Unintended consequences of decreased PSA-based prostate cancer screening

Changing times: trends in risk classification, tumor upstaging, and positive surgical margins after radical prostatectomy - results from a contemporary National Cancer Database study

PURPOSE

Recent advancements in screening, prostate MRI, robotic surgery, and active surveillance have influenced the profile of patients undergoing radical prostatectomy (RP). We sought to examine their impact on trends in clinicodemographic, risk classification, and adverse pathology in men undergoing surgery.

METHODS

We queried the National Cancer Database for clinicodemographic, risk group, and pathology data in men undergoing upfront RP between 2006 and 2020. Patients were categorized by NCCN risk groups, and trends were assessed among 2006-2010, 2011-2015, and 2016-2020 periods. Endpoints included rates of pT3, positive surgical margins (PSM), pathologic upstaging, and Gleason grade group (GG) upgrading.

RESULTS

610,762 patients were included. There were significant increases in African Americans (9.8-14.1%), comorbidities (2.1-5.2% with Charlson scores > 1), and robot-assisted RP (78-84%). Over the three time periods, high-risk cases increased from 15 to 20 to 27%, and intermediate-risk from 54 to 51 to 60%. Overall rates of pT3 rose from 20 to 38%, and PSM from 20 to 27% (p < 0.001). Pathologic upstaging increased in low (6-15%), intermediate (20-33%), and high-risk groups (42-58%) -p < 0.001. Gleason upgrading rose in low-risk (45-59%, p < 0.001), with slight reductions in the intermediate and high-risk groups.

CONCLUSIONS

Recent trends in RP indicate a shift towards more advanced disease, evidenced by increasing rates of pT3, PSM, and pathologic upstaging across all NCCN risk groups. These findings emphasize the need for a careful balance in applying fascia and nerve-sparing techniques to avoid compromising oncological safety.

[Risk-adapted early detection program for prostate cancer 2.0-position paper of the German Society of Urology 2024]

BACKGROUND AND OBJECTIVE

Despite the proven effectiveness of organized PSA-based screening in reducing prostate cancer-related mortality, there is currently no program in Germany covered by statutory health insurance. In accordance with the EU Council Decision (2022/0290(NLE)), the German Society of Urology (DGU) has developed a concept for risk-adapted prostate cancer early detection.

MATERIALS AND METHODS

Based on a literature review of current screening studies, an algorithm for PSA-based prostate cancer early detection was developed.

RESULTS

Risk-adapted prostate cancer screening involves PSA testing in the age group of 45-70 years, followed by PSA-based individual risk stratification and stepwise expansion of diagnostics through magnetic resonance imaging (MRI) to biopsy. While initially up to 2.6 million men will undergo PSA testing, a reduction in these initial examinations to fewer than 200,000 men per year will occur from year four onwards.

CONCLUSIONS

The presented algorithm provides clear recommendations for risk-adapted PSA-based early detection for prostate cancer for urologists and patients. The goal is to improve diagnosis of clinically significant prostate cancer, while reducing overdiagnosis and overtreatment.

Trends in prostate cancer incidence among Black men in the Caribbean and the United States

BACKGROUND

Prostate cancer incidence is highest for Black men of the African diaspora in the United States and Caribbean. Recent changes in recommendations for prostate cancer screening have been shown to decrease overall prostate cancer incidence and increase the likelihood of late stage disease. However, it is unclear how trends in prostate cancer characteristics among high risk Black men differ by geographic region during the changes in screening recommendations.

METHODS

In this study, we used population-based prostate cancer registry data to describe age-adjusted prostate cancer incidence trends from 2008 to 2015 among Black men from six geographic regions. We obtained data on incident Black prostate cancer patients from six cancer registries (in the United States: Florida, Alabama, Pennsylvania, and New York; and in the Caribbean: Guadeloupe and Martinique). After age standardization, we used descriptive analyses to compare the demographics and tumor characteristics by cancer registry site. The Joinpoint regression program was used to compare the trends in incidence by site.

RESULTS

A total of 59,246 men were analyzed. We found the highest incidence rates (per 100,000) for prostate cancer in the Caribbean countries (181.99 in Martinique and 176.62 in Guadeloupe) and New York state (178.74). Incidence trends decreased significantly over time at all sites except Martinique, which also showed significantly increasing rates of late stage (III/IV) and Gleason score 7+ tumors.

CONCLUSIONS

We observed significant differences in prostate cancer incidence trends among Black men after major changes prostate screening recommendations. Future studies will examine the factors that differentially influence prostate cancer trends among the African diaspora.

Personalizing approaches to the management of metastatic hormone sensitive prostate cancer: role of advanced imaging, genetics and therapeutics

PURPOSE

To summarize contemporary and emerging strategies for the diagnosis and management of metastatic hormone sensitive prostate cancer (mHSPC), focusing on diagnostic testing and therapeutics.

METHODS

Literature review using PUBMED-Medline databases as well as clinicaltrials.gov to include reported or ongoing clinical trials on treatment for mHSPC. We prioritized the findings from phase III randomized clinical trials, systematic reviews, meta-analyses and clinical practice guidelines.

