Serum prostate-specific antigen and digital rectal examination for early detection of prostate cancer in a national community-based program. The Prostate Cancer Education Council

Extracellular Vesicle Proteome in Prostate Cancer: A Comparative Analysis of Mass Spectrometry Studies

Molecular diagnostics based on discovery research holds the promise of improving screening methods for prostate cancer (PCa). Furthermore, the congregated information prompts the question whether the urinary extracellular vesicles (uEV) proteome has been thoroughly explored, especially at the proteome level. In fact, most extracellular vesicles (EV) based biomarker studies have mainly targeted plasma or serum. Therefore, in this study, we aim to inquire about possible strategies for urinary biomarker discovery particularly focused on the proteome of urine EVs. Proteomics data deposited in the PRIDE archive were reanalyzed to target identifications of potential PCa markers. Network analysis of the markers proposed by different prostate cancer studies revealed moderate overlap. The recent throughput improvements in mass spectrometry together with the network analysis performed in this study, suggest that a larger standardized cohort may provide potential biomarkers that are able to fully characterize the heterogeneity of PCa. According to our analysis PCa studies based on urinary EV proteome presents higher protein coverage compared to plasma, plasma EV, and voided urine proteome. This together with a direct interaction of the prostate gland and urethra makes uEVs an attractive option for protein biomarker studies. In addition, urinary proteome based PCa studies must also evaluate samples from bladder and renal cancers to assess specificity for PCa.

Detection of TMPRSS2-ERG Fusion Transcript in Biopsy Specimen of Prostate Cancer Patients: A Single Centre Experience

INTRODUCTION

Prostate carcinoma is the most frequent malign neoplasm among men with an ever-growing incidence rate. TMPRSS2-ERG fusion transcript leads to the androgen induction of ERG proto-oncogenes expression, representing a high presence of oncogenes alteration among prostate tumour cells.

AIM

The aim of this research was to detect and evaluate theTMPRSS2-ERG fuse transcript in the tissues of patients with prostate cancer, and establish a base of material of these samples for further genetic examination.

MATERIALS AND METHODS

The research was a prospective clinical study that involved and focused on random sampling of 101 patients (62 with prostate cancer-study group and 39 with benign changes in the prostate-control group). Real time PCR analysis for detection of the TMPRSS2-ERG fusion transcript in prostate tissue was performed and also data from the histopathology results of tissues were used, as well as data for the level of PSA (prostate-specific antigen) in blood.

RESULTS

TMPRSS2-ERG fusion transcript was detected in 20 out of 62 (32.2%) patients with prostate carcinoma and among no patients with benign changes whatsoever. There were no significant differences between patients with/without detected TMPRSS2-ERG fusion related to Gleason score. Among 50%, in the study group this score was greater than 7 per/for Median IQR=7 (6-8). Significant difference was recognized, related to the average value of PSA in favour of significantly higher value of PSA in the study group with prostate cancer, but there was also no significant difference between samples with prostate cancer who were with/without detected TMPRSS2-ERG fusion transcript related to PSA level.

DISCUSSION

The results from this research are in accordance with the values and results from analyses done in several research centres and oncological institutes.

CONCLUSION

The positive findings in small scale studies encourage the implementation of larger scale studies that will be enriched with results of genetic transcript in blood and urine and will define the positive diagnostic meaning of the TMPRSS-ERG fusion transcript.

LncRNA MCM3AP-AS1 Promotes Cell Proliferation and Invasion Through Regulating miR-543-3p/SLC39A10/PTEN Axis in Prostate Cancer

Objective

Long-chain noncoding RNAs (lncRNAs) are key players in a wide range of biological processes, especially the pathogenesis and development of tumors. LncRNA MCM3AP-AS1 has been demonstrated to be involved in the invasion of various tumors including prostate cancer (PCa). However, its functions in PCa have not been fully elucidated.

Methods

qRT-PCR was conducted to measure the expression levels of lncRNA MCM3AP-AS1 and miR-543-3p in PCa tissue samples and cell lines. The expression levels of E-cadherin and SLC39A10 proteins were detected by Western blots. CCK-8 test, cell scratch test and trans-well test were used to evaluate the proliferation, invasion and migration abilities of PCa cells, respectively. Annexin V-FITC/PI experiments were carried out to determine the status of apoptosis. Bioinformatics analysis and Luciferase assay were used to explore the relationship between lncRNA MCM3AP-AS1, miR-543-3p and SLC39A10.

Results

In PCa tissue samples and cell lines, lncRNA MCM3AP-AS1 was up-regulated while miR-543-3p was down-regulated. Over-expression of MCM3AP-AS1 could promote the proliferation and invasion of PCa cells. Correlation analysis showed that the expression of MCM3AP-AS1 and miR-543-3p was significantly and inversely correlated. We further verified that miR-543-3p inhibitor was able to reverse si-MCM3AP-AS1-mediated inhibitory effects on the PCa cell proliferation, migration and invasion through regulating the downstream protein axis SLC39A10/PTEN/Akt. Finally, in vivo experiments indicated that knocking down of MCM3AP-AS1 could largely reduce tumor volumes, and decreased the ratio of Ki67-positive cells and the expression of SLC39A10 in tumor samples.

Conclusion

LncRNA MCM3AP-AS1 can promote the proliferation, migration and invasion abilities of PCa cells through regulating the miR-543-3p/SLC39A10/PTEN axis, which suggests that lncRNA MCM3AP-AS1 might be a potential target for prostate cancer therapy.

Creation of a Novel Digital Rectal Examination Evaluation Instrument to Teach and Assess Prostate Examination Proficiency

OBJECTIVE

To create a validated tool to measure digital rectal examination proficiency and aid with teaching of the examination.

