Defining the Impact of Family History on Detection of High-grade Prostate Cancer in a Large Multi-institutional Cohort

A systematic review of family history, race/ethnicity, and genetic risk on prostate cancer detection and outcomes: Considerations in PSA-based screening

AIM

To investigate the role of family history, race/ethnicity, and genetics in prostate cancer (PCa) screening.

METHODS

We conducted a systematic review of articles from January 2013 through September 2023 that focused on the association of race/ethnicity and genetic factors on PCa detection. Of 10,815 studies, we identified 43 that fulfilled our pre-determined PICO (Patient, Intervention, Comparison and Outcome) criteria.

RESULTS

Men with ≥1 first-degree relative(s) with PCa are at increased risk of PCa, even with negative imaging and/or benign prostate biopsy. Black men have higher PCa risk, while Asian men have lower risk. Most of the differences in risks are attributable to environmental and socioeconomic factors; however, genetic differences may play a role. Among numerous pathogenic variants that increase PCa risk, BRCA2, MSH2, and HOXB13 mutations confer the highest risk of PCa. Polygenic risk score (PRS) models identify men at higher PCa risk for a given age and PSA; these models improve when considering other clinical factors and when the model population matches the study population's ancestry.

CONCLUSIONS

Family history of PCa, race/ethnicity, pathogenic variants (particularly BRCA2, MSH2, and HOXB13), and PRS are associated with increased PCa risk and should be considered in shared decision-making to determine PCa screening regimens.

Diabetes Mellitus and Prostate Cancer Risk-A Systematic Review and Meta-Analysis

INTRODUCTION

Prostate cancer is the second most commonly diagnosed malignant tumor worldwide and poses a significant challenge to public health. This systematic review and meta-analysis aims to investigate the association between diabetes mellitus and the risk of developing prostate cancer.

METHODS

We conducted a search of PubMed, Embase, and the Cochrane Library from 1998 to 2024. The risk of bias within the included studies was assessed using the Newcastle-Ottawa Scale. The DerSimonian-Laird random-effect model was employed for the meta-analysis. Heterogeneity was evaluated using a forest plot and statistically assessed via the Q test, I2 index, and p-values.

RESULTS

Forty-three studies involving a total of 3,746,769 patients were included. Both case-control (pOR = 0.68, 95% CI: 0.61-0.97; I2 = 92.24%) and cohort studies (pRR = 0.71, 95% CI: 0.59-0.99; I2 = 85.41%) suggest that diabetes mellitus is associated with a reduced risk of prostate cancer, though with significant heterogeneity (p < 0.05). Subgroup analysis revealed that the risk of developing prostate cancer was significantly higher in patients with a family history of prostate cancer (pRR = 1.25, 95% CI: 1.16-1.35; I2 = 69.51%).

CONCLUSIONS

Our meta-analysis of recent observational studies indicates that diabetes mellitus is associated with a reduced risk of developing prostate cancer.

Prostate Cancer: Emerging Modifiable Risk Factors and Therapeutic Strategies in the Management of Advanced Cancer

Prostate cancer (PCa) is the third highest cause of cancer death in men. PCa is a very heterogeneous tumor form in terms of grade, phenotypes, and genetics, often accompanied by complex networks. PCa is characterized by slow growth that does not compromise the patient's quality of life, unlike more aggressive forms showing rapid growth and progression. Early diagnosis, even for the most aggressive forms, increases the possibilities of cure with less aggressive treatments and fewer side effects. However, it is important to know how to decrease the exposure to modifiable risk factors, including diet, sedentary life, smoking and alcohol, can represent an effective tool to reduce the incidence of PCa. In addition, the chronic exposure to environmental factors, most of which act as endocrine disruptors, is the focus of recent studies for their potential role in promoting the onset and progression of PCa. Although molecular therapies and clinical trials for biomarker identification have been introduced into the management of PCa, these still lag behind research performed in other solid tumors. This review provides an overview of the modifiable factors of PCa, linked to lifestyle and environmental pollutants, which together with the development of new therapeutic targets, can reduce the incidence of PCa and improve the quality of life of patients.

Impact of family history of prostate cancer on disease progression for prostatic cancer patients undergoing active surveillance: A systematic review and meta-analysis

PURPOSE

To evaluate how a family history of prostate cancer influences the progression of the disease in individuals with prostate cancer undergoing active surveillance.