RESULTS

There have been significant changes to the diagnosis and staging evaluation of mHSPC with the integration of increasingly accurate positron emission tomography (PET) imaging tracers that exceed the performance of conventional computerized tomography (CT) and bone scan. Germline multigene testing is recommended for the evaluation of patients newly diagnosed with mHSPC given the prevalence of actionable alterations that may create candidacy for specific therapies. Although androgen deprivation therapy (ADT) remains the backbone of treatment for mHSPC, approaches to first-line treatment include the integration of multiple agents including androgen receptor synthesis inhibitors (ARSI; abiraterone) Androgen Receptor antagonists (enzalutamide, darolutamide, apalautamide), and docetaxel chemotherapy. The combination of ADT, ARSI, and docetaxel chemotherapy has recently been evaluated in a randomized trial and was associated with significantly improved overall survival including in patients with a high burden of disease. The role of local treatment to the prostate with radiation has been evaluated in randomized trials with additional studies underway evaluating the role of cytoreductive radical prostatectomy.

CONCLUSION

The staging and initial management of patients with mHSPC has undergone significant advances in the last decade with advancements in the diagnosis, treatment and sequencing of therapies.

Variations in Age-Adjusted Prostate Cancer Incidence Rates by Race and Ethnicity After Changes in Prostate-Specific Antigen Screening Recommendation

IMPORTANCE

After publication of US Preventive Task Force Prostate-Specific Antigen (PSA) screening guidelines in 2008 and 2012, there have been documented associations with incidence and stage distributions of prostate cancer. It is unclear if these changes were temporary or differed by age or race and ethnicity.

OBJECTIVE

To assess the association of 2008 and 2012 PSA guidelines with prostate cancer incidence by age and race and ethnicity in the US.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study evaluated prostate cancer incidence from 2005 to 2018 in the US using data from the US Cancer Statistics public use database. Data were analyzed from August 2020 through June 2022.

MAIN OUTCOMES AND MEASURES

The primary outcome was the year when rates of prostate cancer incidence changed directionality by age and race and ethnicity. Age-adjusted incidence rates of prostate cancer and corresponding 95% CIs were created, followed by join point regression analysis to evaluate trends of age-adjusted incidence rates of prostate cancer by age, race, Hispanic ethnicity, and stage of diagnosis.

RESULTS

Among 2 944 387 men with prostate cancer, 2 869 943 (97.5%) men were aged 50 years and older. Men aged 50 years and older accounted for 185 476 of 191 533 Hispanic individuals (96.8%) and 2 684 467 of 2 752 854 non-Hispanic individuals (97.5%). Men aged 50 years and older accounted for 427 016 of 447 847 African American individuals (95.4%), 12 141 of 12 470 American Indian or Alaska Native individuals (97.4%), 61 126 of 62 159 Asian or Pacific Islander individuals (98.3%), and 2 294 171 of 2 344 392 White individuals (97.9%). Men with unknown race (77 519 men) were excluded from the analysis. A decrease in age-adjusted rate of prostate cancer after the 2008 guideline change was observed in all age groups by race and ethnicity. For example, among African American men ages 65 to 74 years, 10 784 of 807 080 men (1.34%) had a prostate cancer diagnosis in 2007 vs 10 714 of 835 548 men in 2008 (1.28%). The mean annual age-adjusted incidence rates of prostate cancer per 100 000 men were 157.7 men (95% CI, 157.4-158.0 men) in 2005 to 2008 and 131.9 men (95% CI, 131.6-132.2 men) in 2009 to 2012. The number of inflections and annual percent changes (APCs) for segments separated by inflections varied by age, race, and Hispanic ethnicity. For men ages 65 to 74 years, the APC was -6.53 (95% CI, -9.28 to -3.69) for 2009 to 2014 among African American men (2 join points), -5.96 (95% CI, -6.84 to -5.07) for 2007 to 2018 among American Indian or Alaska Native men (1 join point), -6.52 (95% CI, -9.22 to -3.74) for 2007 to 2014 among Asian or Pacific Islander men (2 join points), -7.92 (95% CI, -11.36 to -4.35) for 2009 to 2014 among Hispanic men (2 join points), and -7.02 (95% CI, -9.41 to -4.57) for 2007 to 2014 among White men (2 join points).‬‬‬‬‬‬‬‬.

CONCLUSIONS AND RELEVANCE

In this study, men in different age, race, and ethnicity groups had different APC patterns after 2008 and 2012 PSA screening guideline changes. These findings may provide important data on the timing and durations of changes in cancer diagnoses that are associated with changes in PSA screening recommendations and may be valuable for targeted strategies to reduce regional- and distant-staged cancers.

Changes in prostate cancer survival among insured patients in relation to USPSTF screening recommendations

BACKGROUND

To investigate the effects of the U.S. Preventive Services Task Force's (USPSTF) 2012 recommendation against prostate-specific antigen (PSA)-based screening for prostate cancer on survival disparities based on insurance status. Prior to the USPSTF's 2012 screening recommendation, previous studies found that insured patients with prostate cancer had better outcomes than uninsured patients.

METHODS

Using the SEER 18 database, we examined prostate cancer-specific survival (PCSS) based on diagnostic time period and insurance status. Patients were designated as belonging to the pre-USPSTF era if diagnosed in 2010-2012 or post-USPSTF era if diagnosed in 2014-2016. PCSS was measured with the Kaplan-Meier method, while disparities were measured with the Cox proportional hazards model.

