Similarly, starting screening before age 55 is not a favored strategy based on our cost‐effectiveness analysis.
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Affiliation(s)
- Abraham M Getaneh
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Eveline A M Heijnsdijk
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Monique J Roobol
- Department of Urology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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35
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de Kok IMCM, Burger EA, Naber SK, Canfell K, Killen J, Simms K, Kulasingam S, Groene E, Sy S, Kim JJ, van Ballegooijen M. The Impact of Different Screening Model Structures on Cervical Cancer Incidence and Mortality Predictions: The Maximum Clinical Incidence Reduction (MCLIR) Methodology. Med Decis Making 2020; 40:474-482. [PMID: 32486894 PMCID: PMC7322998 DOI: 10.1177/0272989x20924007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background. To interpret cervical cancer screening model results, we need to understand the influence of model structure and assumptions on cancer incidence and mortality predictions. Cervical cancer cases and deaths following screening can be attributed to 1) (precancerous or cancerous) disease that occurred after screening, 2) disease that was present but not screen detected, or 3) disease that was screen detected but not successfully treated. We examined the relative contributions of each of these using 4 Cancer Intervention and Surveillance Modeling Network (CISNET) models. Methods. The maximum clinical incidence reduction (MCLIR) method compares changes in the number of clinically detected cervical cancers and mortality among 4 scenarios: 1) no screening, 2) one-time perfect screening at age 45 that detects all existing disease and delivers perfect (i.e., 100% effective) treatment of all screen-detected disease, 3) one-time realistic-sensitivity cytological screening and perfect treatment of all screen-detected disease, and 4) one-time realistic-sensitivity cytological screening and realistic-effectiveness treatment of all screen-detected disease. Results. Predicted incidence reductions ranged from 55% to 74%, and mortality reduction ranged from 56% to 62% within 15 years of follow-up for scenario 4 across models. The proportion of deaths due to disease not detected by screening differed across the models (21%–35%), as did the failure of treatment (8%–16%) and disease occurring after screening (from 1%–6%). Conclusions. The MCLIR approach aids in the interpretation of variability across model results. We showed that the reasons why screening failed to prevent cancers and deaths differed between the models. This likely reflects uncertainty about unobservable model inputs and structures; the impact of this uncertainty on policy conclusions should be examined via comparing findings from different well-calibrated and validated model platforms.
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Affiliation(s)
- Inge M C M de Kok
- Department of Public Health, Erasmus MC-University Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Emily A Burger
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Steffie K Naber
- Department of Public Health, Erasmus MC-University Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Karen Canfell
- Cancer Research Division, Cancer Council NSW, Sydney, Australia.,School of Public Health, University of Sydney, Sydney, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - James Killen
- Cancer Research Division, Cancer Council NSW, Sydney, Australia
| | - Kate Simms
- Cancer Research Division, Cancer Council NSW, Sydney, Australia
| | | | - Emily Groene
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Stephen Sy
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Jane J Kim
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Marjolein van Ballegooijen
- Department of Public Health, Erasmus MC-University Medical Center, Rotterdam, Zuid-Holland, The Netherlands
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Villers A, Bessaoud F, Trétarre B, Grosclaude P, Malavaud B, Rebillard X, Iborra F, Daubisse L, Malavaud S, Roobol M, Heijnsdijk EA, de Koning HJ, Hugosson J, Rischmann P, Soulié M. Contamination in control group led to no effect of PSA-based screening on prostate cancer mortality at 9 years follow-up: Results of the French section of European Randomized Study of Screening for Prostate Cancer (ERSPC). Prog Urol 2020; 30:252-260. [PMID: 32197936 DOI: 10.1016/j.purol.2020.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/16/2020] [Accepted: 02/18/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION European Randomized Study of Screening for Prostate Cancer (ERSPC) mortality results were reported for 7 European countries (excluding France) and showed a significant reduction in Prostate cancer (PCa) mortality. As those results have not been part of the global ERSPC results, it is of interest to report PCa mortality at a median follow-up of 9 years for French section of ERSPC. MATERIAL AND METHODS Two administrative departments were involved in the study. Only men after randomization in the screening group were invited by mail to be screened by PSA testing with two rounds at 4-6 year intervals. Biopsy was recommended if PSA>=3.0 ng/mL. No information other that the French Association of Urology recommandations on the use of PSA was offered to the control group (own decision of physicians and patients). Follow up was based on cancer registry database. Contamination defined as the receipt of PSA testing in control arm was measured. Poisson regression models were used to estimate the Rate Ratio (RR) of PCa mortality and incidence in the screening vs. control arm. RESULTS Starting from 2003, 80,696 men aged 55-69 years were included. The percentage of men in the screening arm with at least one PSA test (compliance) was 31%. Compared to the control arm, PCa incidence increased by 10% in the screening arm (RR=1.10; 95% CI=[1.04-1.16], P=0.001), but PCa mortality did not differ (0.222 and 0.215 deaths/1000 person-years; RR=1.03[0.75-1.42], P=0.9). DISCUSSION Limitations include low participation rate. PSA testing in the control arm was observed in 32% of men (contamination). CONCLUSIONS Contamination in control group led to no effect of PSA-based screening on prostate cancer mortality at 9 years follow-up. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- A Villers
- Department of Urology, University Lille, CHU Lille, Lille, France.