MATERIALS AND METHODS

We conducted a thorough literature search in PubMed/MEDLINE, Embase, and Cochrane Library up to June 2023. This systematic review was registered in PROSPERO (CRD42023441853). The study evaluated the effects of family history of prostate cancer (intervention) on disease progression (outcome) in prostate cancer patients undergoing active surveillance (population) and compared them to those without a family history (comparators). For time to disease progression outcomes, the extracted data were synthesized using the inverse variance method on the log hazard ratios scale.

RESULTS

A total of eight studies were incorporated into this systematic review and meta-analysis. The combined hazard ratio for unadjusted disease progression was 1.06 (95% confidential interval [CI] 0.66-1.69; p=0.82). The combined hazard ratio for adjusted disease progression was 1.31 (95% CI 1.16-1.48; p<0.0001). All the enlisted studies demonstrated high quality based on the Newcastle-Ottawa scale. The certainty of evidence for univariate and multivariate analysis of disease progression was very low and low, respectively. Publication bias for all studies was not significant.

CONCLUSIONS

For individuals with prostate cancer opting for active surveillance, a family history of prostate cancer may serve as an independent risk factor associated with an elevated risk of disease progression. Clinicians should be counseled about the increased risk of disease progression in patients with a family history of prostate cancer undergoing active surveillance.

BioPrev-C - development and validation of a contemporary prostate cancer risk calculator

Objectives

To develop a novel biopsy prostate cancer (PCa) prevention calculator (BioPrev-C) using data from a prospective cohort all undergoing mpMRI targeted and transperineal template saturation biopsy.

Materials and methods

Data of all men who underwent prostate biopsy in our academic tertiary care center between 11/2016 and 10/2019 was prospectively collected. We developed a clinical prediction model for the detection of high-grade PCa (Gleason score ≥7) based on a multivariable logistic regression model incorporating age, PSA, prostate volume, digital rectal examination, family history, previous negative biopsy, 5-alpha-reductase inhibitor use and MRI PI-RADS score. BioPrev-C performance was externally validated in another prospective Swiss cohort and compared with two other PCa risk-calculators (SWOP-RC and PBCG-RC).

Results

Of 391 men in the development cohort, 157 (40.2%) were diagnosed with high-grade PCa. Validation of the BioPrev C revealed good discrimination with an area under the curve for high-grade PCa of 0.88 (95% Confidence Interval 0.82-0.93), which was higher compared to the other two risk calculators (0.71 for PBCG and 0.84 for SWOP). The BioPrev-C revealed good calibration in the low-risk range (0 - 0.25) and moderate overestimation in the intermediate risk range (0.25 - 0.75). The PBCG-RC showed good calibration and the SWOP-RC constant underestimation of high-grade PCa over the whole prediction range. Decision curve analyses revealed a clinical net benefit for the BioPrev-C at a clinical meaningful threshold probability range (≥4%), whereas PBCG and SWOP calculators only showed clinical net benefit above a 30% threshold probability.

Conclusion

BiopPrev-C is a novel contemporary risk calculator for the prediction of high-grade PCa. External validation of the BioPrev-C revealed relevant clinical benefit, which was superior compared to other well-known risk calculators. The BioPrev-C has the potential to significantly and safely reduce the number of men who should undergo a prostate biopsy.

Incorporating Genetic Risk Into Prostate Cancer Care: Implications for Early Detection and Precision Oncology

The availability and cost of germline and somatic genetic testing have dramatically improved over the past two decades, enabling precision medicine approaches in oncology, with significant implications for prostate cancer (PCa) care. Roughly 12% of individuals with advanced disease are carriers of rare pathogenic germline variants that predispose to particularly aggressive and earlier-onset disease. Several of these variants are already established as clinically actionable by modern precision oncology therapeutics, while others may come to aid the selection of active surveillance, definitive local therapies, and systemic therapies. Concurrently, the number of common variants (ie, incorporated into polygenic risk scores) associated with PCa risk has continued to grow, but with several important considerations both at the intersection of race and ancestry and for early detection of aggressive disease. Family history has historically been used as a proxy for this inherited genetic risk of PCa, but recently emerging evidence examining this relation has shifted our understanding of how best to leverage this tool in PCa care. This review seeks to clarify and contextualize the existing and emerging precision oncology paradigms that use inherited genetic risk in PCa care, for both early detection and localized disease management.