RESULTS

During the pre-USPSTF era, uninsured patients experienced worse PCSS compared to insured patients (adjusted HR 1.256, 95% CI 1.037-1.520, p = 0.020). This survival disparity was no longer observed during the post-USPSTF era as a result of decreased PCSS among insured patients combined with unchanged PCSS among uninsured patients (adjusted HR 0.946, 95% CI 0.642-1.394, p = 0.780).

CONCLUSIONS

Although the underlying reasons are not clear, the USPSTF's 2012 PSA screening recommendation may have hindered insured patients from being regularly screened for prostate cancer and selectively led to worse outcomes for insured patients without affecting the survival of uninsured patients.

Novel Dormancy Mechanism of Castration Resistance in Bone Metastatic Prostate Cancer Organoids

Advanced prostate cancer (PCa) patients with bone metastases are treated with androgen pathway directed therapy (APDT). However, this treatment invariably fails and the cancer becomes castration resistant. To elucidate resistance mechanisms and to provide a more predictive pre-clinical research platform reflecting tumor heterogeneity, we established organoids from a patient-derived xenograft (PDX) model of bone metastatic prostate cancer, PCSD1. APDT-resistant PDX-derived organoids (PDOs) emerged when cultured without androgen or with the anti-androgen, enzalutamide. Transcriptomics revealed up-regulation of neurogenic and steroidogenic genes and down-regulation of DNA repair, cell cycle, circadian pathways and the severe acute respiratory syndrome (SARS)-CoV-2 host viral entry factors, ACE2 and TMPRSS2. Time course analysis of the cell cycle in live cells revealed that enzalutamide induced a gradual transition into a reversible dormant state as shown here for the first time at the single cell level in the context of multi-cellular, 3D living organoids using the Fucci2BL fluorescent live cell cycle tracker system. We show here a new mechanism of castration resistance in which enzalutamide induced dormancy and novel basal-luminal-like cells in bone metastatic prostate cancer organoids. These PDX organoids can be used to develop therapies targeting dormant APDT-resistant cells and host factors required for SARS-CoV-2 viral entry.

Trends in Incidence of Metastatic Prostate Cancer in the US

IMPORTANCE

The US Preventive Services Task Force (USPSTF) has recommended against routine prostate-specific antigen (PSA)-based prostate cancer (PCa) screening, initially for men older than 75 years in 2008, and then for all men in 2012. Concern has been raised that, by recommending against screening, and thus early detection, the USPSTF recommendations may be associated with an increase in the incidence of metastatic PCa (mPCa).

OBJECTIVE

To explore the incidence of mPCa before and after the USPSTF recommendations against routine PCa screening.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used the recently released Surveillance, Epidemiology, and End Results (SEER) 18 registry incidence data to identify men aged 45 years and older with a diagnosis of invasive PCa from 2004 through 2018. Data were analyzed from January 1, 2004 to December 31, 2018.

EXPOSURE

Outcomes were assessed before vs after the USPSTF recommendations against routine screening.

MAIN OUTCOMES AND MEASURES

Annual age-adjusted incidence rates per 100 000 population of mPCa (defined using SEER Summary Stage and American Joint Committee on Cancer [AJCC] staging systems), with adjustments for age structure and reporting delay from 2004 to 2011, according to race and age were examined. Annual percentage changes (APCs) were calculated to quantify changes in the annual incidence rates.

RESULTS

From 2004 to 2018, a total of 836 282 patients with PCa were recorded in the SEER database; 26 642 (56.5%) distant mPCa cases were reported in men aged 45 to 74 years, and 20 507 (43.5%) cases were reported in men aged 75 years or older. Among men aged 45 to 74 years, the incidence rate of distant mPCa (SEER Summary staging) remained stable during 2004 to 2010 (APC, -0.4%; 95% CI, -1.7% to 1.1%; P = .60), then increased significantly during 2010 to 2018 (APC, 5.3%; 95% CI, 4.5% to 6.0%; P < .001). In men aged 75 years or older, the incidence rate of distant mPCa decreased from 2004 to 2011 (APC, -1.5%; 95% CI, -3.0% to 0%; P = .046), and then increased from 2011 to 2018 (APC, 6.5%; 95% CI, 5.1% to 7.8%; P < .001). Similar trends were also seen for M1 mPCa defined per the AJCC staging system. These increased trends in mPCa incidence were particularly significant in non-Hispanic White men (2010-2018 APC, 6.9%; 95% CI, 5.4% to 8.4%; P < .001).

CONCLUSIONS AND RELEVANCE

Analysis of the emerging trends from the most recently released SEER data set (2004-2018) suggests that the incidence rates of mPCa have increased significantly and coincide temporally with the USPSTF recommendations against PCa screening across races and age groups. These mPCa trends are associated with reported changes in screening practices following the USPSTF recommendations.

Effects of the 2012 and 2018 US preventive services task force prostate cancer screening guidelines on pathologic outcomes after prostatectomy

BACKGROUND

In May 2018, the US Preventive Services Task Force (USPSTF) recommended prostate cancer (PCa) screening for ages 55-69 be an individual decision. This changed from the USPSTF's May 2012 recommendation against screening for all ages. The effects of the 2012 and 2018 updates on pathologic outcomes after prostatectomy are unclear.

