A mobile mass screening unit for prostatic disease

Mobile Health Solutions for Prostate Cancer Diagnostics-A Systematic Review

Prostate cancer, the most common cause of cancer in men in the UK and one of the most common around the world to date, has no consensus on screening. Multiple large-scale trials from around the world have produced conflicting outcomes in cancer-specific and overall mortality. A main part of the issue is the PSA test, which has a high degree of variability, making it challenging to set PSA thresholds, as well as limited specificity. Prostate cancer has a predisposition in men from black backgrounds, and outcomes are worse in men of lower socioeconomic groups. Mobile targeted case finding, focusing on high-risk groups, may be a solution to help those that most need it. The aim of this systematic review was to review the evidence for mobile testing for prostate cancer. A review of all mobile screening studies for prostate cancer was performed in accordance with the Cochrane guidelines and the PRISMA statement. Of the 629 unique studies screened, 6 were found to be eligible for the review. The studies dated from 1973 to 2017 and came from four different continents, with around 30,275 men being screened for prostate cancer. Detection rates varied from 0.6% in the earliest study to 8.2% in the latest study. The challenge of early diagnosis of potentially lethal prostate cancer remains an issue for developed and low- and middle-income countries alike. Although further studies are needed, mobile screening of a targeted population with streamlined investigation and referral pathways combined with raising awareness in those communities may help make the case for screening for prostate cancer.

Progression of prostatic cancer in relation to age in patients detected by mass screening program

With the aim of revealing the natural history of prostatic cancer, the distribution of age was examined in relation to disease progression in patients detected by mass screening programs. Between 1975 and 1996, such programs detected a total number of 132 patients with prostatic cancer. The mean ages of patients with Stage B, Stage C and Stage D disease were 71.2, 73.8 and 75.3 years, respectively. This might suggest that the difference of 3 years in mean age between Stage B and Stage C disease reflects the time interval of the progression of prostatic cancer from the early (Stage B) to the advanced (Stage C) stage. These results coincided well with the natural history of prostatic cancer, which we proposed previously based upon the "size of ranking" analysis of latent prostatic cancer and doubling time obtained from ultrasonic measurement of prostatic volume. An epidemiological study of prostatic cancer detected by mass screening would offer data of value for the elucidation of the natural history of that disease.

Transrectal ultrasonic planimetry of the prostate in relation to age and lower urinary tract symptoms among elderly men in Japan

The aim of the present study is to correlate transrectal ultrasonic planimetric parameters of the prostate in relation to age and urinary symptoms as evaluated by the American Urological Association (AUA) symptom index score for benign prostatic hyperplasia (BPH). In 647 examinees on a mass screening program for prostatic diseases using transrectal sonography (TRS) in Japan, prostatic volume, transition zone volume, transition zone index (transition zone volume/prostatic volume) and presumed circle area ratio (PCAR) were determined using transrectal ultrasonic planimetry and compared with age and AUA symptom score. Increase in age, prostatic volume, transition zone volume and PCAR were significantly correlated with AUA symptom score. However, multiple regression analysis demonstrated that age and PCAR were the only significant independent determinant of symptom score. In particular, PCAR was the only significant determinants of symptom score in men with an intermediately enlarged prostate (20-30 ml in volume). The most significant difference in AUA symptom score was found between subgroups divided by PCAR with a cutoff point of 0.8. Among the planimetric parameters obtained by TRS, PCAR was the most powerful for evaluating BPH in terms of the severity of lower urinary tract symptoms.

Transrectal ultrasonography for the detection and staging of carcinoma of the prostate

Transrectal ultrasonography (TRUS) has become the most frequently used imaging modality for the prostate. The internal architecture of the prostate is readily detailed by TRUS, and the procedure allows an accurate measurement of prostate size. Carcinoma of the prostate has a characteristic hypoechoic pattern which is sometimes distinct from the normal echo pattern of the peripheral portion of the prostate. TRUS does not have sufficient sensitivity and specificity to support its use for routine screening for prostate cancer. In men with an abnormality of either digital rectal palpation of the prostate or serum prostate specific antigen, TRUS is useful for directing prostate biopsy. Transrectal core biopsies are obtained under ultrasound direction, and precise placement of the biopsy needles can be accomplished using TRUS.