| | - F Bessaoud
- Hérault cancer registry, ICM Montpellier, Montpellier, France
| | - B Trétarre
- Hérault cancer registry, ICM Montpellier, Montpellier, France
| | | | - B Malavaud
- Department of Urology, University Toulouse, CHU Toulouse, Toulouse, France
| | - X Rebillard
- Department of Urology, Clinique Beau Soleil, Montpellier, France
| | - F Iborra
- Department of Urology, University Montpellier, CHU Montpellier, Montpellier, France
| | - L Daubisse
- Hérault cancer registry, ICM Montpellier, Montpellier, France
| | - S Malavaud
- Department of Public Health, University Toulouse, CHU Toulouse, Toulouse, France
| | - M Roobol
- Department of Urology, Erasmus University Medical center, Rotterdam, The Netherlands
| | - E A Heijnsdijk
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - H J de Koning
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - J Hugosson
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Göteborg, Göteborg, Sweden
| | - P Rischmann
- Department of Urology, University Toulouse, CHU Toulouse, Toulouse, France
| | - M Soulié
- Department of Urology, University Toulouse, CHU Toulouse, Toulouse, France
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Filella X. Towards personalized prostate cancer screening. ADVANCES IN LABORATORY MEDICINE 2020; 1:20190027. [PMID: 37362554 PMCID: PMC10197357 DOI: 10.1515/almed-2019-0027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 09/26/2019] [Indexed: 06/28/2023]
Abstract
The value of the prostate-specific antigen (PSA) in prostate cancer (PCa) screening is controversial. Contradictory results have been reported in the literature as to whether PSA-based screening reduces mortality. Also, some of the studies published are methodologically flawed. However, evidence consistently demonstrates that screening programs results in the identification of patients with indolent prostatic tumors which rate has increased. Controversy is not only about the value of PSA-based screening, but also about the age range for screening, risk groups based on baseline PSA, PSA ranges, or the use of other biomarkers (PHI, 4Kscore). At present, PCa screening in the general population is not recommended by most scientific societies, although it can be used after discussing the risks and benefits with the patient. When discussing the need to perform a screening, the risks of using screening (lack of specificity of PSA, overdiagnosis) must be weighed against the risks of not performing it (increased rate of patients with initial diagnosis of metastasis). In the recent years, a number of authors have advocated the use of personalized screening, which could change the risk/benefit evaluation, thereby making screening necessary on the basis of a set of individual factors.