METHODS

This study included 647 patients with PCa who underwent prostatectomy at our institution from 2005 to 2018. Patient groups were those diagnosed before the 2012 update (n = 179), between 2012 and 2018 updates (n = 417), and after the 2018 update (n = 51). We analyzed changes in the age of diagnosis, pathologic Gleason grade group (pGS), pathologic stage, lymphovascular invasion (LVI), and favorable/unfavorable pathology. Multivariable logistic regression adjusting for pre-biopsy covariables (age, prostate-specific antigen [PSA], African American race, family history) assessed impacts of 2012 and 2018 updates on pGS and pathologic stage. A p  < 0.05 was statistically significant.

RESULTS

Median age increased from 60 to 63 (p = 0.001) between 2012 and 2018 updates and to 64 after the 2018 update. A significant decrease in pGS1, pGS2, pT2, and favorable pathology (p < 0.001), and a significant increase in pGS3, pGS4, pGS5, pT3a, and unfavorable pathology (p < 0.001) was detected between 2012 and 2018 updates. There was no significant change in pT3b or LVI between 2012 and 2018 updates. On multivariable regression, diagnosis between 2012 and 2018 updates was significantly associated with pGS4 or pGS5 and pT3a (p < 0.001). Diagnosis after the 2018 update was significantly associated with pT3a (p = 0.005). Odds of pGS4 or pGS5 were 3.2× higher (p < 0.001) if diagnosed between 2012 and 2018 updates, and 2.3× higher (p = 0.051) if after the 2018 update. Odds of pT3a were 2.4× higher (p < 0.001) if diagnosed between 2012 and 2018 updates and 2.9× higher (p = 0.005) if after the 2018 update.

CONCLUSIONS

The 2012 USPSTF guidelines negatively impacted pathologic outcomes after prostatectomy. Patients diagnosed between 2012 and 2018 updates had increased frequency of higher-risk PCa and lower frequency of favorable disease. In addition, data after the 2018 update demonstrate a continued negative impact on postprostatectomy pathology. Thus, further investigation of the long-term effects of the 2018 USPSTF update is warranted.

Changing trends in robot-assisted radical prostatectomy: Inverse stage migration-A retrospective analysis

Background

With increasing availability of data on outcomes of surgery for prostate cancer, the profile of patients undergoing robot-assisted radical prostatectomy (RARP) has changed over the past decade. This impacts the decision-making process for surgeons and patients, particularly in low-incidence regions of Asia. Our institution was among the first in Asia to acquire a da Vinci surgical robot in 2005. We evaluated the changes in the clinical and pathology profile of patients undergoing RARP at our institution over the past 15 years (2005-2019).

Methods

A retrospective analysis of patients undergoing RARP between April 2005 and December 2019 was conducted from the hospital database. The patients were divided into two groups; patients undergoing RARP from April 2005 to December 2012 (Group I, first 8 years) and January 2013 to December 2019 (Group II, next 7 years). The perioperative characteristics were compared between these two groups to assess changes in their profile and outcome.

Results

Four hundred forty-seven patients were included in this study; 244 (54.6%) in Group I and 203 (45.4%) in Group II. The median prostate specific antigen in Group II was significantly higher than that in Group I (14.5 vs. 11.7 ng/ml, P = 0.016). Unfavorable pathological characteristics, i.e., Gleason Grade ≥3, perineural invasion, and the margin positivity rate increased substantially from 18.5% to 37.5%, 20.5% to 36.9%, and 15.2% to 26.6%, respectively, in Group II compared with Group I. More patients in Group II received adjuvant therapy than in Group I (P < 0.001).

Conclusion

There has been a change in profile of patients undergoing RARP and patients with more unfavorable disease characteristics such as higher prostate specific antigen and tumor grade are undergoing surgery. In line with international trends, the number of patients with low-grade disease undergoing surgery has substantially decreased. Multimodal treatment with adjuvant therapy is increasingly used, particularly in high-risk disease.

Influence of Urethra Sparing on Tumor Control Probability and Normal Tissue Complication Probability in Focal Dose Escalated Hypofractionated Radiotherapy: A Planning Study Based on Histopathology Reference

Purpose

Multiparametric magnetic resonance tomography (mpMRI) and prostate specific membrane antigen positron emission tomography (PSMA-PET/CT) are used to guide focal radiotherapy (RT) dose escalation concepts. Besides improvements of treatment effectiveness, maintenance of a good quality of life is essential. Therefore, this planning study investigates whether urethral sparing in moderately hypofractionated RT with focal RT dose escalation influences tumour control probability (TCP) and normal tissue complication probability (NTCP).

Patients and Methods

10 patients with primary prostate cancer (PCa), who underwent 68Ga PSMA-PET/CT and mpMRI followed by radical prostatectomy were enrolled. Intraprostatic tumour volumes (gross tumor volume, GTV) based on both imaging techniques (GTV-MRI and -PET) were contoured manually using validated contouring techniques and GTV-Union was created by summing both. For each patient three IMRT plans were generated with 60 Gy to the whole prostate and a simultaneous integrated boost up to 70 Gy to GTV-Union in 20 fractions by (Plan 1) not respecting and (Plan 2) respecting dose constraints for urethra as well as (Plan 3) respecting dose constraints for planning organ at risk volume for urethra (PRV = urethra + 2mm expansion). NTCP for urethra was calculated applying a Lyman-Kutcher-Burman model. TCP-Histo was calculated based on PCa distribution in co-registered histology (GTV-Histo). Complication free tumour control probability (P+) was calculated. Furthermore, the intrafractional movement was considered.