Underdetection of clinical benign prostatic hyperplasia in a general medical practice

OBJECTIVE

To measure detection of clinical benign prostatic hyperplasia (BPH) in a general medicine practice.

DESIGN

Self-administered questionnaire and retrospective ambulatory medical record review.

SETTING

Hospital-based general medicine practice.

PATIENTS

Two hundred and four men aged 50 years and older.

MEASUREMENTS AND MAIN RESULTS

Clinical information was obtained from a self-administered questionnaire containing the American Urological Association symptom index and the BPH Impact Index bother scale, and from retrospective review of ambulatory medical records for the previous 24 months. Thirty percent of patients had moderate to severe urinary tract symptoms, and 67% of these individuals were bothered by the symptoms. Only 52% with moderate to severe symptoms recalled any discussion with their primary care physician about their symptoms. There was medical record documentation of a review of urinary tract symptoms in only 18% and a prostate examination in only 64%. Patients with more symptoms and bother tended to recall a discussion of urinary tract symptoms with their physician. However, moderate to severe symptoms and bother were not associated with increased documentation of a history of urinary tract symptoms or prostate examination.

CONCLUSIONS

Clinical BPH was underdetected in a general medicine practice. Because many men do not complain to their physicians about urinary tract symptoms and reduced quality of life, perhaps primary care physicians should pay more attention to recognizing this common condition of older men.

Diagnostic challenges of prostatic carcinoma

The early detection and staging of prostatic carcinoma are challenging the diagnostic acumen of urologists. Mass screening programmes of asymptomatic men are not justified, as only a small number of cases are diagnosed when the tumour is confined to the prostatic capsule. Diagnostic work-ups of symptomatic men yield a similarly low rate of detection. The most extensively used diagnostic methods include digital rectal examination (DRE), transrectal ultrasound (TRUS) and prostate-specific antigen (PSA) assay. Although DRE is an inexpensive technique that improves early detection, its sensitivity and specificity are low. The specificity and sensitivity of TRUS are higher, but false-positive and false-negative rates are significant. In a study of 566 patients, the rates were 86% and 84%, respectively. A determination of PSA may be informative in the early stages of prostatic cancer, but confirmation of the results by other methods is necessary. Thus, there is no safe method to achieve early diagnosis and precise staging of prostatic carcinoma. Only clinical trials comparing all the different methods will help to establish the definitive role of each one.

Benign prostatic hyperplasia. The scope of the problem

BACKGROUND

The prevalence and incidence of clinical problems secondary to and associated with benign prostatic hyperplasia (BPH) are of increasing concern as the population ages.

METHODS

Selected published reports using anatomical and clinical criteria to identify BPH and its clinical sequelae were reviewed.

RESULTS

The following observations seem to reflect the current state of knowledge: (1) BPH develops with increasing frequency as men age; (2) BPH causes significant pathologic changes in the urinary tract of some patients and symptoms in others; and (3) other identifiable or cryptic etiologic factors may be the predominant cause of identical voiding dysfunction in patients with BPH.

CONCLUSION

Essential information about factors initiating and promoting development of BPH, the exact mechanisms by which BPH alters voiding mechanisms, and definitive diagnostic criteria to establish the role of BPH in clinical changes are lacking. Progress in these problem areas is essential to guide appropriate clinical management.

Clinical evidence for and implications of the multistep development of prostate cancer

Based upon a large body of experimental and clinical data, it is evident that multiple malignant events are necessary for a normal cell to give rise to a fully malignant cancer cell. A critical issue with regard to human prostatic carcinogenesis is the clinical significance of the large number of cancers that are present histologically in the elderly male prostate gland. A possibility is that these histological prostate cancers already have undergone all of the malignant events necessary to produce clinically manifest cancer and, thus, only further tumor growth is required to produce a clinical tumor. Alternatively, these histological cancers may have undergone some but not all of the events necessary to produce clinical disease and, therefore, despite host longevity the cancer will remain clinically silent as long as no further malignant changes occur. This issue has importance clinically with respect to the diagnosis, therapy and possible prevention of prostatic cancer. Clinical observations and the mathematical relationship between prostate cancer prevalence and host age (time) support the fact that, in addition to growth, histological prostate cancer requires further malignant events to produce clinical disease. A better understanding of the events involved in prostate cancer development will be necessary to have a greater impact on this disease in the future.