Contemporary Strategies for Clinical Chemoprevention of Localized Prostate Cancer

Prostate cancer (PCa) is the most common cancer among men in the United States and the second leading cause of cancer-related deaths. Metastatic castration-resistant PCa is still a fatal disease. On the other hand, between 2016 and 2020, about 70% of PCa cases were diagnosed at a localized stage. Evolving data demonstrates that men with low-grade cancers treated with definitive therapies may now be exposed to morbidities of overtreatment and poor quality of life, with little or no benefit in terms of cancer specific mortality. Active surveillance (AS) is thus the recommended management strategy for men with low-grade disease. Although this subgroup of men have reported anxiety during the AS period, they account to be highly motivated to make positive lifestyle changes to further reduce their risk of PCa progression, underscoring the urgent need to identify novel strategies for preventing progression of localized PCa to metastatic disease through pharmacologic means, an approach termed chemoprevention. Although several promising agents and approaches have been examined over the past 2 decades, currently, there are several limitations in the approach used to systematically examine agents for chemoprevention targeting men on AS. The goal of this review is to summarize the current agents and approaches evaluated, targeting men on AS, recognize the gaps, and identify a contemporary and comprehensive path forward. Results of these studies may inform the development of phase III clinical trials and ultimately provide a strategy for clinical chemoprevention in men on AS, for whom, currently, there are no options for reducing the risk of progression to metastatic disease.

Checkpoint Kinase 2 (CHEK2) Gene Mutation in a Patient With Breast and Prostate Cancer: A Unique Presentation of a Rare Disease

Breast cancer is one of the rarest malignancies in males, with a low incidence rate compared to all breast cancers. Gene mutation plays a significant role in the pathologic process of cancer. Mutations in breast cancer gene 1 (BRCA1) and breast cancer gene 2 (BRCA2) have been associated with male breast cancer (MBC), as well as prostate cancer (PCa). Despite the etiopathogenetic similarity, combined MBC and PCa is a rare entity. This report presents the case of a 57-year-old male with a history of breast cancer who underwent modified radical mastectomy (MRM) with lymph node dissection followed by adjuvant chemoradiotherapy four years ago. The patient presented with recurrent episodes of voiding dysfunction for three months, followed by urine retention. His family history was positive for breast and lung cancer. High prostate-specific antigen (PSA) and Prostate Imaging-Reporting and Data System 5 (PI-RADS5) necessitate transrectal ultrasound-guided biopsy, which confirmed the diagnosis of PCa. Molecular genetics testing and next-generation sequencing (NGS) analysis identified heterozygous variant c.636T>G, p.(Tyr212*) in the checkpoint kinase 2 (CHEK2) gene. The patient is planned for neoadjuvant luteinizing hormone-releasing hormone (LHRH) for 3-6 months, to be followed by transurethral tunneling of the prostate (TUTP) with adjuvant LHRH. The allele frequency of this patient mutation was documented for the first time among the general population, and it has not been described in the literature. This unique and rare case was presented with clinical, morphological, and immunohistochemical features together with a review of the current literature.

Is Active Surveillance an Option for the Management of Men with Low-grade Prostate Cancer and a Positive Family History? Results from a Large, Single-institution Series

BACKGROUND

Family history (FH) of prostate cancer (PCa) is associated with an increased risk of PCa and adverse disease features. However, whether patients with localized PCa and FH could be considered for active surveillance (AS) remains controversial.

OBJECTIVE

To assess the association between FH and reclassification of AS candidates, and to define predictors of adverse outcomes in men with positive FH.

DESIGN, SETTING, AND PARTICIPANTS

Overall, 656 patients with grade group (GG) 1 PCa included in an AS protocol at a single institution were identified.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Kaplan-Meier analyses assessed the time to reclassification (GG ≥2 and GG ≥3 at follow-up biopsies) overall and according to FH status. Multivariable Cox regression tested the impact of FH on reclassification and identified the predictors among men with FH. Men treated with delayed radical prostatectomy (n = 197) or external-beam radiation therapy (n = 64) were identified, and the impact of FH on oncologic outcomes was assessed.