Results

Median overlap of GTV-Union and PRV-Urethra was 1.6% (IQR 0-7%). Median minimum distance of GTV-Histo to urethra was 3.6 mm (IQR 2 - 7 mm) and of GTV-Union to urethra was 1.8 mm (IQR 0.0 - 5.0 mm). The respective prescription doses and dose constraints were reached in all plans. Urethra-sparing in Plans 2 and 3 reached significantly lower NTCP-Urethra (p = 0.002) without significantly affecting TCP-GTV-Histo (p = p > 0.28), NTCP-Bladder (p > 0.85) or NTCP-Rectum (p = 0.85), resulting in better P+ (p = 0.006). Simulation of intrafractional movement yielded even higher P+ values for Plans 2 and 3 compared to Plan 1.

Conclusion

Urethral sparing may increase the therapeutic ratio and should be implemented in focal RT dose escalation concepts.

Impact on prostate cancer clinical presentation after non-screening policies at a tertiary-care medical center- a retrospective study

Background

In May 2012 the US Preventive Task Force issued a ‘D’ recommendation against routine PSA-based early detection of prostate cancer. This recommendation was implemented progressively in our health system. The aim of this study is to define its impact on prostate cancer staging at a tertiary care institution.

Methods

A retrospective analysis was performed from 2012 until 2015 at a single center. We analyzed the total number of biopsies performed per year and the positive biopsy rate. For those patients with positive biopsies we recorded diagnostic PSA, clinical stage, ISUP grade group, nodal involvement and metastatic status at diagnosis.

Results

A total of 1686 biopsies were analyzed. The positive biopsy rate increased from 25% in 2012 to 40% in 2015 (p < 0.05). No change in median PSA was noticed (p = 0.627). The biopsies detected higher ISUP grades (p = 0.000). In addition, newly diagnosed prostate cancer presented a higher clinical stage (p = 0.005), higher metastatic rates (p = 0.03) and a tendency to higher lymph node involvement although not statistically significant (p = 0.09).

Conclusion

After the 2012 recommendation, patients presented a higher probability of a prostate cancer diagnosis, with a more adverse ISUP group, clinical stage and metastatic disease.

These results should be taken into consideration to implement a risk adapted strategy for prostate cancer screening.

Prostate Cancer Screening Recommendations for General and Specific Populations in the Western Nations

There is a chaotic scenario that exists in the field of prostate cancer (PCa) screening. To balance goals, such as decreasing mortality, avoiding unnecessary procedures, and decreasing the cost of medical care, the pendulum seems to have swung to the side of more restricted screening. The decrease in PCa screening has led to a slowly creeping decline in the favourable outcomes that existed among patients with PCa. If a potential patient or a family member is trying to get clear guidance about PCa screening by searching the internet, they will end up confused by several recommendations from many organisations. It is even more challenging to obtain any clarity about PCa screening for special populations, such as those with a family history of PCa, those of African descent/African Americans, and the elderly. The advent of genomic medicine and precision medicine is an opportunity to identify those at a very high risk of developing aggressive PCa, so that PCa screening can be more actively undertaken among them. In this paper, the authors review the current recommendations by different entities and summarise emerging molecular markers that may help bring clarity to PCa screening. The authors predict that concrete, consensual guidelines will emerge in less than one decade. Meanwhile, this article suggests intermediary steps that will help save lives from PCa mortality, especially for under-represented populations. This paper is a catalyst to stimulate further discussion and serves as a guide to noncancer-specialists for the near future as precision medicine progresses to better understand risk–benefit and cost–benefit ratios in PCa screening.

Associations of Prostate-Specific Antigen (PSA) Testing in the US Population: Results from a National Cross-Sectional Survey

Prostate-specific antigen (PSA) testing is one of the standard screening methods for prostate cancer (PC); however, a high proportion of men with abnormal PSA findings lack evidence for PC and may undergo unnecessary treatment. Furthermore, little is known about the prevalence of PSA testing for US men, after the US Preventive Services Task Force (USPSTF) recommended against routine PSA screening in 2012. Our objectives were to: (1) examine the self-reported patterns of PSA testing following a change in the USPSTF prostate cancer screening recommendations and (2) to determine the associated socio-demographic factors. Data were from the 2010 and 2015 National Health Interview Surveys. Men were ages ≥ 40 years and responded to the question "Ever had a PSA test?". Multivariable logistic regression was used to examine PSA testing prevalence in 2010 and 2015, and their associated socio-demographic factors. The analytic sample contained 15,372 men. A majority (75.2%) identified as non-Hispanic (NHW) and 14.2% were foreign-born. Those surveyed in 2015 were less likely to report ever having had a PSA test when compared to those in 2010. Compared to US-born and older NHW men, PSA testing was statistically significantly lower among foreign-born men and men belonging to all other racial categories. Fewer men reported PSA testing following the USPSTF 2012 recommendations. Associated socio-demographic factors included nativity, age, race/ethnicity, educational attainment and type of health insurance. Further studies are required to elucidate our findings and their health implications for the US native and foreign-born population.