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Affiliation(s)
- Xavier Filella
- Department of Biochemistry and Molecular Genetics (CDB), IDIBAPS, Hospital Clínic, Barcelona, Catalonia, Spain
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38
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Personalized Risks of Over Diagnosis for Screen Detected Prostate Cancer Incorporating Patient Comorbidities: Estimation and Communication. J Urol 2019; 202:936-943. [PMID: 31112106 DOI: 10.1097/ju.0000000000000346] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE Shared patient-physician decision making regarding the treatment of prostate cancer detected by prostate specific antigen screening involves a complex calculus weighing cancer risk and patient life expectancy. We sought to quantify these competing risks using the probability that the cancer was over diagnosed, ie would not have been clinically diagnosed (diagnosed without screening) during the remaining lifetime of the patient. MATERIALS AND METHODS Using an established model of prostate cancer screening and clinical diagnosis we simulated screen detected cases and determined whether a modeled clinical diagnosis would occur before noncancer death. Time of noncancer death was based on comorbidity adjusted population lifetables. Logistic regression models were fitted to the simulated data and used to estimate over diagnosis probabilities given patient age, prostate specific antigen level, Gleason sum and comorbidity category. An online calculator was developed to communicate over diagnosis estimates. Face validity and ease of use were assessed by surveying 32 clinical experts. RESULTS Estimated probabilities of over diagnosis ranged from 4% to 78% across clinicopathological variables and comorbidity status. When ignoring comorbidity, the estimated probability of over diagnosis in a 70-year-old man with prostate specific antigen 9.4 ng/ml and Gleason 6 was 34%. With severe comorbidities the estimate increased to 51%. Such a personalization may help inform the choice between active surveillance and definitive treatment. Based on responses from 20 of 32 experts we modified the explanation of over diagnosis for the online calculator and the input method for comorbid conditions. CONCLUSIONS The probability of over diagnosis is strongly influenced by comorbidity status in addition to age. Personalized estimates incorporating comorbidity may contribute to shared decision making between patients and providers regarding personalized treatment selection.
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Heijnsdijk EAM, Adolfsson J, Auvinen A, Roobol MJ, Hugosson J, de Koning HJ. The Impact of Design and Performance in Prostate-Specific Antigen Screening: Differences Between ERSPC Centers. Eur Urol 2019; 76:276-279. [PMID: 31031050 PMCID: PMC6800079 DOI: 10.1016/j.eururo.2019.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 04/09/2019] [Indexed: 11/20/2022]
Abstract
The European Randomized study of Screening for Prostate Cancer (ERSPC) has shown a 20% relative reduction in prostate cancer mortality after 16yr [rate ratio (RR) 0.80], but centers varied by attendance, screen interval, biopsy compliance, contamination in the control arm, and treatments. We used a microsimulation model, calibrated to the ERSPC individual-level data, to predict influence of study features on the results. The relative reduction in prostate cancer mortality would have been somewhat larger with improved study features: increased attendance (90% attendance in all volunteer-based and 70% in all population-based centers, resulting in RR 0.77), a 2-yr screen interval (RR 0.75), and an 80% biopsy compliance (RR 0.79). The RR would have been substantially lower with a 30% attendance (RR 0.92), 40% biopsy compliance (RR 0.90), or 100% contamination (RR 0.85). The variations in results by trial center may reflect differences in study design and performance and results of our simulations highlight the effect of quality indicators in prostate-specific antigen screening in different settings. PATIENT SUMMARY: We evaluated the effect of various features of prostate-specific antigen (PSA) screening on its effectiveness. The compliance to PSA testing and those having a biopsy after an elevated PSA substantially influence the prostate cancer mortality.
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Affiliation(s)
- Eveline A M Heijnsdijk
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Jan Adolfsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Anssi Auvinen
- School of Health Sciences, University of Tampere, Tampere, Finland
| | - Monique J Roobol
- Department of Urology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jonas Hugosson
- Department of Urology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Harry J de Koning
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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40
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Gandaglia G, Albers P, Abrahamsson PA, Briganti A, Catto JWF, Chapple CR, Montorsi F, Mottet N, Roobol MJ, Sønksen J, Wirth M, van Poppel H. Structured Population-based Prostate-specific Antigen Screening for Prostate Cancer: The European Association of Urology Position in 2019. Eur Urol 2019; 76:142-150. [PMID: 31092338 DOI: 10.1016/j.eururo.2019.04.033] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 04/17/2019] [Indexed: 01/21/2023]
Abstract
Prostate cancer (PCa) is one of the first three causes of cancer mortality in Europe. Screening in asymptomatic men (aged 55-69yr) using prostate-specific antigen (PSA) is associated with a migration toward lower staged disease and a reduction in cancer-specific mortality. By 20yr after testing, around 100 men need to be screened to prevent one PCa death. While this ratio is smaller than for breast and colon cancer, the long natural history of PCa means many men die from other causes. As such, the nonselective use of PSA testing and radical treatments can lead to overdiagnosis and overtreatment. The European Association of Urology (EAU) supports measures to encourage appropriate PCa detection through PSA testing, while reducing overdiagnosis and overtreatment. These goals may be achieved using personalized risk-stratified approaches. For diagnosis, the greatest benefit from early detection is likely to come in men assessed using baseline PSA levels at the age of 45yr to individualize screening intervals. Multiparametric magnetic resonance imaging as well as risk calculators based on family history, ethnicity, digital rectal examination, and prostate volume should be considered to triage the need for biopsy, thus reducing the risk of overdiagnosis. For treatment, the EAU advocates balancing patient's life expectancy and cancer's mortality risk when deciding an approach. Active surveillance is encouraged in well-informed patients with low-risk and some intermediate-risk cancers, as it decreases the risks of overtreatment without compromising oncological outcomes. Conversely, the EAU advocates radical treatment in suitable men with more aggressive PCa. Multimodal treatment should be considered in locally advanced or high-grade cancers. PATIENT SUMMARY: Implementation of prostate-specific antigen (PSA)-based screening should be considered at a population level. Men at risk of prostate cancer should have a baseline PSA blood test (eg, at 45yr). The level of this test, combined with family history, ethnicity, and other factors, can be used to determine subsequent follow-up. Magnetic resonance imaging scans and novel biomarkers should be used to determine which men need biopsy and how any cancers should be treated.