RESULTS AND LIMITATIONS

Overall, 119 men (18%) had FH. The median follow-up was 54 mo (interquartile range 29-84 mo), and 264 patients experienced reclassification. The 5-yr reclassification-free survival rate was 39% versus 57% for FH versus no FH (p = 0.006), and FH was associated with reclassification to GG ≥2 (hazard ratio [HR] 1.60, 95% confidence interval [CI] 1.19-2.15, p = 0.002). In men with FH, the strongest predictors of reclassification were prostate-specific antigen (PSA) density (PSAD), high-volume GG 1 (≥33% of cores involved or ≥50% of any core involved), and suspicious magnetic resonance imaging (MRI) of the prostate (HRs 2.87, 3.04, and 3.87, respectively; all p < 0.05). No association between FH, adverse pathologic features, and biochemical recurrence was observed (all p > 0.05).

CONCLUSIONS

Patients with FH on AS are at an increased risk of reclassification. Negative MRI, low disease volume, and low PSAD identify men with FH and a low risk of reclassification. Nonetheless, sample size and wide CIs entail caution in drawing conclusions based on these results.

PATIENT SUMMARY

We tested the impact of family history in men on active surveillance for localized prostate cancer. A significant risk of reclassification, but not adverse oncologic outcomes after deferred treatment, prompts the need for cautious discussion with these patients, without precluding initial expectant management.

2022 Update on Prostate Cancer Epidemiology and Risk Factors-A Systematic Review

CONTEXT

Prostate cancer (PCa) is one of the most common cancers worldwide. Understanding the epidemiology and risk factors of the disease is paramount to improve primary and secondary prevention strategies.

OBJECTIVE

To systematically review and summarize the current evidence on the descriptive epidemiology, large screening studies, diagnostic techniques, and risk factors of PCa.

EVIDENCE ACQUISITION

PCa incidence and mortality rates for 2020 were obtained from the GLOBOCAN database of the International Agency for Research on Cancer. A systematic search was performed in July 2022 using PubMed/MEDLINE and EMBASE biomedical databases. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and was registered in PROSPERO (CRD42022359728).

EVIDENCE SYNTHESIS

Globally, PCa is the second most common cancer, with the highest incidence in North and South America, Europe, Australia, and the Caribbean. Risk factors include age, family history, and genetic predisposition. Additional factors may include smoking, diet, physical activity, specific medications, and occupational factors. As PCa screening has become more accepted, newer approaches such as magnetic resonance imaging (MRI) and biomarkers have been implemented to identify patients who are likely to harbor significant tumors. Limitations of this review include the evidence being derived from meta-analyses of mostly retrospective studies.

CONCLUSIONS

PCa remains the second most common cancer among men worldwide. PCa screening is gaining acceptance and will likely reduce PCa mortality at the cost of overdiagnosis and overtreatment. Increasing use of MRI and biomarkers for the detection of PCa may mitigate some of the negative consequences of screening.

PATIENT SUMMARY

Prostate cancer (PCa) remains the second most common cancer among men, and screening for PCa is likely to increase in the future. Improved diagnostic techniques can help reduce the number of men who need to be diagnosed and treated to save one life. Avoidable risk factors for PCa may include factors such as smoking, diet, physical activity, specific medications, and certain occupations.

Early Detection of Prostate Cancer: AUA/SUO Guideline Part I: Prostate Cancer Screening

PURPOSE

The summary presented herein covers recommendations on the early detection of prostate cancer and provides a framework to facilitate clinical decision-making in the implementation of prostate cancer screening, biopsy, and follow-up. This is Part I of a two-part series that focuses on prostate cancer screening. Please refer to Part II for discussion of initial and repeat biopsies as well as biopsy technique.

MATERIALS AND METHODS

The systematic review utilized to inform this guideline was conducted by an independent methodological consultant. The systematic review was based on searches in Ovid MEDLINE and Embase and Cochrane Database of Systematic Reviews (January 1, 2000-November 21, 2022). Searches were supplemented by reviewing reference lists of relevant articles.