Abrogation of survival disparity between Black and White individuals after the USPSTF's 2012 prostate-specific antigen-based prostate cancer screening recommendation

BACKGROUND

In May 2012, the US Preventive Services Task Force (USPSTF) recommended against prostate-specific antigen (PSA)-based screening for prostate cancer (PCa), assigning it a grade D. This decision then was modified in 2018 to a grade C for men aged 55 to 69 years. The authors hypothesized that changes in screening practices would reduce survival outcomes for both Black and White men but maintain racial discrepancies in outcomes.

METHODS

Using the Surveillance, Epidemiology, and End Results database, the authors examined PCa-specific survival based on race and year of diagnosis. The period between January 2010 and December 2012 was categorized as the pre-USPSTF era, whereas the period between January 2014 and December 2016 was classified as the post-USPSTF era. The year 2013 was considered the transition year and was excluded from the analysis.

RESULTS

A total of 49,388 men were identified in the pre-USPSTF era who were diagnosed with PCa, approximately 83.7% of whom were White and 16.3% of whom were Black. In the post-USPSTF era, a total of 41,829 men were diagnosed with PCa, approximately 82.7% of whom were White and 17.3% of whom were Black. When compared with the pre-USPSTF era, men diagnosed in the post-USPSTF era were found to have more adverse clinical features. In the pre-USPSTF era, White men were less likely to die of PCa than Black men. This survival disparity between White and Black men was no longer observed in the post-USPSTF era.

CONCLUSIONS

In men diagnosed with PCa between 2014 and 2016, a survival disparity between White and Black men was not observed due to a decrease in survival among White men while the survival of Black men remained steady.

Impact of the evolving United States Preventative Services Task Force policy statements on incidence and distribution of prostate cancer over 15 years in a statewide cancer registry

Background

The United States Preventative Services Task Force (USPSTF) guideline on Prostate Specific Antigen (PSA)-based prostate cancer screening evolved both in 2008 (Grade I for men < 75 years and Grade D for men > 75 years) and in 2012 (Grade D for all ages).

Materials and methods

A statewide cancer registry operated by the Pennsylvania Department of Health was accessed to analyze over a 15-year period prostate cancer rates across different categories including age, stage, and geographic distribution.

Results

Local prostate cancer rates decreased significantly when comparing before and after USPSTF's guideline changes: 2002-2008 vs. 2009-2012 vs. 2013-2016 (p < 0.005). Conversely, the distant cancer rates increased significantly in Caucasian men (but not in African American men) (p = 0.0078). In age group analysis, distant cancer rates increased significantly in all age ranges, most notably in younger men (50-59 years). No observed difference in the trend of distant cancer rates when considering rural versus urban counties.

Conclusions

Incident prostate cancer cases diagnosed in Pennsylvania have decreased over the past 15 years with a recent rise in distant carcinomas potentially attributable to the USPSTF recommendations against PSA-based screening. Although the USPSTF revised their PSA-based prostate cancer screening guideline in 2018 (Grade C for men 55-69 years and Grade D for men > 70 years), the implications of the aforementioned observations on mortality outcomes merit further follow-up.

Impact of surgically maximized versus native membranous urethral length on 30-day and long-term pad-free continence after robot-assisted radical prostatectomy

BACKGROUND

Pelvic multiparametric magnetic resonance imaging (mpMRI)-determined membranous urethral length (MUL) and its surgical maximization have been reported to impact early- and long-term pad-free urinary continence after robot-assisted radical prostatectomy (RARP).

OBJECTIVE

The objective of this study was to present evidence (data and video) of important effects on post-RARP continence recovery from both innate mpMRI-assessed and surgical preservation of MUL.

DESIGN SETTING AND PARTICIPANTS

Of 605 men undergoing RARP, 580 with complete follow-up were included: Group 1, prior (N = 355), and Group 2, subsequent (N = 225) to technique change of MUL maximization. Effect of innate, mpMRI-assessed MUL on postoperative continence was assessed.

SURGICAL PROCEDURE

Before technique change, the dorsal venous complex was stapled before transection of the membranous urethra. After the change, the final step of extirpation was transection of the dorsal venous complex and periurethral attachments, thus facilitating surgical maximization of MUL.

MEASUREMENTS

Primary and secondary outcomes for technique change and mpMRI-assessed MUL were both patient-reported 30-day and 1-year pad-free continence after RARP, respectively.

RESULTS

Preoperative prostate-specific antigen, age, and disease aggressiveness were significantly higher in Group 2. After technique change and surgical maximization of MUL, 30-day and 1-year pad-free continence were both significantly improved (p < 0.05). In multivariate analysis, maximization of MUL significantly increased the likelihood of both early- and long-term continence recovery. For men undergoing MUL preservation, mpMRI-assessed MUL>1.4 cm also independently predicted higher 30-day (odds ratio: 4.85, 95% confidence interval: 1.24-18.9) and 1-year continence recovery (odds ratio: 11.26, 95% confidence interval: 1.07-118).

CONCLUSIONS

Prostatic rotation and circumferential release of apical attachments and maximization of MUL improves continence after RARP. Separately, innate MUL>1.4 cm independently increased 30-day and 1-year continence recovery.

PATIENT SUMMARY

Surgeon efforts to maximize MUL during radical prostatectomy are highly encouraged, as maximally preserved MUL likely improves post-RARP continence recovery. In addition, individual patients' mpMRI-assessed MUL (approximately >1.4 cm) independently limits continence recovery.