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Affiliation(s)
- Giorgio Gandaglia
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy.
| | - Peter Albers
- Department of Urology, Heinrich-Heine University, Medical Faculty, Düsseldorf, Germany
| | | | - Alberto Briganti
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - James W F Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Christopher R Chapple
- Sheffield Teaching Hospitals NHS Foundation Trust, University of Sheffield, Sheffield, UK
| | - Francesco Montorsi
- Unit of Urology/Division of Oncology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Nicolas Mottet
- Department of Urology, University Hospital, St. Etienne, France
| | - Monique J Roobol
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jens Sønksen
- Department of Urology, Herlev and Gentofte University Hospital, Herlev, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Manfred Wirth
- Department of Urology, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
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Kappen S, Jürgens V, Freitag MH, Winter A. Early detection of prostate cancer using prostate-specific antigen testing: an empirical evaluation among general practitioners and urologists. Cancer Manag Res 2019; 11:3079-3097. [PMID: 31114352 PMCID: PMC6489576 DOI: 10.2147/cmar.s193325] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 02/18/2019] [Indexed: 01/07/2023] Open
Abstract
Background: Prostate cancer (PCa) is the most frequent cancer and the third leading cause of cancer death among German men. One option for PCa early detection is prostate-specific antigen (PSA) testing, which is still under debate regarding its risk benefits. Besides recommendations on the early PCa detection, daily practice on PSA testing varies in, for example, information communication and usage of the test. This pilot study assessed potential differences between general practitioners (GPs) and urologists in handling PSA testing and guidelines on early detection of PCa. Methods: 172 GPs belonging to the teaching network of the University of Oldenburg in Lower Saxony and Bremen and 128 practicing urologists were included in the online survey focusing on PSA testing. The questionnaire covered 43 questions on topics as the usage of the test, information communication, handling of test results and handling of/knowledge about national and international guidelines on PCa. Wether PSA testing is used in accordance with guidelines was also explored in four standardized case scenarios. Statistical analysis was done at a descriptive level. Results: In total, 65 doctors participated in the survey (response proportion: 21.7%, n=65; 27.9%, n=48 [GPs]; 13.2%, n=17 [urologists]). Results of 41 GPs and 14 urologists were analyzed. The PSA test was judged as useful by all urologists, while almost half of the GPs valued the test as ambivalent or not useful. Urologists showed a more proactive approach of informing men on PSA testing. Regarding guidelines and recommendations on PSA testing, GPs were less familiar with them compared to the urologists. Doctors of both specialties did not always treat men in consistence with the guidelines. This was partially in contradiction to their self-appraisal. Conclusion: This pilot study is highlighting differences in PSA testing practices between GPs and urologists in Germany. Urologists showed a more proactive approach. For further verification, we plan a more comprehensive study covering several German states.
