The Prevalence of Prostate Carcinoma and Its Precursor in Hungary: An Autopsy Study

The Short- and Long-Term Anticipation of Prostate Cancer Incidence in Korea: Based on Social Aging Trends and Prostate-Specific Antigen Testing Rate during the Last Decade

The current incidence of prostate-specific antigen (PSA) testing, which plays a crucial role in detecting prostate cancer (PCa) in an aged population, is low in Korea. Reflecting these epidemiologic characteristics, we estimated the short- and long-term incidences of PCa. A regression equation model was extracted based on two critical pieces of information: (1) the distribution of newly detected PCa cases in each age group of the 50s, 60s, 70s, and over 80s from a recent period (2006-2020), and (2) the PSA testing rate (PSAr) from the previous decade (2006-2016) for each age subgroup. The incidence increased fourfold (4533 in 2006 to 16,815 in 2020), with each age subgroup accounting for 7.9% (50s), 31.4% (60s), 43.0% (70s), and 17.1% (over 80s) of cases in 2020. PSAr increased by an average of 1.08% annually. If these trends are maintained, 28,822 new cases will be diagnosed in 2030 (expected PSAr: 14.4%) and 40,478 cases in 2040 (expected PSAr: 26.4%). If a public PSA screening were implemented for men only in their 60s (assuming a PSAr of 60% in the 60s) and 70s (assuming a PSAr of 80% in the 70s) in 2030, 37,503 cases in 2030 (expected PSAr: 23.1%) and 43,719 cases in 2040 (expected PSAr: 29.9%) would be estimated. According to the projection, the incidence of PCa will increase twofold by 2034 compared to 2020. If national screening were only conducted in the 60s and 70s, a higher detection of almost threefold would be expected by 2040.

Updated prevalence of latent prostate cancer in Chinese population and comparison of biopsy results: An autopsy-based study

Prostate cancer detected by autopsy is named latent prostate cancer. As the repertoire of clinical prostate cancer, latent cancer may better reflect the disease burden. Unlike clinical prostate specimens, which are obtained exclusively from biopsy-positive cases, prostate specimens obtained through autopsy provide information on biopsy-negative cases, helping calculate the true sensitivity of prostate biopsy. From 2014 to 2021, we collected autopsy specimens of the prostate from body donors in China and performed transperineal and transrectal biopsies on specimens before step-sectioning and pathological measurements. We found that the crude prevalence of latent prostate cancer in middle-aged and elderly men was 35.1% (81/231), which was higher than previous estimates for Chinese populations. The overall per-patient sensitivities of transperineal and transrectal biopsies were not significantly different (33.3% vs. 32.1%, p = 0.82), but the two approaches differed in preferential sampling area along the proximal-distal axis of the prostate. Transperineal biopsy had a higher sensitivity for detecting clinically significant lesions in the distal third (34.7% vs. 16.3%, p = 0.02) and distal half (30.6% vs. 18.1%, p = 0.04), while transrectal biopsy had a higher sensitivity for lesions in the proximal half (25.0% vs. 13.9%, p = 0.046). Both transperineal and transrectal methods of biopsy missed most small lesions (<0.1 mL) and 35.3% (6/17) of large lesions (>0.5 mL). In conclusion, the prevalence of latent prostate cancer in China has increased over the past 2 decades. Systematic transperineal and transrectal methods of biopsy had comparable sensitivities but had different preferential sampling areas. Both approaches miss one-third of large lesions.

Cost-Effectiveness Analysis of Stockholm 3 Testing Compared to PSA as the Primary Blood Test in the Prostate Cancer Diagnostic Pathway: A Decision Tree Approach

OBJECTIVE

This study evaluated the cost effectiveness of using Stockholm 3 (STHLM3) testing compared to the prostate-specific antigen (PSA) test in the diagnostic pathway for prostate cancer.

METHODS

We created a decision tree model for PSA (current standard) and STHLM3 (new alternative). Cost effectiveness was evaluated in a hypothetical cohort of male individuals aged 50-69 years. The study applied a Danish hospital perspective with a time frame restricted to the prostate cancer diagnostic pathway, beginning with the initial PSA/STHLM3 test, and ending with biopsy and histopathological diagnosis. Estimated values from the decision-analytical model were used to calculate the incremental cost-effectiveness ratio. Deterministic and probabilistic sensitivity analyses were conducted to test the robustness of the base-case analysis.

RESULTS

The model-based analysis revealed that STHLM3 testing was more effective than the PSA, but also more costly, with an incremental cost-effectiveness ratio of €511.7 (95% credible interval, 359.9-674.3) for each additional correctly classified individual. In the deterministic sensitivity analysis, variations in the cost of STHLM3 had the greatest influence on the incremental cost-effectiveness ratio. In the probabilistic sensitivity analysis, all iterations were positioned in the north-east quadrant of the incremental cost-effectiveness scatterplot. At a willingness to pay of €700 for an additional correctly classified individual, STHLM3 had a 100% probability of being cost effective.

CONCLUSIONS

Compared to the PSA test as the initial testing modality in the prostate cancer diagnostic workup, STHLM3 testing showed improved incremental effectiveness, however, at additional costs. The results were sensitive to the cost of the STHLM3 test; therefore, a lower cost of the STHLM3 test would improve its cost effectiveness compared with PSA tests.

Eating Habits, Risk of Breast Cancer, and Diet-Dependent Quality of Life in Postmenopausal Women after Mastectomy

The present study examined dietary risk factors for breast cancer, their association with quality of life, and changes in eating habits in postmenopausal women after mastectomy. The study included 210 women with histologically confirmed invasive breast cancer and 225 women without a cancer diagnosis. Questionnaire data on frequency of intake of 40 different foods, the Block Food Frequency Questionnaire, and SF-36 for evaluation of quality of life were used. All questionnaire data in the patient group were collected after diagnosis. Questions about eating habits covered two time points—before breast cancer diagnosis and after completion of treatment. Logistic regression was applied to calculate the odds ratios of breast cancer risk and 95% confidence intervals. A significant positive association was found between the risk of breast cancer and more frequent intake of red meat, smoked products, offal, animal fat, white bread, potatoes, and sweets, high intake of total fat, and low consumption of dietary fibre. Foods that were inversely associated with the risk of breast cancer included fish, vegetables, fruit, wholemeal bread, and groats. The relationship between quality of life and dietary habits according to the Block Eating Frequency Questionnaire was analysed using multiple regression. It was shown that high intake of total fat reduces the quality of life in its mental components. We observed a positive change in eating habits after cancer diagnosis, albeit not always to the level in the control group. As an important lifestyle component, the diet is of great significance for primary prevention of breast cancer as well as for improving the quality of life of breast cancer patients.

The national-wide incidence of prostate-specific antigen testing trend for a decade in Korea by age group

Purpose

To document nationwide serum prostate-specific antigen (PSA) testing trends over the past decade and to investigate the impact of testing on prostate cancer (PCa) detection.

Materials and Methods

Using annual National Health Insurance Service of Korea data for the period 2006 to 2016, PSA testing rates were investigated for men aged ≥40 years by decade, and associations between test rates and registered PCa cases were analyzed.

Results

During the study period, the incidence of PCa increased about threefold (4,415 in 2006 to 15,046 in 2016). PCa incidences increased with age (p<0.001) and about 60% of cases were over 70 years old. Despite a fourfold increase in PSA testing (246,911 in 2006 to 937,548 in 2016), the average exposure rate among all men was only 7.27% in 2016, and the mean number of repeat tests for those that did not develop PCa during the study period was 2.9. PSA test rates increased with age and in 2016 were 1.65% for those in their 40s, 4.90% for those in their 50s, 12.0% for those in their 60s, 19.2% for those in their 70s, and 21.6% for those aged ≥80. Regardless of the age groups, a significant association was found between PSA test numbers and the detection of PCas.