National trends in the management of low-risk prostate cancer: analyzing the impact of Medicaid expansion in the United States

PURPOSE

To evaluate recent trends in the management of low-risk prostate cancer (PCa) and analyze differences in adoption of surveillance based on state Medicaid-expansion status in the United States (US).

METHODS

Using the National Cancer Database, we identified men diagnosed from 2012 to 2016. Men with histologically confirmed low-risk PCa defined as PSA less than 10 ng/ml, Gleason score ≤ 6, and cT1-T2a were included. The Cochran Armitage test was used to evaluate trends in surveillance versus treatment. Comparisons on surveillance adoption based on 2014 Medicaid expansion status and difference-in-difference analysis were performed.

RESULTS

The cohort included 84,340 men. During the study period, surveillance as initial management increased from 13.6% in 2012 to 32.1% in 2016 (p < 0.01). When comparing by Medicaid-expansion status, expansion states had higher rates in adoption of surveillance as compared to non-expansion states over the study period (36.6 vs 28.5%). Following expansion, men in expansion states were 1.94% more likely to be treated with surveillance than in earlier years (p < 0.01). Men in non-expansion states were 1.97% more likely to receive surveillance following expansion (p < 0.01) for a relative 0.03% difference in active surveillance adoption among men with low-risk PCa (95% CI - 0.004 to 0.013, p = 0.344).

CONCLUSION

Based on the data from 2012 to 2016, there has been a significant increase in active surveillance as initial management for low-risk PCa in the US. Medicaid expansion was not found to be detrimental in adoption of surveillance. Understanding the impact of payer status on health outcomes can aid in the development of future health care policies aiming to mitigate disparities.

Trends in clinical and oncological outcomes of robot-assisted radical prostatectomy before and after the 2012 US Preventive Services Task Force recommendation against PSA screening: a decade of experience

OBJECTIVE

To assess the influence of the 2012 US Preventive Services Task Force (USPSTF) recommendation against prostate-specific antigen (PSA)-based screening on oncological and functional outcomes following robot-assisted laparoscopic prostatectomy (RALP).

MATERIALS AND METHODS

We retrospectively analysed patients who underwent RALP between 2008 and 2018 with a minimum of 12-month follow-up from a prospectively collected institutional review board-approved database. The impact of the USPSTF recommendation against PSA screening on our surgical outcomes was assessed using a logistic regression model using two groups comprising patients treated before/after the USPSTF statement and indicating time trends for each successive year.

RESULTS

The mean preoperative PSA increased from 6.0 to 7.4 ng/mL after the USPSTF recommendation. We detected statistically significant time-trend changes after 2012, including an increase in the positive slope of Gleason ≥3 + 4 or ≥pT3 disease. We detected a fall in bilateral full nerve-sparing and an increase in partial nerve-sparing. The total positive surgical margin (PSM) rate increased after the USPSTF recommendation; however, PSM rates pertinent to each pathological stage did not change significantly after 2012. There was a significant negative trend change in the postoperative 12-month continence and potency rates, indicating a breakpoint in functional outcomes after 2012. We detected a 1.7-fold increase in 12-month biochemical recurrence (BCR) rates. The 12-month BCR, potency and continence rates were maintained in young (<55 years) patients with a Sexual Health Inventory for Men score >22 and low-volume disease.

CONCLUSION

Since the USPSTF's recommendation in 2012, we have seen a significant increase in the incidence of high-risk disease that has forced us to modify our approach to the procedure and the grade of nerve-sparing used, leading to a wider resection, in order to reduce PSMs. This has led to a decrease in postoperative functional recovery. Patients with favourable characteristics had good outcomes before and after the USPSTF's recommendation, implying that the quality of surgery did not change over time.

Fifteen-year analysis of prostate biopsies in Western Australia including recent impact of multiparametric magnetic resonance imaging

BACKGROUND

The number of men undergoing prostate biopsy and subsequent cancer detection rates has changed significantly over the past 15 years. We aim to evaluate changes in the diagnostic pathway of prostate cancer between 2003 and 2018.

METHODS

A total of 13 844 Western Australian biopsy-naive men were assessed to determine trends in age, prostate-specific antigen levels, number of core samples, positive cores and tumour grade (Gleason) between 2003 and 2018. Further, in 2018, the impact of pre-biopsy multiparametric magnetic resonance imaging (mpMRI) was also assessed.

RESULTS

Between 2003 and 2012, the number of men undergoing biopsy increased from 1445 to 3100. During this time, the prostate cancer detection rate (%) remained unchanged. However, in 2018, 2042 men underwent prostate biopsy (reduction of 34.1%) and the detection rate increased to 72.6%. The incidence of low-grade cancer (Gleason score <7) increased from 28.1% in 2003 to 36.2% in 2012, but it decreased significantly to 15.1% by 2018. High-grade cancer (Gleason score >7) declined from 21.3% in 2003 to 15.2% in 2012 but then increased to 35.7% in 2018. The use of mpMRI in 2018 improved the detection rate of high-grade cancer. However, its specificity remains low (29.7%) and a considerable proportion of low Prostate Imaging Reporting and Data System score lesions was later diagnosed with cancer unsuitable for active surveillance.