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Affiliation(s)
- Sanny Kappen
- Division of Epidemiology and Biometry, Department of Health Services Research, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Verena Jürgens
- Division of Epidemiology and Biometry, Department of Health Services Research, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Michael H Freitag
- Division of General Practice/Family Medicine, Department of Health Services Research, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Alexander Winter
- University Hospital for Urology, Klinikum Oldenburg, School of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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42
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Osses DF, Roobol MJ, Schoots IG. Prediction Medicine: Biomarkers, Risk Calculators and Magnetic Resonance Imaging as Risk Stratification Tools in Prostate Cancer Diagnosis. Int J Mol Sci 2019; 20:E1637. [PMID: 30986955 PMCID: PMC6480079 DOI: 10.3390/ijms20071637] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/27/2019] [Accepted: 03/29/2019] [Indexed: 12/11/2022] Open
Abstract
This review discusses the most recent evidence for currently available risk stratification tools in the detection of clinically significant prostate cancer (csPCa), and evaluates diagnostic strategies that combine these tools. Novel blood biomarkers, such as the Prostate Health Index (PHI) and 4Kscore, show similar ability to predict csPCa. Prostate cancer antigen 3 (PCA3) is a urinary biomarker that has inferior prediction of csPCa compared to PHI, but may be combined with other markers like TMPRSS2-ERG to improve its performance. Original risk calculators (RCs) have the advantage of incorporating easy to retrieve clinical variables and being freely accessible as a web tool/mobile application. RCs perform similarly well as most novel biomarkers. New promising risk models including novel (genetic) markers are the SelectMDx and Stockholm-3 model (S3M). Prostate magnetic resonance imaging (MRI) has evolved as an appealing tool in the diagnostic arsenal with even stratifying abilities, including in the initial biopsy setting. Merging biomarkers, RCs and MRI results in higher performances than their use as standalone tests. In the current era of prostate MRI, the way forward seems to be multivariable risk assessment based on blood and clinical parameters, potentially extended with information from urine samples, as a triaging test for the selection of candidates for MRI and biopsy.
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Affiliation(s)
- Daniël F Osses
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands.
- Department of Urology, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands.
| | - Monique J Roobol
- Department of Urology, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands.
| | - Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands.
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A 16-yr Follow-up of the European Randomized study of Screening for Prostate Cancer. Eur Urol 2019; 76:43-51. [PMID: 30824296 DOI: 10.1016/j.eururo.2019.02.009] [Citation(s) in RCA: 348] [Impact Index Per Article: 69.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 02/07/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND The European Randomized study of Screening for Prostate Cancer (ERSPC) has previously demonstrated that prostate-specific antigen (PSA) screening decreases prostate cancer (PCa) mortality. OBJECTIVE To determine whether PSA screening decreases PCa mortality for up to 16yr and to assess results following adjustment for nonparticipation and the number of screening rounds attended. DESIGN, SETTING, AND PARTICIPANTS This multicentre population-based randomised screening trial was conducted in eight European countries. Report includes 182160 men, followed up until 2014 (maximum of 16yr), with a predefined core age group of 162389 men (55-69yr), selected from population registry. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The outcome was PCa mortality, also assessed with adjustment for nonparticipation and the number of screening rounds attended. RESULTS AND LIMITATIONS The rate ratio of PCa mortality was 0.80 (95% confidence interval [CI] 0.72-0.89, p<0.001) at 16yr. The difference in absolute PCa mortality increased from 0.14% at 13yr to 0.18% at 16yr. The number of men needed to be invited for screening to prevent one PCa death was 570 at 16yr compared with 742 at 13yr. The number needed to diagnose was reduced to 18 from 26 at 13yr. Men with PCa detected during the first round had a higher prevalence of PSA >20ng/ml (9.9% compared with 4.1% in the second round, p<0.001) and higher PCa mortality (hazard ratio=1.86, p<0.001) than those detected subsequently. CONCLUSIONS Findings corroborate earlier results that PSA screening significantly reduces PCa mortality, showing larger absolute benefit with longer follow-up and a reduction in excess incidence. Repeated screening may be important to reduce PCa mortality on a population level. PATIENT SUMMARY In this report, we looked at the outcomes from prostate cancer in a large European population. We found that repeated screening reduces the risk of dying from prostate cancer.