RESULTS

The Early Detection of Prostate Cancer Panel developed evidence- and consensus-based guideline statements to provide guidance in prostate cancer screening, initial and repeat biopsy, and biopsy technique.

CONCLUSIONS

Prostate-specific antigen (PSA)-based prostate cancer screening in combination with shared decision-making (SDM) is recommended. Current data regarding risk from population-based cohorts provide a basis for longer screening intervals and tailored screening, and the use of available online risk calculators is encouraged.

Recent Research Advances in Double-Strand Break and Mismatch Repair Defects in Prostate Cancer and Potential Clinical Applications

Prostate cancer remains a leading cause of cancer-related death in men worldwide. Recent research advances have emphasized the critical roles of mismatch repair (MMR) and double-strand break (DSB) in prostate cancer development and progression. Here, we provide a comprehensive review of the molecular mechanisms underlying DSB and MMR defects in prostate cancer, as well as their clinical implications. Furthermore, we discuss the promising therapeutic potential of immune checkpoint inhibitors and PARP inhibitors in targeting these defects, particularly in the context of personalized medicine and further perspectives. Recent clinical trials have demonstrated the efficacy of these novel treatments, including Food and Drugs Association (FDA) drug approvals, offering hope for improved patient outcomes. Overall, this review emphasizes the importance of understanding the interplay between MMR and DSB defects in prostate cancer to develop innovative and effective therapeutic strategies for patients.

Genetic Risk Prediction for Prostate Cancer: Implications for Early Detection and Prevention

CONTEXT

Prostate cancer (PCa) is a leading cause of death and partially heritable. Genetic risk prediction might be useful for strategies to reduce PCa mortality through early detection and prevention.

OBJECTIVE

To review evidence for genetic risk prediction for PCa.

EVIDENCE ACQUISITION

A collaborative literature review was conducted using PubMed and Google Scholar. Search terms included genetic, risk, prediction, and "prostate cancer". Articles addressing screening, early detection, or prevention were prioritized, as were studies involving diverse populations.

EVIDENCE SYNTHESIS

Rare pathogenic mutations (RPMs), especially in DNA damage repair genes, increase PCa risk. RPMs in BRCA2 are most clearly deleterious, conferring 2-8.6 times higher risk of PCa and a higher risk of aggressive disease. Common genetic variants can be combined into genetic risk scores (GRSs). A high GRS (top 20-25% of the population) confers two to three times higher risk of PCa than average; a very high GRS (top 1-5%) confers six to eight times higher risk. GRSs are not specific for aggressive PCa, possibly due to methodological limitations and/or a field effect of an elevated risk for both low- and high-grade PCa. It is challenging to disentangle genetics from structural racism and social determinants of health to understand PCa racial disparities. GRSs are independently associated with a lethal PCa risk after accounting for family history and race/ancestry. Healthy lifestyle might partially mitigate the risk of lethal PCa.

CONCLUSIONS

Genetic risk assessment is becoming more common; implementation studies are needed to understand the implications and to avoid exacerbating healthcare disparities. Men with a high genetic risk of PCa can reasonably be encouraged to adhere to a healthy lifestyle.

PATIENT SUMMARY

Prostate cancer risk is inherited through rare mutations and through the combination of hundreds of common genetic markers. Some men with a high genetic risk (especially BRCA2 mutations) likely benefit from early screening for prostate cancer. The risk of lethal prostate cancer can be reduced through a healthy lifestyle.

The profile of Black South African men diagnosed with prostate cancer in the Free State, South Africa

BACKGROUND

Prostate cancer (PCa) ranks high in terms of morbidity and mortality, especially in Africa. Prostate-specific antigen (PSA) screening remains a practical method of screening for and thereby detecting PCa early, especially among African men who are more negatively affected. Modifiable risk factors for PCa are mostly behavioural and lifestyle. Understanding community-specific determinants is important when developing health promotion interventions.

OBJECTIVE

This study aimed to determine the profile of African men with PCa in the Free State, South Africa.

METHOD

A cross-sectional descriptive study was conducted using case record information and self-administered questionnaires among 341 African men with PCa attending the oncology and urology clinics of a tertiary hospital.