Conclusions

In contrast to the soaring incidence of PCa especially in those aged over 70 years who have a more frequent chance for PSA testing triggered by concomitant voiding symptoms, low exposure in general and among relatively younger men favors a countrywide screening policy.

Cellular senescence as a possible link between prostate diseases of the ageing male

Senescent cells accumulate with age in all tissues. Although senescent cells undergo cell-cycle arrest, these cells remain metabolically active and their secretome - known as the senescence-associated secretory phenotype - is responsible for a systemic pro-inflammatory state, which contributes to an inflammatory microenvironment. Senescent cells can be found in the ageing prostate and the senescence-associated secretory phenotype and can be linked to BPH and prostate cancer. Indeed, a number of signalling pathways provide biological plausibility for the role of senescence in both BPH and prostate cancer, although proving causality is difficult. The theory of senescence as a mechanism for prostate disease has a number of clinical implications and could offer opportunities for targeting in the future.

A comparison of the survival outcomes of robotic-assisted radical prostatectomy and radiation therapy in patients over 75 years old with non-metastatic prostate cancer: A Korean multicenter study

PURPOSE

To compare overall survivals (OSs) and cancer-specific survivals (CSSs) after robotic-assisted radical prostatectomy (RARP) and radiation therapy (RT), the latter of which has long been recommended primarily for elderly patients (≥75 years) with non-metastatic prostate cancer (PCa), given the Korean male life span of 79.7 years (2018).

MATERIALS AND METHODS

Retrospective data for aged ≥75 years who underwent RARP or RT at seven tertiary hospitals were analyzed. To account for indication-related bias, inverse probability of treatment-weighting (IPTW) was applied before and after Cox regression.

RESULTS

Of the 1,110 study subjects, 883 underwent RARP and 227 RT from 2007 to 2016. The differences between groups including the age (≥80 y; 25.4% vs. 32.8%; p=0.034), concomitant diabetes (14.9% vs. 22.9%; p=0.007), coronary heart disease (3.5% vs. 7.5%; p=0.015), and PCa risk stratification (high-risk; 18.2% vs. 59.7%; p<0.001) were balanced after IPTW. During a mean follow-up of 74.5 months, OSs (91.9% vs. 91.0%) and CSSs (97.8% vs. 98.0%) were similar. After IPTW, overall mortality was associated with diabetes (hazard ratio [HR], 2.273; p<0.0001) and inversely with low-risk PCa (HR, 0.314; p<0.0001), the last of which was solely associated with cancer-specific mortality (HR, 0.245; p=0.0005). The implementation of local treatment between RARP and RT demonstrated no impact on survival, for whole and high-risk populations.

CONCLUSIONS

Even aged over 75 years, patients who underwent RARP for non-metastatic PCa had similar survival with RT regardless of risk stratification. However, the survival needs to be weighed with the morbidity of local treatment in a future study.

Optimization of polyethylene glycol-based hydrogel rectal spacer for focal laser ablation of prostate peripheral zone tumor

PURPOSE

Focal Laser ablation therapy is a technique that exposes the prostate tumor to hyperthermia ablation and eradicates cancerous cells. However, due to the excessive heating generated by laser irradiation, there is a possibility of damage to the adjacent healthy tissues. This paper through in silico study presents a novel approach to reduce collateral effects due to heating by the placement of polyethylene glycol (PEG) spacer between the rectum and tumor during laser irradiation. The PEG spacer thickness is optimized to reduce the undesired damage at common laser power used in the clinical trials. Our study also encompasses novelty by conducting the thermal analysis based on the porous structure of prostate tumor.

METHODS

The thermal parameters and two thermal phase lags between the temperature gradient and the heat flux, are determined by considering the vascular network of prostate tumor. The Nelder-Mead algorithm is applied to find the minimum thickness of the PEG spacer.

RESULTS

In the absence of the spacer, the predicted results for the laser power of 4 W, 8 W, and 12 W show that the temperature of the rectum rises up to 58.6 °C, 80.4 °C, and 101.1 °C, while through the insertion of 2.59 mm, 4 mm, and 4.9 mm of the PEG spacer, it dramatically reduces below 42 °C.

CONCLUSIONS

The results can be used as a guideline to ablate the prostate tumors while avoiding undesired damage to the rectal wall during laser irradiation, especially for the peripheral zone tumors.

Prostate volume does not provide additional predictive value to prostate health index for prostate cancer or clinically significant prostate cancer: results from a multicenter study in China

To evaluate whether prostate volume (PV) would provide additional predictive utility to the prostate health index (phi) for predicting prostate cancer (PCa) or clinically significant prostate cancer, we designed a prospective, observational multicenter study in two prostate biopsy cohorts. Cohort 1 included 595 patients from three medical centers from 2012 to 2013, and Cohort 2 included 1025 patients from four medical centers from 2013 to 2014. Area under the receiver operating characteristic curves (AUC) and logistic regression models were used to evaluate the predictive performance of PV-based derivatives and models. Linear regression analysis showed that both total prostate-specific antigen (tPSA) and free PSA (fPSA) were significantly correlated with PV (all P < 0.05). [-2]proPSA (p2PSA) was significantly correlated with PV in Cohort 2 (P < 0.001) but not in Cohort 1 (P = 0.309), while no significant association was observed between phi and PV. When combining phi with PV, phi density (PHID) and another phi derivative (PHIV, calculated as phi/PV0.5) did not outperform phi for predicting PCa or clinically significant PCa in either Cohort 1 or Cohort 2. Logistic regression analysis also showed that phi and PV were independent predictors for both PCa and clinically significant PCa (all P < 0.05); however, PV did not provide additional predictive value to phi when combining these derivatives in a regression model (all models vs phi were not statistically significant, all P > 0.05). In conclusion, PV-based derivatives (both PHIV and PHID) and models incorporating PV did not improve the predictive abilities of phi for either PCa or clinically significant PCa.

The GÖTEBORG prostate cancer screening 2 trial: a prospective, randomised, population-based prostate cancer screening trial with prostate-specific antigen testing followed by magnetic resonance imaging of the prostate

Objective:

To describe the study design of the GÖTEBORG prostate cancer screening (PC) 2 (Göteborg-2), a prospective, randomised, population-based trial of PC screening. This trial evaluates whether prostate-specific antigen (PSA) testing followed by 3 Tesla prostate magnetic resonance imaging (MRI) and targeted biopsy can reduce overdiagnosis, while maintaining the detection of clinically significant cancer, compared to PSA-screening and systematic biopsy.

Materials and methods:

A random sample of men 50–60 years in the Göteborg area, Sweden, identified from the Total Population Register, were randomised to either a screening or control group (CG). Participants in the screening group (SG) were further randomised into one of three arms: (1) PSA-test; if PSA ≥ 3 ng/mL, then MRI and systematic biopsy, plus targeted biopsy to suspicious lesions as per Prostate Imaging – Reporting and Data System, version 2 (PI-RADSv2) 3–5; (2) PSA-test; if PSA ≥ 3 ng/mL, then MRI, and targeted biopsy only if PI-RADSv2 3–5; (3) identical to Arm 2, except lower PSA-cut-off ≥1.8 ng/mL. The primary outcome is the detection rate of clinically insignificant PC (defined as Gleason Score 3 + 3 [Grade Group 1]) comparing all men with PSA ≥ 3 ng/mL in Arm 1 vs. Arm 2 + 3.

Results:

Randomisation and enrolment started in September 2015. Accrual has hitherto resulted in 38,770 men randomised to the SG. The participation rate is 50%. Invitation to the first screening round was completed in June 2020.