Evaluation of transrectal ultrasound in the early detection of prostate cancer

To determine the ability of transrectal ultrasound to detect early localized prostate cancer, unsuspected (nonpalpable) cancer in the contralateral lobe of patients undergoing radical prostatectomy for clinically localized disease was evaluated. A total of 59 patients with palpable prostate cancer clinically confined to 1 lobe underwent transrectal ultrasound before radical prostatectomy and step-sectioning of the radical prostatectomy specimen. Transrectal ultrasound was performed with 5 or 7 MHz. real-time transrectal units. Pathological findings in these 59 cases revealed no tumor in the contralateral lobe in 34 (58%) and the presence of unsuspected tumor in 25 (42%). Transrectal ultrasound detected 13 of 25 unsuspected cancers for a sensitivity of 52%. Of 34 patients with no contralateral lobe lesion transrectal ultrasound was correct in 23 for a specificity of 68%. The positive and negative predictive values for transrectal ultrasound in this study group were 54 and 66%, respectively. There was no significant difference in the pathological size of the clinically suspected and clinically unsuspected cancers as measured by average largest dimension, and transrectal ultrasound sensitivity did not correlate with the size of the cancer. Based on careful sonopathological analysis, transrectal ultrasound may not be a good method to detect clinically unsuspected prostate cancer and the false positive rate would appear to be high.

The use of transrectal prostatic ultrasonography in the evaluation of patients with prostatic carcinoma

Transrectal ultrasonography is a relatively new diagnostic technique that has received much of the same enthusiasm that often is associated with the introduction of other new diagnostic or therapeutic instruments. The study allows for imaging of the prostate but benign conditions often cannot be differentiated reliably from malignant ones. The technique has clinical application in staging, monitoring tumor response to therapy and assisting in biopsy. Its role as a screening study when used either alone or in combination with other diagnostic tests has yet to be determined and well controlled, carefully performed investigations with state of the art instruments probably will help to establish the role of this examination when used for this purpose.

Adenocarcinoma of the prostate in cystoprostatectomy specimens removed for bladder cancer

The prostate glands of 84 men undergoing cystoprostatectomy for bladder cancer were examined by whole-mount sections at 4-mm to 5-mm intervals to identify unsuspected prostate adenocarcinoma (PCa). Of 72 white patients with entirely normal digital rectal examinations (DRE), 33 (46%) were found to have PCa, including 12 (17%) who had a Gleason score of 6 or greater and seven (10%) who had penetration through the prostatic capsule. These observations are consistent with previous studies in autopsy populations but allow a more appropriate comparison with morphologic data generated from radical prostatectomy specimens. If these data can be extended to the age-matched general population, treatment at a 1% mortality rate for all white men 60 to 74 years of age with a PCa with a Gleason score of 6 or greater could cause between 6190 and 30,951 deaths, in contrast to 7335 deaths expected from the cancer. These data stress the need for a control group in a study designed to evaluate the benefit of early diagnosis and treatment of PCa.

Screening for carcinoma of the prostate: efficacy of available screening tests

Despite the high prevalence and mortality from carcinoma of the prostate, very few prospective, controlled, population-based studies are available to assess the impact of early diagnosis programs. Three screening modalities have been suggested for this tumor: rectal examination, serum tumor markers, and transrectal ultrasound. Prostatic acid phosphatase and prostatic specific antigen have proven to be insensitive and nonspecific in large trials and generally, when elevated, allow diagnosis of metastatic disease. Transrectal ultrasound also suffers from poor specificity. Rectal examination, although insensitive to small tumors (less than 1 ml in volume), has the advantage of possibly detecting tumors of a higher biologic activity. An improved survival has been demonstrated in populations undergoing routine rectal examinations. Further prospective, population-based trials comparing early detection techniques are necessary before mass screening for carcinoma of the prostate can be recommended.