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Karlsson A, Jauhiainen A, Gulati R, Eklund M, Grönberg H, Etzioni R, Clements M. A natural history model for planning prostate cancer testing: Calibration and validation using Swedish registry data. PLoS One 2019; 14:e0211918. [PMID: 30763406 PMCID: PMC6375591 DOI: 10.1371/journal.pone.0211918] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 01/22/2019] [Indexed: 12/23/2022] Open
Abstract
Recent prostate cancer screening trials have given conflicting results and it is unclear how to reduce prostate cancer mortality while minimising overdiagnosis and overtreatment. Prostate cancer testing is a partially observable process, and planning for testing requires either extrapolation from randomised controlled trials or, more flexibly, modelling of the cancer natural history. An existing US prostate cancer natural history model (Gulati et al, Biostatistics 2010;11:707-719) did not model for differences in survival between Gleason 6 and 7 cancers and predicted too few Gleason 7 cancers for contemporary Sweden. We re-implemented and re-calibrated the US model to Sweden. We extended the model to more finely describe the disease states, their time to biopsy-detectable cancer and prostate cancer survival. We first calibrated the model to the incidence rate ratio observed in the European Randomised Study of Screening for Prostate Cancer (ERSPC) together with age-specific cancer staging observed in the Stockholm PSA (prostate-specific antigen) and Biopsy Register; we then calibrated age-specific survival by disease states under contemporary testing and treatment using the Swedish National Prostate Cancer Register. After calibration, we were able to closely match observed prostate cancer incidence trends in Sweden. Assuming that patients detected at an earlier stage by screening receive a commensurate survival improvement, we find that the calibrated model replicates the observed mortality reduction in a simulation of ERSPC. Using the resulting model, we predicted incidence and mortality following the introduction of regular testing. Compared with a model of the current testing pattern, organised 8 yearly testing for men aged 55–69 years was predicted to reduce prostate cancer incidence by 14% and increase prostate cancer mortality by 2%. The model is open source and suitable for planning for effective prostate cancer screening into the future.
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Affiliation(s)
- Andreas Karlsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | | | - Roman Gulati
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, United States of America
| | - Martin Eklund
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Grönberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Urology, Karolinska University Hospital Solna, Stockholm, Sweden
| | - Ruth Etzioni
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, United States of America
- Department of Health Services, University of Washington, Seattle, United States of America
- Department of Biostatistics, University of Washington, Seattle, United States of America
| | - Mark Clements
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Turkbey B, Choyke PL. Prostate Magnetic Resonance Imaging: Lesion Detection and Local Staging. Annu Rev Med 2019; 70:451-459. [DOI: 10.1146/annurev-med-053117-123215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Dramatic changes in the use of prostate magnetic resonance imaging (MRI) have occurred in the last decade. The recognition that MRI detects and localizes cancers with reasonable accuracy led to the development of directed biopsies. These image-guided biopsies have a higher sensitivity for clinically significant cancers and a lower sensitivity for indolent disease. Prospective trials provide level 1 evidence supporting the use of prostate MRI. For local staging, while the specificity of prostate MRI is high, its sensitivity is lacking for microscopic extraprostatic extension. Computer-aided diagnosis of prostate MRI promises to bring the diagnostic power of MRI to nonexpert readers and thus further integrate MRI into the diagnostic workup.
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Affiliation(s)
- Baris Turkbey
- Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892, USA
| | - Peter L. Choyke
- Molecular Imaging Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892, USA
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46
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Osses DF, Remmers S, Schröder FH, van der Kwast T, Roobol MJ. Results of Prostate Cancer Screening in a Unique Cohort at 19yr of Follow-up. Eur Urol 2018; 75:374-377. [PMID: 30420254 DOI: 10.1016/j.eururo.2018.10.053] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 10/26/2018] [Indexed: 10/27/2022]
Abstract
We assessed the effect of screening in the European Randomized study of Screening for Prostate Cancer (ERSPC) Rotterdam pilot 1 study cohort with men randomized in 1991-1992. A total of 1134 men were randomized on a 1:1 basis to a screening (S) and control (C) arm after prostate-specific antigen (PSA) testing (PSA ≥10.0ng/ml was excluded from randomization). Further PSA testing was offered to all men in the S-arm with 4-yr intervals starting at age 55yr and screened up to the age of 74yr. Overall, a PSA level of ≥3.0ng/ml triggered biopsy. At time of analysis, 63% of men had died. Overall relative risk of metastatic (M+) disease and prostate cancer (PCa) death was 0.46 (95% confidence interval [CI]: 0.19-1.11) and 0.48 (95% CI: 0.17-1.36), respectively, in favor of screening. This ERSPC Rotterdam pilot 1 study cohort, screened in a period without noteworthy contamination, shows that PSA-based screening could result in considerable reductions of M+ disease and mortality which if confirmed in larger datasets should trigger further discussion on pros/cons of PCa screening. PATIENT SUMMARY: In a cohort with 19yr of follow-up, we found indications for a more substantial reduction in metastatic disease and cancer-specific mortality in favor of prostate cancer screening than previously reported. If confirmed in larger cohorts, these findings should be considered in the ongoing discussion on harms and benefits of prostate cancer screening.