Conclusions:

The Göteborg-2 trial will provide new knowledge about the performance of prostate MRI in a screening setting.

Global Trends of Latent Prostate Cancer in Autopsy Studies

Simple Summary

The incidence of prostate cancer (PC) is statistically biased due to the increase in prostate-specific antigen (PSA) screening and the accuracy of national cancer registration systems. However, studies on latent PC provide less biased information. This comprehensive review included studies evaluating latent PC in several countries. The prevalence of latent PC has been stable since 1950 in Western countries, but it has increased over time in Asian countries. Latent PC in Asian men has increased in prevalence and is higher in grade. This increase occurred not only due to the increase in PSA screening, but also due to increasing adoption of a Westernized lifestyle. Racial differences between Caucasian and Asian men may also explain the tumor location of latent PC. The autopsy findings in patients with latent PC included a significant proportion of high grade and stage cancers, suggesting a need to reconsider the definition of clinically insignificant PC.

Abstract

The incidence of prostate cancer (PC) has been increasing in Asian countries, where it was previously low. Although the adoption of a Westernized lifestyle is a possible explanation, the incidence is statistically biased due to the increase in prostate-specific antigen (PSA) screening and the accuracy of national cancer registration systems. Studies on latent PC provide less biased information. This review included studies evaluating latent PC in several countries after excluding studies using random or single-section evaluations and those that did not mention section thickness. The findings showed that latent PC prevalence has been stable since 1950 in Western countries, but has increased over time in Asian countries. Latent PC in Asian men has increased in both prevalence and number of high-grade cases. Racial differences between Caucasian and Asian men may explain the tumor location of latent PC. In conclusion, the recent increase in latent PC in Asian men is consistent with an increase in clinical PC. Evidence suggests that this increase is caused not only by the increase in PSA screening, but also by the adoption of a more Westernized lifestyle. Autopsy findings suggest the need to reconsider the definition of clinically insignificant PC.

"More men die with prostate cancer than because of it" - an old adage that still holds true in the 21st century

BACKGROUND

Prostate cancer (PCa) incidence has risen due to PSA testing, making it the commonest male malignancy. Most PSA-detected cases are organ-confined. Whilst radical treatment has increased, there has been little change in PCa-specific mortality. Over-detection of clinically insignificant PCa and active surveillance are increasing. We compared studies from the 21st century versus earlier reports demonstrating how commonly PCa is incidentally detected at autopsy. We describe the ongoing increasing prevalence of PCa with age, along with features of autopsy-detected disease.

METHODS

A literature review of PubMed and Scopus was conducted using the search terms "prostate cancer or carcinoma", "latent" or "autopsy", to January 2019. Citations and references from all publications found in this search were manually reviewed to identify additional articles.

RESULTS

63 publications were identified between 1898 and 2017, reporting over 29,000 autopsies on subjects aged between 20 and ≥90 years. PCa prevalence was 21% across all ages, and we found no significant difference in 21st century studies versus earlier studies. Autopsy-detected incidental PCa cases were typically small (~0.5cubic cm), predominantly low grade, and only occasionally (10%) extra-prostatic. PCa prevalence increased with age, being detected in >50% in men aged ≥90 years. The frequency of high-grade PCa almost doubled with each increasing age category.

CONCLUSION

Most autopsy-detected PCa cases continue to be clinically insignificant. The prevalence of autopsy-detected PCa was 30-fold greater than PCa-specific mortality in each ten-year age category. This should be considered when counselling elderly men regarding PSA-testing, particularly in the context of competing co-morbidity.

The comparison of the survival outcome between robotic-assisted radical prostatectomy and radiation therapy for localized prostate cancer in men over 70 years: Korean Nationwide Observational Study

This study aimed to investigate the survival after robotic-assisted radical prostatectomy (RARP) in comparison with radiation therapy (RT) in elderly patients (≥ 70 years) with non-metastatic prostate cancer (PCa), given the contemporary Korean life span of 80 years. From the National Health Insurance Sharing Service data, men aged ≥ 70 years diagnosed with PCa from 2006 through 2016 undergoing RARP or RT without systemic chemotherapy or prolonged androgen deprivation therapy (ADT) were identified, then the mortality was compared after adjusting host factors. Data revealed 13,952 patients with RARP (N = 7535) or RT (N = 6417). Patients who underwent RARP were younger (73.81 ± 3.58 vs. 75.05 ± 3.83 years) and had a higher income. While the majority of the RARP group (94.1%) received no additional therapy, 57.4% of the RT group combined ADT. The adjusted mortality rate for total patients was lower in the RARP group (HR = 0.767, 95% CI 0.072-0.818, p < 0.0001). From the age of 75 years, more patients underwent RT (n = 3239) than RARP (n = 2478). When dividing patients by this age cut-off, the adjusted mortality for the younger patient (70-74 years) was lower in the RARP group than the RT group (HR = 0.580, p < 0.0001). In contrast, the adjusted mortality rate for men older than 75 years was similar (HR = 0.98, 95% CI 0.897-1.07, p = 0.649). This study demonstrates that even the patient over 75 years old who could afford to undergo robotic-assisted radical prostatectomy for non-metastatic PCa had a similar survival in comparison with RT, which had long been a standard of care for this particular age group.

Prostate Cancer Incidence under Androgen Deprivation: Nationwide Cohort Study in Trans Women Receiving Hormone Treatment

CONTEXT

Trans women (male sex assigned at birth, female gender identity) mostly use antiandrogens combined with estrogens and can subsequently undergo vaginoplasty including orchiectomy. Because the prostate remains in situ after this procedure, trans women are still at risk for prostate cancer.

OBJECTIVE

To assess the incidence of prostate cancer in trans women using hormone treatment. The incidence of prostate cancer in trans women using hormone treatment.

DESIGN

In this nationwide retrospective cohort study, data of participants were linked to the Dutch national pathology database and to Statistics Netherlands to obtain data on prostate cancer diagnosis and mortality.

SETTING

Gender identity clinic.

PARTICIPANTS

Trans women who visited our clinic between 1972 and 2016 and received hormone treatment were included.

MAIN OUTCOME MEASURES

Standardized incidence ratios (SIRs) were calculated using the number of observed prostate cancer cases in our cohort and the number of expected cases based on age-specific incidence numbers from the Netherlands Comprehensive Cancer Organization.

RESULTS

The study population consisted of 2281 trans women with a median follow-up time of 14 years (interquartile range 7-24), and a total follow-up time of 37 117 years. Six prostate cancer cases were identified after a median 17 years of hormone treatment. This resulted in a lower prostate cancer risk in trans women than in Dutch reference males (SIR 0.20, 95% confidence interval 0.08-0.42).

CONCLUSIONS

Trans women receiving androgen deprivation therapy and estrogens have a substantially lower risk for prostate cancer than the general male population. Our results support the hypothesis that androgen deprivation has a preventive effect on the initiation and development of prostate cancer.

Forensic Autopsies can Determine Latent Prostate Cancer Prevalence

To evaluate the usefulness of forensic autopsies in determining latent prostate cancer (PC) prevalence, we examined latent PC prevalence from autopsies and compared our findings between decedents with and without cancer. Data from forensic autopsies performed in Japan from 2004 to 2014 were obtained. For each prostate, histopathological examinations were performed in both the base and the apex sections. Three hundred and seventeen Japanese decedents were selected for analysis. The mean age of decedents was 56.4 ± 17.8 years (range, 14-94 years). Among this population, 39.4% died suddenly of disease and 60.6% died of external causes. Latent PC was identified in 45 (14.2%) decedents, who ranged from 27 to 93 years old (mean, 71.1 ± 12.9 years). The prevalence of clinically significant PC with a Gleason score of 7 or more was 8.8%, and the rate increased with age. Fifteen males had cancers other than PC. The prevalence of overall latent PC was significantly higher for those with cancer compared with those without (40.0% vs. 12.9%; P = 0.003). In this study, the use of forensic autopsy materials provided the opportunity to obtain a more accurate natural history of PC, as the decedents in this situation would have been more likely to have died suddenly while behaving as normal prior to death, and less likely to have been impacted by long-term medical interventions.