CONCLUSION

In recent years, there has been a significant increase in the diagnosis high-grade cancer and a reduction in cancer suitable for active surveillance. mpMRI identifies high-grade tumours but is not a reliable alternative to prostate biopsy.

Mapping the Germline and Somatic Mutation Interaction Landscape in Indolent and Aggressive Prostate Cancers

BACKGROUND

A majority of prostate cancers (PCas) are indolent and cause no harm even without treatment. However, a significant proportion of patients with PCa have aggressive tumors that progress rapidly to metastatic disease and are often lethal. PCa develops through somatic mutagenesis, but emerging evidence suggests that germline genetic variation can markedly contribute to tumorigenesis. However, the causal association between genetic susceptibility and tumorigenesis has not been well characterized. The objective of this study was to map the germline and somatic mutation interaction landscape in indolent and aggressive tumors and to discover signatures of mutated genes associated with each type and distinguishing the two types of PCa.

MATERIALS AND METHODS

We integrated germline mutation information from genome-wide association studies (GWAS) with somatic mutation information from The Cancer Genome Atlas (TCGA) using gene expression data from TCGA on indolent and aggressive PCas as the intermediate phenotypes. Germline and somatic mutated genes associated with each type of PCa were functionally characterized using network and pathway analysis.

RESULTS

We discovered gene signatures containing germline and somatic mutations associated with each type and distinguishing the two types of PCa. We discovered multiple gene regulatory networks and signaling pathways enriched with germline and somatic mutations including axon guidance, RAR, WINT, MSP-RON, STAT3, PI3K, TR/RxR, and molecular mechanisms of cancer, NF-kB, prostate cancer, GP6, androgen, and VEGF signaling pathways for indolent PCa and MSP-RON, axon guidance, RAR, adipogenesis, and molecular mechanisms of cancer and NF-kB signaling pathways for aggressive PCa.

CONCLUSION

The investigation revealed germline and somatic mutated genes associated with indolent and aggressive PCas and distinguishing the two types of PCa. The study revealed multiple gene regulatory networks and signaling pathways dysregulated by germline and somatic alterations. Integrative analysis combining germline and somatic mutations is a powerful approach to mapping germline and somatic mutation interaction landscape.

Changing clinical trends in 10 000 robot-assisted laparoscopic prostatectomy patients and impact of the 2012 US Preventive Services Task Force's statement against PSA screening

OBJECTIVES

To evaluate the clinical trend changes in our robot-assisted laparoscopic prostatectomy (RALP) practice and to investigate the effect of 2012 US Preventive Services Task Force (USPSTF) statement against PSA screening on these trends.

PATIENTS AND METHODS

Data of 10 000 RALPs performed by a single surgeon between 2002 and 2017 were retrospectively analysed. Time trends in successive 1000 cases for clinical, surgical and pathological characteristics were analysed with linear and logistic regression. Time-trend changes before and after the USPSTF's statement were compared using a logistic regression model and likelihood-ratio test.

RESULTS

Unfavourable cancer characteristics rate, including D'Amico high risk, pathological non-organ-confined disease and Gleason score ≥4+4 increased from 11.5% to 23.3%, 14% to 42.5%, and 7.7% to 20.9%, respectively, over time (all P < 0.001). Significant time-trend changes were detected after the USPSTF's statement with an increase in the positive trend of Gleason ≥4+4 and increase in the negative trends of Gleason ≤3+4 tumours. There was a significant negative trend in the rate of full nerve-sparing (NS) with a decrease from 59.3% to 35.7%, and a significant positive trend in partial NS with an increase from 15.8% to 62.5% over time (both P < 0.001). The time-trend slope in 'high-grade' partial NS significantly decreased and 'low-grade' partial NS significantly increased after the USPSTF's statement. The overall positive surgical margin rate increased from 14.6% to 20.3% in the first vs last 1000 cases (P < 0.001), with a significant positive slope after the USPSTF's statement.

CONCLUSIONS

The proportion of high-risk patients increased in our series over time with a significant impact of the USPSTF's statement on pathological time trends. This stage migration resulted in decreased utilisation of high-quality NS and increased performance of poor-quality NS.

Trends in Prostate Cancer Prevalence and Radical Prostatectomy Rate according to Age Structural Changes in South Korea between 2005 and 2015

PURPOSE

Radical prostatectomy (RP) is one of main treatments for prostate cancer (Pca). The prevalence of Pca has been decreasing in recent reports. However, no study has reported trends in Pca prevalence or RP rate according to age structural changes. The objective of this study was to investigate trends in Pca prevalence and frequency of RP according to age structural change.

MATERIALS AND METHODS

We evaluated trends in Pca prevalence and RP rate using National Health Insurance Data from 2005 to 2015. Relationships for Pca prevalence and RP rate with age structural change were also determined. Primary outcomes included trends in Pca prevalence and RP rates according to age groups, comparing those before and after 2011.

RESULTS

Pca prevalence tended to increase before 2011 and decreased after 2011 in persons in the 60-years age group. RP rate increased pattern before 2011 and decreased after 2011 in age groups of 50s, 60s, and over 70s. Pca prevalence and age structural change showed a significantly positive relationship in all age groups, except for the age group under 40 years. RP rate and age structural change also showed a significantly positive relationship in all age groups.

CONCLUSION

Age structural change can affect the decreasing trend in Pca prevalence and RP rate in South Korea. Future studies are needed to validate this result.