RESULT

Participants' median age at diagnosis was 66 years. Only 76 (22.3%) participants had ever heard of PCa prior to being diagnosed with the disease, 36 (47.4%) of whom had ever had screening performed. The majority (n = 298, 87.4%) were symptomatic; 50% sought medical help within six months. At diagnosis, 133 (39.0%) men presented with stage T3 or T4 disease, 75 (22.0%) with metastatic disease and 84 (24.6%) with Gleason score ≥ 8. Factors associated with advanced and high-grade disease included smoking, decreased sunlight exposure and physical activity, relatively increased ingestion of dairy products and red meat. Factors associated with early stage and low-grade disease included relatively increased ingestion of fruits, vegetables and fish.

CONCLUSION

Advanced and high-grade PCa disease is not uncommon among men ≥ 60 years in this study setting. Certain modifiable risk factors associated with advanced disease were established in this study. The majority had lower urinary tract symptoms (LUTS) prior to PCa diagnosis, but they were of poor health-seeking behaviour. Although there seems not to be a systematic delay in the definitive diagnosis and initiation of treatment for PCa, there is a need to improve on health education and awareness in the study setting.

Impact of family history on clinicopathological variables and disease progression in Japanese prostate cancer patients undergoing robotic-assisted radical prostatectomy

OBJECTIVE

We evaluated whether a first-degree family history (FH) of prostate cancer (PCa) in Japanese patients undergoing robotic-assisted radical prostatectomy (RP) is correlated with clinicopathological variables and disease progression.

METHODS

We reviewed consecutive 392 localized PCa patients undergoing robotic-assisted RP at our institution between 2015 and 2020. Information on FH was obtained via a self-administered questionnaire. A positive FH was defined as having a first-degree FH: a father and/or one or more brothers with PCa prior to diagnosis. All patients had clinically localized PCa treated by robotic-assisted RP. We evaluated the relationship between clinical characteristics, pathological findings, and biochemical progression-free survival (bPFS) according to first-degree FH status.

RESULTS

Median follow-up was 20.8 months. FH was identified in 42 (10.7%) patients. Patients in the FH group (median, 64.8 years) were diagnosed at a significantly younger age than patients in the non-FH (NFH) group (patients without FH) (median, 67.7 years) (p = 0.003). The 5-year bPFS in the FH and NFH groups was 72.0% and 78.1%, respectively (p = 0.90). A subgroup analysis revealed a significant difference in prostate-specific antigen (PSA) density between the FH group (median, 0.51 ng/ml/cm3 ) and the NFH group (median, 0.29 ng/ml/cm3 ) in patients younger than 60 years (p = 0.033).

CONCLUSIONS

In this RP population, FH of PCa was not associated with worse clinical characteristics, pathological findings, or disease progression. Patients with a FH underwent surgery at a significantly younger age, and among patients <60 years, patients with a FH had significantly higher PSA density compared with patients without a FH.

Quality of life and secondary outcomes for open versus robot-assisted radical cystectomy: a double-blinded, randomised feasibility trial

PURPOSE

This study aims to examine quality of life (QoL) before and after radical cystectomy (RC) and compare robot-assisted laparoscopy with intracorporeal urinary diversion (iRARC) to open radical cystectomy (ORC).

METHODS

This study is a predefined secondary analysis of a single-centre, double-blinded, randomised feasibility trial. Fifty patients were randomly assigned to iRARC with ileal conduit (n = 25) or ORC with ileal conduit (n = 25). Patients were followed 90 days postoperatively. The primary outcome was patient-reported QoL using the EORTC Cancer-30 and muscle-invasive bladder cancer BLM-30 QoL questionnaires before and after RC. Differences between randomisation arms as well as changes over time were evaluated. Secondary outcomes included 30- and 90 day complication rates, 90 day readmission rates, and 90 day days-alive-and-out-of-hospital and their relationship to QoL.

RESULTS

All patients underwent the allocated treatment. We found no difference in QoL, complication rates, readmission rates, and days-alive-and-out-of-hospital between randomisation arms. An overall improvement in QoL was found in the following domains: future perspectives, emotional functioning, and social functioning. Sexual functioning worsened postoperatively. There was no association between having experienced a major complication or lengthy hospitalisation and worse postoperative QoL.

CONCLUSION

The QoL does not appear to depend on surgical technique. Apart from sexual functioning, patients report stable or improved QoL within the first 90 postoperative days.