A Study of Ser217Leu and Ala541Thr Polymorphism in the Men Afflicted with Prostate Cancer and in the Men being Suspicious of Prostate Cancer

Background and objective:

Prostate cancer is one of the most widespread cancers among men throughout the world. In addition, it is the second cause of death after lung cancer. Occurrence of the prostate cancer is variable in various regions of the world. Solely, there are three known risk factors for the prostate cancer, including: Age, inheritance and ethnic origin. ELAC2 protein is a phosphodiesterase enzyme encoded by ELAC2 gene in human. This gene is placed on chromosome 17, and it is believed that product of the mentioned gene is an endonuclease contributed in puberty of mitochondrion’s tRNA. From clinical viewpoint, variables of ELAC2 gene such as Ser217Leu and Ala541Thr Missense mutations which are accompanied by hereditary prostate cancer (HPC2).Objective of this study is to investigate Ser217Leu (rs4792311) and Ala541Thr (rs5030739) polymorphisms in the individuals with prostate cancer or those who are suspicious of prostate cancer with family past record/history.

Study method:

In this study conducted by case-control method in 2018, 102 men with prostate cancer and 98 men being suspicious of prostate cancer out of 10 families referred to shahid Rajaei Hospital in Tonekabon county to study and check were investigated. After collection of data using questionnaire, sampling from individuals and performance of the rest steps, study of polymorphism was carried out by PCR sequencing technique, and the results were analyzed by Chromas software.

Finding:

Of the total studied 102 individuals, 44 individuals (43.1%) were homozygote for Ser217Leu mutation, 36 individuals (35.2%) were heterozygote and 22 individuals (21.5%) lacked Missense mutation. for Ala541Thr mutation, 18 ones (17.6%) were heterozygote and 84 ones (82.3%) lacked Missense mutation. For Ser217Leu mutation, out of 98 suspicious individuals, 21 individuals (21.4%) were homozygote. 6 individuals (6.1%) were heterozygote and 71 individuals (72.4%) lacked the mutation. For Ala541Thr mutation, 15 ones (15.3%) were homozygote and 84 ones (84.6%) lacked the studied mutation.

Conclusion:

Results of this research showed that, in the individuals with the prostate cancer, there is a relationship between Ser217Leu and Ala541Thr polymorphism of ELAC2 gene and/with prostate cancer, and the suspicious individuals gotten involved in the mutation must take action to prevent this cancer.

Performance and inter-observer variability of prostate MRI (PI-RADS version 2) outside high-volume centres

Objective: Despite the growing trend to embrace pre-biopsy MRI in the diagnostic pathway for prostate cancer (PC), its performance and inter-observer variability outside high-volume centres remains unknown. This study aims to evaluate sensitivity of and variability between readers of prostate MRI outside specialized units with radical prostatectomy (RP) specimen as the reference standard.Materials and methods: Retrospective study comprising a consecutive cohort of all 97 men who underwent MRI and subsequent RP between January 2012 and December 2014 at a private hospital in Sweden. Three readers, blinded to clinical data, reviewed all images (including 11 extra prostate MRI to reduce bias). A tumour was considered detected if the overall PI-RADS v2 score was 3-5 and there was an approximate match (same or neighbouring sector) of tumour sector according to a 24 sector system used for both MRI and whole mount sections.Results: Detection rate for the index tumour ranged from 67 to 76%, if PI-RADS 3-5 lesions were considered positive and 54-66% if only PI-RADS score 4-5 tumours were included. Detection rate for aggressive tumours (GS ≥ 4 + 3) was higher; 83.1% for PI-RADS 3-5 and 79.2% for PI-RADS 4-5. The agreement between readers showed average [Formula: see text] values of 0.41 for PI-RADS score 3-5 and 0.51 for PI-RADS score 4-5.Conclusions: Prostate MRI evidenced a moderate detection rate for clinically significant PC with a rather large variability between readers. Clinics outside specialized units must have knowledge of their performance of prostate MRI before considering omitting biopsies in men with negative MRI.

Genomic classifiers for treatment selection in newly diagnosed prostate cancer

OBJECTIVES

To review systematically the literature on genomic tests for prostate cancer (PCa) and to evaluate the current state of the evidence on their use in patients with newly diagnosed PCa.

METHODS

We conducted a systematic review by searching PubMed, Embase, Cochrane Central and conference abstracts from the American Urological Association, published between 2010 and 2018. Studies evaluating Prolaris, Oncotype Dx and Decipher assays were assessed for inclusion by two authors. Studies were excluded if the results were derived from surgical specimens rather than biopsy specimens. A meta-analysis was not performed owing to significant variations in methodologies, definitions and outcome measures.

RESULTS

A total of 729 articles were retrieved in our initial search. After removing duplicates (270) and excluding articles deemed not relevant (432), 21 full-text articles were deemed suitable for inclusion in the present analysis. The full-text articles comprised eight studies on Prolaris, eight studies on Oncotype Dx and five studies on Decipher. For each genomic test we extracted data regarding the risks of adverse pathology, biochemical recurrence, metastasis and PCa-specific mortality.

CONCLUSION

The results of genomic tests that use biomarkers derived from prostate biopsy can be used in conjunction with clinicopathological variables to improve our ability to risk-stratify patients with newly diagnosed PCa. Additional data are needed on the impact of using these tests on long-term patient outcomes and their cost-effectiveness.

Age and aggressiveness of prostate cancer: analysis of clinical and pathological characteristics after radical prostatectomy for men with localized prostate cancer

Introduction

The aim of this study was to describe age- related prostate cancer (PCa) characteristics in men after radical prostatectomy (RP).

Material and methods

There were 2,373 men who underwent RP for clinically localized PCa between 2002 and 2017 and had complete data that were included into the study. Among them, 315 (13.3%) men aged ≤55 years (GR-1), 1,098 (46.3%) men aged between 56 to 65 years (GR-2) and 960 (40.4%) men aged older than 65 years (GR-3) were identified. All preoperative and pathological parameters were compared between all three groups and between each group separately. High-risk prostate cancer (HRPCa) cases were analyzed separately. Regression analysis was used to evaluate the impact of age on cancer aggressiveness.

Result

Clinical stage (cT), biopsy Gleason score and D'Amico risk groups were different comparing age-related study groups (all p <0.01), respectively. Preoperatively cT1 and Gleason 6 were in the highest rate for GR-1 in comparison with GR-3: 35.9 vs. 27.1%, p = 0.003 and 65.1% vs. 56.7%, p = 0.008, respectively. Analyzing pathological parameters, only Gleason 9–10 was different between GR-1 and GR-3–3.8 vs. 7.6%, p = 0.02. There were 921 (38.8%) HRPCa cases identified. Age was a significant predictor for HRPCa (p = 0.019) in the regression analysis. The oldest men (GR-3) had up to 1.5 fold increased risk for HRPCa detection in comparison with the youngest one (p = 0.008, HR1.44. 95% CI 1.098–1.87).

Conclusions

Younger, ≤55-year-old men, are more likely to present with less aggressive clinical and pathological PCa features in comparison with the older ones. Increasing age has a significant influence on HRPCa detection after RP.

How to choose proper local treatment in men aged ≥75 years with cT2 localized prostate cancer?