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Affiliation(s)
- Daniël F Osses
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Sebastiaan Remmers
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Fritz H Schröder
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Theo van der Kwast
- Department of Pathology, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Pathology, Toronto General Hospital, Toronto, Canada
| | - Monique J Roobol
- Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Abstract
Prostate cancer is a common malignancy seen worldwide. The incidence has risen in recent decades, mainly fuelled by more widespread use of prostate-specific antigen (PSA) testing, although prostate cancer mortality rates have remained relatively static over that time period. A man's risk of prostate cancer is affected by his age and family history of the disease. Men with prostate cancer generally present symptomatically in primary care settings, although some diagnoses are made in asymptomatic men undergoing opportunistic PSA screening. Symptoms traditionally thought to correlate with prostate cancer include lower urinary tract symptoms (LUTS), such as nocturia and poor urinary stream, erectile dysfunction and visible haematuria. However, there is significant crossover in symptoms between prostate cancer and benign conditions affecting the prostate such as benign prostatic hypertrophy (BPH) and prostatitis, making it very challenging to distinguish between them on the basis of symptoms. The evidence for the performance of PSA in asymptomatic and symptomatic men for the diagnosis of prostate cancer is equivocal. PSA is subject to false positive and false negative results, affecting its clinical utility as a standalone test. Clinicians need to counsel men about the risks and benefits of PSA testing to inform their decision-making. Digital rectal examination (DRE) by primary care clinicians has some evidence to show discrimination between benign and malignant conditions affecting the prostate. Patients referred to secondary care for diagnostic testing for prostate cancer will typically undergo a transrectal or transperineal biopsy, where a number of samples are taken and sent for histological examination. These biopsies are invasive procedures with side effects and a risk of infection and sepsis, and alternative tests such as multiparametric magnetic resonance imaging (mpMRI) are currently being trialled for their accuracy and safety in diagnosing clinically significant prostate cancer.
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Affiliation(s)
| | - Garth Funston
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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48
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Karnes RJ, MacKintosh FR, Morrell CH, Rawson L, Sprenkle PC, Kattan MW, Colicchia M, Neville TB. Prostate-Specific Antigen Trends Predict the Probability of Prostate Cancer in a Very Large U.S. Veterans Affairs Cohort. Front Oncol 2018; 8:296. [PMID: 30128303 PMCID: PMC6088151 DOI: 10.3389/fonc.2018.00296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/16/2018] [Indexed: 11/13/2022] Open
Abstract
If prostate-specific antigen (PSA) trends help identify elevated prostate cancer (PCa) risk, they might provide early warning of progressing cancer for further evaluation and justify annual testing. Our objective was to determine whether PSA trends predict PCa likelihood. A biopsy cohort of 361,657 men was obtained from a Veterans Affairs database (1999–2012). PSA trends were estimated for the 310,458 men with at least 2 PSA tests prior to biopsy. Cancer tumors may grow exponentially with cells doubling periodically. We hypothesized that PSA from prostate cancer grows exponentially above a no cancer baseline. We estimated PSA trends on that basis along with five descriptive variables: last PSA before biopsy, growth rate in PSA from cancer above a baseline, PSA variability around the trend, number of PSA tests, and time span of tests. PSA variability is a new variable that measures percentage deviations of PSA tests from estimated trends with 0% variability for a smoothly increasing trend. Logistic regression models were used to estimate relationships between the probability of PCa at biopsy and the trend variables and age. All five PSA trend variables and age were significant predictors of prostate cancer at biopsy (p < 0.0001). An overall logistic regression model achieved an AUC of 0.67 for men with at least 4 tests over at least 3 years, which was a substantial improvement over a single PSA (AUC 0.58). High probability of PCa was associated with low PSA variability (smooth trends), high PSA, high growth rate, many tests over a long time-span and older age. For example, at 4.0 PSA the probability of cancer is 32% for 1 PSA test and increases to 68% for 8 tests over 7 years with smooth, fast growth (0% variability and 50% exponential growth). Our results show that smooth, fast exponential growth in PSA above a baseline predicts an increased probability of PCa. The probability increases as smooth (low variability) trends are observed for more tests over a longer time span, which makes annual testing worth considering. Worrisome PSA trends might be used to trigger further evaluation and continued monitoring of the trends—even at low PSA levels.