BACKGROUND

For localized prostate cancer (PCa), radical prostatectomy (RP) and radiotherapy (RT) are two standard interventions to decrease PCa mortality. Contemporary studies contained the elderly people; analyses focusing on patients over 75 years of age were still lacking.

METHOD

In the Surveillance Epidemiology and End Results (SEER) database (2004-2015), people over 75 years of age with cT2 stage were selected in our research. Multivariable Cox proportional hazard models were used to analyze cancer-specific mortality (CSM) and overall mortality (OM) after adjustment. The propensity score matching was performed to assume the randomization. An instrument variate (IVA) was used to calculate the unmeasured confounders.

RESULTS

Radical prostatectomy is superior to RT in OM and CSM after adjustment for covariates (HR = 0.54, 95% CI = 0.47-0.62, P < 0.001 and HR = 0.30, 95% CI = 0.20-0.45, P < 0.001, respectively). The cox model after matching indicated similar consequence (OM: HR = 0.53, 95% CI = 0.46-0.62, P < 0.001; CSM: HR = 0.27, 95% CI = 0.17-0.43, P < 0.001). In the IVA-adjusted model, the effect of treatment changed slightly (OM: HR = 0.65, 95% CI = 0.54-0.78, P < 0.001; CSM: HR = 0.21, 95% CI = 0.12-0.37, P < 0.001). Subgroup analyses showed that for patients with GS = 7, those received RP obtained the highest risk decline for overall death (HR = 0.41, 95% CI = 0.32-0.52); and for patients with younger age, those received RP obtained the highest risk decline for CSM (HR = 0.11, 95% CI = 0.01-0.52).

CONCLUSION

Patients over 75 years of age with cT2 stage will obtain more benefit from RP compared with RT, especially for patients with GS = 7 and younger age.

The prognostic impact of incidental prostate cancer following radical cystoprostatectomy: a nationwide analysis

BACKGROUND

To determine the prevalence and prognostic impact of incidental prostate cancer in patients undergoing radical cystoprostatectomy.

METHODS

A nationwide population-based study of incidental prostate cancer diagnosed following radical cystoprostatectomy. Information on vital status, Gleason score, positive and negative tumor margins, pT-category and subsequent prostate cancer therapies were obtained from the Danish Prostate Cancer Registry and by manual chart review.

RESULTS

A total of 1,450 men who underwent radical cystoprostatectomy in Denmark from 1995-2011 were identified. Forty-six men were excluded from analysis, thus 1,404 patients were eligible. The median follow-up was 7.8 years. A total of 466 (33.2%) had incidental prostate cancer diagnosed. No statistical differences in 10- and 15-year cumulative overall mortality were observed when comparing men with, or without, incidental prostate cancer. In men diagnosed with incidental prostate cancer, neither Gleason score, positive surgical margins or locally advanced prostate cancer (pT3-4) was associated with mortality. Only 0.9% received post-operative prostate cancer-related treatment.

CONCLUSION

In this population-based cohort of patients with incidental prostate cancer diagnosed at radical cystoprostatectomy, we found no impact of incidental prostate cancer on overall mortality, regardless of Gleason score, surgical margin status and pathological T-category. Patients diagnosed with incidental prostate cancer following radical cystoprostatectomy are unlikely to benefit from additional follow-up.

PSA kinetics before 40 years of age

Purpose:

The baseline PSA has been proposed as a possible marker for prostate cancer. The PSA determination before 40 years seems interesting because it not suffers yet the drawbacks related to more advanced ages. Considering the scarcity of data on this topic, an analysis of PSA kinetics in this period seems interesting.

Materials and Methods:

A retrospective assay in a database of a private diagnostic center was performed from 2003 to 2016. All subjects with a PSA before 40 years were included.

Results:

92995 patients performed PSA between the ages of 21 – 39. The mean value ranged from 0.66 ng / mL (at age 22) to 0.76 ng / mL (at age 39) and the overall mean was 0.73 ng / mL. As for outliers, 3783 individuals presented a baseline PSA > 1.6 ng / mL (p95). A linear regression model showed that each year there is a PSA increase of 0.0055 ng / mL (β = 0.0055; r² = 0.0020; p < 0.001). A plateau in PSA between 23 and 32 years was found and there were only minimal variations among the ages regardless of the evaluated percentile.

Conclusion:

It was demonstrated that PSA kinetics before 40 years is a very slow and progressive phenomenon regardless of the assessed percentile. Considering our results, it could be suggested that any PSA performed in this period could represent the baseline value without significant distortions.

Atypical Small Acinar Proliferation and High Grade Prostatic Intraepithelial Neoplasia: Should We Be Concerned? An Observational Cohort Study with a Minimum Follow-Up of 3 Years

Introduction

Atypical small acinar proliferation (ASAP) and high grade prostatic intraepithelial neoplasia (HGPIN) are considered precancerous. We aimed to measure the rate of repeat biopsy and adenocarcinoma in patients with ASAP and HGPIN and identify any clinico-pathologic parameters at diagnosis of ASAP/HGPIN that are predictive of adenocarcinoma.

Materials and Methods

Patients with a diagnosis of ASAP/HGPIN with no previous or concomitant cancer were identified. Prostate specific antigen (PSA) and magnetic resonance imaging (MRI) changes were monitored. Re-biopsy was at clinician discretion.

Results

Nineteen were diagnosed with ASAP and 17 with HGPIN. Seven with ASAP (37%) and 6 with HGPIN (35%) underwent re-biopsy. Three (16%) with ASAP and 5 with HGPIN (29%) were diagnosed with adenocarcinoma. The difference in cancer detection rates between ASAP and HGPIN was not significant (p = 0.35). Five (14%) in total required definitive therapy for adenocarcinoma. Twenty-three (64%) did not undergo repeat biopsy. Parameters at diagnosis of HGPIN and ASAP, including PSA, prostate volume and PSA density, were compared between the cancer and non-cancer cohorts with none found to be predictive of adenocarcinoma.

Conclusion

By monitoring PSA and MRI changes, we managed to spare re-biopsy in two-thirds of patients. Further evaluation is necessary to characterize a surveillance protocol in these populations.

Cancer Immunoprevention and Public Health

The power of cancer immune surveillance has been documented beyond doubt, and the successful exploitation of immune response to cancer has started a new era in the war against cancer. Cancer biologists have recognized immunoevasion as an emerging hallmark in addition to the six hallmarks of cancer. Besides the natural connection between the immune system and cancer development, most established environmental risk factors are now known to interfere with immune surveillance mechanisms. Genetic variations regulating immunity may also modulate cancer susceptibility, but evidence for this is currently limited. Molecular cross talk linking “immune” and “genomic” surveillance pathways has been characterized. It appears that immune mechanisms may contribute to the effects of common cancer risk factors. We provide an updated overview of evidence for cancer immune surveillance, cancer risk factors interfering with it, and interventions to enhance cancer immune surveillance as tools to complement ongoing vaccine development efforts for cancer immunoprevention. Although there is a lot of support for cancer immunoprevention with simple lifestyle modifications from observational studies, there is an urgent need for clinical trials to establish the effectiveness of this approach for public health benefits.