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Affiliation(s)
| | | | - Christopher H Morrell
- Mathematics and Statistics Department, Loyola University Maryland, Baltimore, MD, United States
| | - Lori Rawson
- VA Sierra Nevada Health Care System, Reno, NV, United States
| | - Preston C Sprenkle
- VA Connecticut Healthcare System, Yale School of Medicine, New Haven, CT, United States
| | - Michael W Kattan
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States
| | - Michele Colicchia
- Mayo Clinic, Rochester, MN, United States.,Urology, University of Padua, Padua, Italy
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49
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Mantsiou A, Vlahou A, Zoidakis J. Tissue proteomics studies in the investigation of prostate cancer. Expert Rev Proteomics 2018; 15:593-611. [DOI: 10.1080/14789450.2018.1491796] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Anna Mantsiou
- Biotechnology Division,Biomedical Research Foundation Academy of Athens, Greece
| | - Antonia Vlahou
- Biotechnology Division,Biomedical Research Foundation Academy of Athens, Greece
| | - Jerome Zoidakis
- Biotechnology Division,Biomedical Research Foundation Academy of Athens, Greece
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50
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Brikun I, Nusskern D, Decatus A, Harvey E, Li L, Freije D. A panel of DNA methylation markers for the detection of prostate cancer from FV and DRE urine DNA. Clin Epigenetics 2018; 10:91. [PMID: 29988684 PMCID: PMC6029393 DOI: 10.1186/s13148-018-0524-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 06/21/2018] [Indexed: 12/11/2022] Open
Abstract
Background Early screening for prostate cancer (PCA) remains controversial because of overdiagnosis and overtreatment of clinically insignificant cancers. Even though a number of diagnostic tests have been developed to improve on PSA testing, there remains a need for a more informative non-invasive test for PCA. The objective of this study is to identify a panel of DNA methylation markers suitable for a non-invasive diagnostic test from urine DNA collected following a digital rectal exam (DRE) and/or from first morning void (FV). A secondary objective is to determine if the cumulative methylation is indicative of biopsy findings. Methods DRE and FV urine samples were prospectively collected from 94 patients and analyzed using 24 methylation-specific quantitative PCR assays derived from 19 CpG islands. The methylation of individual markers and various combinations of markers was compared to biopsy results. A methylation threshold for cancer classification was determined using a target specificity of 70%. The average methylation and the number of positive markers were also compared to the result of the biopsy, and the area under the receiver operating characteristic curves (AUCs) were calculated. Results Methylation of all 19 markers was detected in FV and DRE DNAs. Combining the methylation of two or more markers improved on individual marker results. Using 6of19 methylated markers as the threshold for cancer classification yielded a specificity of 71% (95% CI, 0.57-0.86) from both DRE and FV and a sensitivity of 89% (95% CI, 0.79-0.97) from DRE and 94% (95% CI, 0.84-1.0) from FV. The negative predictive value at the 6of19 threshold was ≥ 90 for both DNA types. Conclusions PCA-specific methylation was detected in both FV and DRE DNA. There was no significant difference in diagnostic accuracy at the 6of19 threshold between DRE and FV urine DNA. The results support the development of a non-invasive diagnostic test to reduce unnecessary biopsies in men with elevated PSA. The test can also provide patients with personalized recommendations based on their own methylation profile.
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Affiliation(s)
- Igor Brikun
- Euclid Diagnostics LLC, 9800 Connecticut Dr., Crown Point, IN 46307 USA
| | - Deborah Nusskern
- Euclid Diagnostics LLC, 9800 Connecticut Dr., Crown Point, IN 46307 USA.,Present Address: Luminex Corporation, 4088 Commercial Ave, Northbrook, IL 60062 USA
| | - Andrew Decatus
- BioStat Solutions Inc., 5280 Corporate Dr., Suite C200, Frederick, MD 21703 USA
| | - Eric Harvey
- 3Health Decisions Inc., 2510 Meridian Parkway, Durham, NC 27713 USA
| | - Lin Li
- BioStat Solutions Inc., 5280 Corporate Dr., Suite C200, Frederick, MD 21703 USA
| | - Diha Freije
- Euclid Diagnostics LLC, 9800 Connecticut Dr., Crown Point, IN 46307 USA
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