Long-Term Oncological Outcomes for Young Men Undergoing Radical Prostatectomy for Localized Prostate Cancer

Aim. The aim of this study was to describe PCa characteristics and long-term outcomes in young men aged ≤55 years after radical prostatectomy (RP) and to compare them with older men cohort. Methods. Among 2,200 patients who underwent RP for clinically localized PCa at our centre between 2001 and 2015, 277 (10.3%) men aged ≤55 years were identified. All preoperative and pathological parameters were compared between groups. Biochemical progression free survival (BPFS) and disease progression free survival (DPFS) were assessed at 5 and 10 years. Results. Men aged ≤55 years had similar pathological tumor characteristics and biochemical recurrence rate (BCR) compared to their older counterparts. Disease progression rate 2.5% versus 0.4% was higher in older patients (p = 0.026). BPFS rate was not different in both study groups. Estimated 10-year DPFS was 98.8% in younger men compared to 89.2% in their older counterparts (p = 0.031). Multivariate Cox regression showed that Gleason score lymph-nodes and surgical margins status were significant predictors for disease progression. Conclusions. In our cohort, men aged ≤55 years had similar pathological PCa characteristics and BCR rate in comparison with older men. RP can be performed with excellent long-term DPFS results in men with localized PCa at ≤55 years of age.

Diet, Lifestyles, Family History, and Prostate Cancer Incidence in an East Algerian Patient Group

Prostate cancer (PC) is the fourth most common cancer in men and the sixth leading cause of death in Algeria. To examine the relationship between lifestyle factors, including diet, and family history and PC risk, a case-control study was performed in an eastern Algerian population, comprising 90 patients with histologically confirmed PC and 190 controls. Data collection was carried out through a structured questionnaire and statistical analysis was performed to evaluate the different variables. The data showed that consumption of lamb and beef meat and high intake of animal fat and dairy products increased PC risk. Seven to thirteen vegetables servings per week and fourteen or more servings decreased PC risk by 62% and 96%, respectively. Seven to fourteen fruit servings per week decrease PC risk by 98%. Green tea consumption reduced the risk of PC but the results were statistically borderline. Increased risk was observed for individuals with family history of PC in first and in second degree. A positive strong association was also found for alcohol and smoking intake and a dose-response relationship existed for quantity and history of smoking. This study suggests that dietary habits, lifestyle factors, and family history have influence on the development of PC in Algerian population.

Premalignancy in Prostate Cancer: Rethinking What we Know

High-grade prostatic intraepithelial neoplasia (PIN) has been accepted as the main precursor lesion to invasive adenocarcinoma of the prostate, and this is likely to be the case. However, in an unknown number of cases, lesions fulfilling the diagnostic criteria for high-grade PIN may actually represent intra-acinar or intraductal spread of invasive carcinoma. Intriguingly, this possibility would not contradict many of the findings of previous epidemiologic studies linking high-grade PIN to carcinoma or molecular pathologic studies showing similar genomic (e.g., TMPRSS2-ERG gene fusion) as well as epigenomic and molecular phenotypic alterations between high-grade PIN and carcinoma. Also, this possibility would be consistent with previous anatomic studies in prostate specimens linking high-grade PIN and carcinoma in autopsy and other whole prostate specimens. In addition, if some cases meeting morphologic criteria for PIN actually represent intra-acinar spread of invasive carcinoma, this could be an important potential confounder of the interpretation of past clinical trials enrolling patients presumed to be without carcinoma, who are at high risk of invasive carcinoma. Thus, in order to reduce possible bias in future study/trial designs, novel molecular pathology approaches are needed to decipher when an apparent PIN lesion may be intra-acinar/intra-ductal spread of an invasive cancer and when it truly represents a precursor state. Similar approaches are needed for lesions known as intraductal carcinoma to facilitate better classification of them as true intra-ductal/acinar spread on one hand or as precursor high-grade PIN (cribriform type) on the other hand; a number of such molecular approaches (e.g., coevaluating TMPRSS-ERG fusion and PTEN loss) are already showing excellent promise. Cancer Prev Res; 9(8); 648-56. ©2016 AACR.

Role of Magnetic Resonance Imaging in Prostate Cancer Screening: A Pilot Study Within the Göteborg Randomised Screening Trial

BACKGROUND

Magnetic resonance imaging (MRI) and targeted biopsies (TB) have shown potential to more accurately detect significant prostate cancer compared with prostate-specific antigen (PSA) and systematic biopsies (SB).

OBJECTIVE

To compare sequential screening (PSA+MRI) with conventional PSA screening.

DESIGN, SETTING, AND PARTICIPANTS

Of 384 attendees in the 10th screening round of the Göteborg randomised screening trial, 124 men, median age 69.5 yr, had a PSA of ≥ 1.8 ng/ml and underwent a prebiopsy MRI. Men with suspicious lesions on MRI and/or PSA ≥ 3.0ng/ml were referred for biopsy. SB was performed blinded to MRI results and TB was performed in men with tumour-suspicious findings on MRI. Three screening strategies were compared (PSA ≥ 3.0+SB; PSA ≥ 3.0+MRI+TB and PSA ≥ 1.8+MRI+TB).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Cancer detection rates, sensitivity, and specificity were calculated per screening strategy and compared using McNemar's test.

RESULTS AND LIMITATIONS

In total, 28 cases of prostate cancer were detected, of which 20 were diagnosed in biopsy-naïve men. Both PSA ≥ 3.0+MRI and PSA ≥ 1.8+MRI significantly increased specificity compared with PSA ≥ 3.0+SB (0.92 and 0.79 vs 0.52; p<0.002 for both), while sensitivity was significantly higher for PSA ≥ 1.8+MRI compared with PSA ≥ 3.0+MRI (0.73 vs 0.46, p=0.008). The detection rate of significant cancer was higher with PSA ≥ 1.8+MRI compared with PSA ≥ 3.0+SB (5.9% vs 4.0%), while the detection rate of insignificant cancer was lowered by PSA ≥ 3.0+MRI (0.3% vs 1.2%). The primary limitation of this study is the small sample of men.

CONCLUSION

A screening strategy with a lowered PSA cut-off followed by TB in MRI-positive men seems to increase the detection of significant cancers while improving specificity. If replicated, these results may contribute to a paradigm shift in future screening.

PATIENT SUMMARY

Major concerns in prostate-specific antigen screening are overdiagnosis and underdiagnosis. We evaluated whether prostate magnetic resonance imaging could improve the balance of benefits to harm in prostate cancer screening screening, and we found a promising potential of using magnetic resonance imaging in addition to prostate-specific antigen.

The high prevalence of undiagnosed prostate cancer at autopsy: implications for epidemiology and treatment of prostate cancer in the Prostate-specific Antigen-era

Widespread prostate-specific antigen (PSA) screening detects many cancers that would have otherwise gone undiagnosed. To estimate the prevalence of unsuspected prostate cancer, we reviewed 19 studies of prostate cancer discovered at autopsy among 6,024 men. Among men aged 70-79, tumor was found in 36% of Caucasians and 51% of African-Americans. This enormous prevalence, coupled with the high sensitivity of PSA screening, has led to the marked increase in the apparent incidence of prostate cancer. The impact of PSA screening on clinical practice is well-recognized, but its effect on epidemiologic research is less appreciated. Before screening, a larger proportion of incident prostate cancers had lethal potential and were diagnosed at advanced stage. However, in the PSA era, overall incident prostate cancer mainly is indolent disease, and often reflects the propensity to be screened and biopsied. Studies must therefore focus on cancers with lethal potential, and include long follow-up to accommodate the lead time induced by screening. Moreover, risk factor patterns differ markedly for potentially lethal and indolent disease, suggesting separate etiologies and distinct disease entities. Studies of total incident or indolent prostate cancer are of limited clinical utility, and the main focus of research should be on prostate cancers of lethal potential.

Management of Prostate Cancer in the Elderly

The impact of localized prostate cancer in the elderly depends on disease aggressiveness and life expectancy. In men with localized prostate cancer, those with low-risk disease or a shorter life expectancy should be managed expectantly, whereas those with long life expectancy or more aggressive disease may benefit from curative treatment. Comorbidity and quality-of-life concerns are key considerations during the selection of therapeutic modalities in the elderly in localized and metastatic settings. A variety of new agents have changed the therapeutic landscape in castrate-resistant prostate cancer, but their benefits need to be considered alongside their side effects and cost.

Latent prostate cancer in Japanese men who die unnatural deaths: A forensic autopsy study

BACKGROUND

An accurate natural history of prostate cancer (PC) can be obtained from forensic autopsies of individuals who had performed their normal daily activities immediately before death and had not undergone long-term medical interventions. A retrospective analysis of such individuals was performed to understand the features of latent PC in Japan.

METHODS

The findings of forensic autopsies performed at Dokkyo Medical University from August 2002 to July 2005 on men without severely destroyed or severely decomposed tissues were collected. Two cross sections, at the base and apex of the prostate, were examined histopathologically. Data collected included basic history, cause of death, location of PC, and Gleason score.

RESULTS

Of 196 forensically autopsied males aged 0-90 years, 24 (12.7%) had latent PC. When analyzed by age group, PC was most prevalent among individuals in their eighties (33.3%). The prevalence of PC was similar in males who died of disease and of external causes. Most PCs were located at the base of the prostate, but were present on both the anterior and posterior sides. Nine of the 24 autopsied individuals also had other diseases, with three having cancers other than PC.

CONCLUSIONS

This is the first report of the features of latent PC in Asian men who died of unnatural causes. Forensic autopsies can clarify the natural history of PC and may help fill knowledge gaps regarding latent PC.

Prevalence of incidental prostate cancer: A systematic review of autopsy studies

Prostate cancer screening may detect nonprogressive cancers, leading to overdiagnosis and overtreatment. The potential for overdiagnosis can be assessed from the reservoir of prostate cancer in autopsy studies that report incidental prostate cancer rates in men who died of other causes. We aimed to estimate the age-specific incidental cancer prevalence from all published autopsy studies. We identified eligible studies by searches of Medline and Embase, forward and backward citation searches and contacting authors. We screened the titles and abstracts of all articles; checked the full-text articles for eligibility and extracted clinical and pathology data using standardized forms. We extracted mean cancer prevalence, age-specific cancer prevalence and validity measures and then pooled data from all studies using logistic regression models with random effects. The 29 studies included in the review dated from 1948 to 2013. Incidental cancer was detected in all populations, with no obvious time trends in prevalence. Prostate cancer prevalence increased with each decade of age, OR = 1.7 (1.6–1.8), and was higher in studies that used the Gleason score, OR = 2.0 (1.1–3.7). No other factors were significantly predictive. The estimated mean cancer prevalence increased in a nonlinear fashion from 5% (95% CI: 3–8%) at age <30 years to 59% (95% CI: 48–71%) by age >79 years. There was substantial variation between populations in estimated cancer prevalence. There is a substantial reservoir of incidental prostate cancer which increases with age. The high risk of overdiagnosis limits the usefulness of prostate cancer screening.

Urinary prostate protein glycosylation profiling as a diagnostic biomarker for prostate cancer

BACKGROUND

Serum prostate-specific antigen (sPSA) measurement is widely used as opportunistic screening tool for prostate cancer (PCa). sPSA suffers from considerable sensitivity and specificity problems, particularly in the diagnostic gray zone (sPSA 4-10 µg/L). Furthermore, sPSA is not able to discriminate between poorly-, moderately-, and well-differentiated PCa. We investigated prostatic protein glycosylation profiles as a potential PCa biomarker.

METHODS

Differences in total urine N-glycosylation profile of prostatic proteins were determined between healthy volunteers (n = 54), patients with benign prostate hyperplasia (BPH; n = 93) and newly diagnosed PCa patients (n = 74). Variations in N-glycosylation profile and prostate volume were combined into one urinary glycoprofile marker (UGM). Additionally, differences in N-glycosylation were identified between Gleason <7, =7, and >7.

RESULTS

The UGM was able to discriminate BPH from PCa, overall and in the diagnostic gray zone (P < 0.001). The UGM showed comparable diagnostic accuracy to sPSA, but gave an additive diagnostic value to sPSA (P < 0.001). In the diagnostic gray zone the UGM performed significantly better than sPSA (P < 0.001). A significant difference was found in core-fucosylation of biantennary structures and overall core-fucosylation of multiantennary structures between Gleason < 7 and Gleason > 7 (P = 0.010 and P = 0.020, respectively) and between Gleason = 7 and Gleason > 7 (P = 0.011 and P = 0.025, respectively).

CONCLUSIONS

The UGM shows high potential as PCa biomarker, particularly in the diagnostic gray zone. Further research is needed to validate these findings.

Conceptualizing overdiagnosis in cancer screening

The aim of cancer screening is to detect asymptomatic cancers whose treatment will result in extension of life, relative to length of life absent screening. Unfortunately, cancer screening also results in overdiagnosis, the detection of cancers that, in the absence of screening, would not present symptomatically during one's lifetime. Thus, their detection and subsequent treatment is unnecessary and detrimental. This definition of overdiagnosis, while succinct, does not capture the ways it can occur, and our interactions with patients, advocates, researchers, clinicians, and journalists have led us to believe that the concept of overdiagnosis is difficult to explain and, for some, difficult to accept. We propose a dichotomy, the "tumor-patient" classification, to aid in understanding overdiagnosis. The tumor category includes asymptomatic malignant disease that would regress spontaneously if left alone, as well as asymptomatic malignant disease that stagnates or progresses too slowly to be life threatening in even the longest of lifetimes. The patient category includes asymptomatic malignant disease that would progress quickly enough to be life threatening during a lifetime of typical length, but lacks clinical relevance because death due to another cause intercedes prior to what would have been the date of symptomatic diagnosis had screening not occurred. Cancer screening of most organs is likely to result in overdiagnosis of both types. However, the ratio of tumor- to patient-driven overdiagnosis almost certainly varies, and may vary drastically, by organ, screening modality, patient characteristics, and other factors.

Relationship between male pattern baldness and the risk of aggressive prostate cancer: an analysis of the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial

PURPOSE

Male pattern baldness and prostate cancer appear to share common pathophysiologic mechanisms. However, results from previous studies that assess their relationship have been inconsistent. Therefore, we investigated the association of male pattern baldness at age 45 years with risks of overall and subtypes of prostate cancer in a large, prospective cohort—the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial.

METHODS

We included 39,070 men from the usual care and screening arms of the trial cohort who had no cancer diagnosis (excluding nonmelanoma skin cancer) at the start of follow-up and recalled their hair-loss patterns at age 45 years. Hazard ratios (HRs) and 95% CIs were estimated by using Cox proportional hazards regression models with age as the time metric.

RESULTS

During follow-up (median, 2.78 years), 1,138 incident prostate cancer cases were diagnosed, 571 of which were aggressive (biopsy Gleason score ≥ 7, and/or clinical stage III or greater, and/or fatal). Compared with no baldness, frontal plus moderate vertex baldness at age 45 years was not significantly associated with overall (HR, 1.19; 95% CI, 0.98 to 1.45) or nonaggressive (HR, 0.97; 95% CI, 0.72 to 1.30) prostate cancer risk but was significantly associated with increased risk of aggressive prostate cancer (HR, 1.39; 95% CI, 1.07 to 1.80). Adjustment for covariates did not substantially alter these estimates. Other classes of baldness were not significantly associated with overall or subtypes of prostate cancer.

CONCLUSION

Our analysis indicates that frontal plus moderate vertex baldness at age 45 years is associated with an increased risk of aggressive prostate cancer and supports the possibility of common pathophysiologic mechanisms.

Prostate cancer incidence on cystoprostatectomy specimens is directly linked to age: results from a multicentre study

OBJECTIVE

To assess the incidence and age-related histopathological characteristics of incidentally diagnosed prostate cancer from specimens obtained via radical cystoprostatectomy (RCP) for muscle-invasive bladder cancer.

PATIENTS AND METHODS

A retrospective review of the histopathological features of 2424 male patients who underwent a RCP for bladder cancer was done at eight centres between January 1996 and June 2012. No patient had preoperative suspicion of prostate cancer. Statistical analyses were performed in different age-related groups.

RESULTS

Overall, prostate cancer was diagnosed in 518 men (21.4%). Incidences varied significantly according to age (5.2% in those aged <50 years to 30.5% in those aged >75 years, P < 0.001). Most of the prostate cancers were considered as 'non-aggressive', that is to say organ-confined (≤pT2) and well-differentiated (Gleason score <7). Tumour-Node-Metastasis (TNM) stage and proportion with a Gleason score of ≥7 were significantly greater in older patients (P < 0.001). Apart from age, there were no preoperative predictive factors for 'non-aggressive' prostate-cancer status. At the end of the follow-up, only nine patients (1.7%) had biochemical recurrence of prostate cancer, and no preoperative predictive factors were identified.

CONCLUSION

The rate of incidentally diagnosed prostate cancer from RCP specimens is ≈20%, most of them being organ-confined and well-differentiated. The probability of having a 'non-aggressive' prostate cancer decreases in older men.

Challenges of managing elderly men with prostate cancer

The incidence of prostate cancer increases with age. Current evidence suggests that prostate cancer is under treated in patients aged ≥70 years, despite evidence of efficacy and acceptable toxicity. Radical cystectomy and definitive radiotherapy are often denied owing to fears of post-operative complications and radiotherapy-associated gastrointestinal and genitourinary toxicity. However, modern radical prostatectomy techniques provide excellent clinical outcomes with low perioperative morbidity. Moreover, volume-restricted intensity-modulated radiation therapy is a significant improvement over previous 2D conformal radiotherapy with similar efficacy and lower toxicity. Androgen-deprivation therapy is also under-prescribed among the elderly, owing to concerns of increases in cardiac deaths and osteoporosis acceleration. However, prospective trials have not identified any increase in cardiovascular mortality among elderly men receiving androgen-deprivation therapy compared to age-matched controls. Most patients on androgen deprivation eventually progress to a castration-resistant state. At this stage, the disease still responds to newer agents that target the androgen pathway and to chemotherapy. Among the elderly, chemotherapy is under-prescribed even though it has been demonstrated to be palliative and improve survival. We describe the trends in prostate cancer management in the elderly and the importance of assessing comorbidity status, tumour characteristics, and health status, including a complete geriatric evaluation, before making treatment recommendations.

Overdiagnosis and overtreatment of prostate cancer

CONTEXT

Although prostate cancer (PCa) screening reduces the incidence of advanced disease and mortality, trade-offs include overdiagnosis and resultant overtreatment.

OBJECTIVE

To review primary data on PCa overdiagnosis and overtreatment.

EVIDENCE ACQUISITION

Electronic searches were conducted in Cochrane Central Register of Controlled Trials, PubMed, and Embase from inception to July 2013 for original articles on PCa overdiagnosis and overtreatment. Supplemental articles were identified through hand searches.

EVIDENCE SYNTHESIS

The lead-time and excess-incidence approaches are the main ways used to estimate overdiagnosis in epidemiological studies, with estimates varying widely. The estimated number of PCa cases needed to be diagnosed to save a life has ranged from 48 down to 5 with increasing follow-up. In clinical studies, generally lower rates of overdiagnosis have been reported based on the frequency of low-grade minimal tumors at radical prostatectomy (1.7-46.8%). Autopsy studies have reported PCa in 18.5-38.5%, although not all are low grade or low volume. Factors influencing overdiagnosis include the study population, screening protocol, and background incidence, limiting generalizability between settings. Reported rates of overtreatment vary widely in the literature, although contemporary international studies suggest increasing use of conservative management.

CONCLUSIONS

Epidemiological, clinical, and autopsy studies have been used to examine PCa overdiagnosis, with estimates ranging widely from 1.7% to 67%. Correspondingly, estimates of overtreatment vary widely based on patient features and may be declining internationally. Careful patient selection for screening and reducing overtreatment are important to preserve the benefits and reduce the downstream harms of prostate-specific antigen testing. Because all of these estimates are extremely population and context specific, this must be considered when using these data to inform policy.

PATIENT SUMMARY

Screening reduces spread and death from prostate cancer (PCa) but overdiagnoses some low-risk tumors that may not have caused harm. Because treatment has potential side effects, it is critical that not all patients with PCa receive aggressive treatment.

Preneoplasia in the prostate gland with emphasis on high grade prostatic intraepithelial neoplasia

There are a variety of morphological patterns and processes that have been implicated in the pathogenesis of prostate cancer. Prostatic intraepithelial neoplasia (PIN), inflammation with or without atrophy, and adenosis (atypical adenomatous hyperplasia) have all been given candidate status as precursor lesions of prostatic adenocarcinoma. Based on decades of research, high grade prostatic intraepithelial neoplasia (HPIN), a proliferative lesion of prostatic secretory cells, has emerged as the most likely morphological pre-invasive lesion involved in the evolution of many but not all prostatic adenocarcinomas. In this manuscript, we briefly discuss other proposed precursors of prostatic adenocarcinoma and then focus on the history, diagnostic criteria and morphology of HPIN. The incidence of HPIN and its relationship to prostate cancer is reviewed. The differential diagnosis of large glandular patterns in the prostate is discussed in depth. Finally, we summarise the recent clinicopathological studies evaluating the clinical significance of HPIN and discuss follow-up strategies in men diagnosed with HPIN.

Incremental value of transition zone and midline apical biopsy at baseline TRUS-guided biopsy for prostate cancer detection

PURPOSE

To determine the diagnostic yield of transition zone (TZB) and midline apical biopsies (MAB) in baseline transrectal ultrasound (TRUS)-guided biopsies and to establish whether TZB and MAB for the diagnosis of prostate cancer (PCa) add clinical relevant information.

METHODS

We performed baseline 9-core TRUS-guided biopsy in 412 consecutive subjects using sextant biopsies of the PZ (PZB), with an additional TZB on either side and a MAB at the prostatic apex. We determined the incremental diagnostic value of additional TZB an MAB to sextant PZB.

RESULTS

Within a cohort of 412 patients with a median PSA of 7.5 ng/ml, 178 (43.2 %) patients were diagnosed with PCa upon baseline TRUS-guided biopsies. In 102 cases, at least one TZB was positive for PCa, with 6/412 (1.4 %) cases displaying PCa in the TZB only. MAB alone was positive for PCa in 4/412 (1.0 %) cases. One case (1/412; 0.2 %) had only a TZB and a MAB positive for PCa without positive PZB. Thus, 11/412 (2.7 %) of cases would not have been diagnosed with PCa at baseline TRUS-guided biopsy had only sextant PZ biopsy been performed. TZB detected a high-grade Gleason component (Gleason 4 and/or 5) not present in the PZB in 2.4 % of PCa cases.

CONCLUSIONS

There is limited value for TZB and MAB in the context of sextant PZB at baseline TRUS-guided biopsies for PCa.

Prostate cancer: is it time to expand the research focus to early-life exposures?

Although the contribution of lifestyle and environment (non-genetic factors) to prostate carcinogenesis is indicated by international variation in prostate cancer occurrence and migration studies, no conclusive modifiable risk factors have yet been identified. One possible reason for this may be the dearth of epidemiological research on exposures experienced early in life, when the immature prostate may be more susceptible to carcinogenic exposures. In this Opinion article, we summarize the rationale for studying early-life exposures, describe the small body of early-life research and its associated challenges, and point to solutions for future research.