DESIGN

The Digital Rectal Examination Clinical Tool was created using a modified Delphi method with 5 urologists and 5 radiation oncologists. The instrument was then validated in a population of preclinical medical students examining male urological teaching associates, and clinical trainees (third- and fourth-year medical students and urology resident physicians) examining prospectively enrolled subjects. Trainees completed paired examinations with an attending urologist, and responses were scored with reference to the attending responses.

SETTING

The instrument was validated at the University of Virginia in the urology clinic, endoscopic operating room, and main operating room settings.

PARTICIPANTS

We tested the instrument on consenting subjects consisting of male urologic teaching associates (n = 12), clinic patients (n = 4), and operating room patients (n = 64). The participants were undergraduate (n = 302) and graduate (n = 9) medical trainees.

RESULTS

In preclerkship trainees, improved scores in subjects without abnormal compared to those with abnormal findings demonstrated validity. In clinical trainees, scores on the Digital Rectal Examination Clinical Tool increased by 2% for each additional year of training, demonstrating construct validity.

CONCLUSIONS

We used an expert panel to create a novel instrument for measuring digital rectal examination proficiency and validated it with preclinical and clinical trainee cohorts at our institution.

Update on Screening for Urological Malignancies

Urological malignancies are a major source of morbidity and mortality in men over 40. Screening for those malignancies has a potential benefit of reducing both. However, even after more than two decades of screening for prostate cancer, the implications of most resulting information are still a matter of debate. Controversy extends over several aspects of prostate cancer screening programs, including age of onset, defining populations at risk, most appropriate intervals, as well as the optimal methods to be used for screening. The medical community is still divided regarding the effectiveness of prostate cancer-related death prevention and its benefits-to-harms ratio, reflecting an inconsistency regarding screening recommendations. Similarly, benefits of screening for urothelial and kidney tumors are yet lacking high-level evidence, although recent evidence supports screening of populations at risk. Clearly, the current era of evolving molecular and genetic biomarkers harbors the potential to change screening practice. In this paper, we review current guidelines as well as giving an update on new developments which might influence screening strategies in common urological malignancies.

Is it time to abandon the digital rectal examination? Lessons from the PLCO Cancer Screening Trial and peer-reviewed literature

OBJECTIVE

In 2012 the US Preventive Services Task Force released recommendations against prostate specific antigen (PSA) based screening for prostate cancer, but did not fully address screening via digital rectal exam (DRE). As such, many practitioners continue to perform DRE in attempts to identify men with clinically significant prostate cancer (CSPC). This study seeks to determine the value of DRE in detecting CSPC in the era of PSA-based screening.

METHODS

Data from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Screening Trial, a nationwide population-based study evaluating cancer screening programs and their impact on cancer mortality, was analyzed for PSA, DRE, and cancer status. In the screening arm of the PLCO, 38,340 men received annual PSA and DRE examinations for the first 3 years. Those with an abnormal test result were referred to their individual care provider for biopsy. The ability of DRE to detect CSPC, defined as intermediate risk or higher based on National Comprehensive Cancer Network guidelines and age ≤75, was evaluated in the context of both normal and abnormal PSA.

RESULTS

A total of 5064 men had abnormal DRE in the setting of normal PSA, of whom 99 (2%) were diagnosed with CSPC. When both PSA and DRE were abnormal, 218 (20%) participants were diagnosed with CSPC (RR = 2.06 [1.78-2.39] versus abnormal PSA alone).

CONCLUSIONS

DRE screening in the setting of normal PSA captured an additional 2% of men with CSPC. This incremental gain suggests that routine DRE screening subjects a large number of men to invasive, potentially uncomfortable examinations for relatively minimal gain. Key limitations: Our conclusions are based on data derived from the PLCO study which has been criticized on the basis of inconsistent biopsies following positive screening tests, lack of end of study biopsies to determine population disease burden, and low numbers of black men.

Characterising the safety of clomiphene citrate in male patients through prostate-specific antigen, haematocrit, and testosterone levels

OBJECTIVE

To determine the safety profile of clomiphene citrate (CC) in men being treated for hypogonadism or infertility by measuring prostate-specific antigen (PSA), haematocrit (Hct), and testosterone levels.

PATIENTS AND METHODS

We identified patients presenting to our institution who were placed on CC, 50 mg every day or every other day, for male infertility and/or symptomatic hypoandrogenism between September 2013 and April 2016. Patients with documented exogenous testosterone, human chorionic gonadotrophin, or anastrozole use within 2 weeks of baseline evaluations were excluded. Our primary outcomes were the effects of CC on PSA, Hct, and total testosterone levels evaluated at the 3, 6, 9, or 12 months of follow-up. Outcomes were averaged within patients across visits and summarised by mean, median, range, standard deviation (SD) and the 95% confidence interval (CI) for the mean.

RESULTS

A total of 77 patients had recorded PSA, Hct, and/or testosterone values. The mean (SD, range) age and body mass index was 34 (6, 22-51) years and 31 (6, 22-52) kg/m² , respectively. The mean (SD) follow-up was 358 (29) days. Within this group, CC concentration was changed in 24 patients (31%) and was discontinued in 24 patients (31%). The median (range) duration of CC therapy before discontinuation was 127 (44-161) days. The use of CC significantly raised both mean total and bioavailable testosterone levels by 200 ng/dL and 126 ng/dL, respectively (P < 0.001). This increase in testosterone had significant clinical effects with improvements in Androgen Deficiency in Aging Male questionnaire scores (P < 0.01) but not Sexual Health Inventory for Men scores. CC had no effect on mean PSA (1 ng/dL, 95% CI 0.8-1.1) or Hct (49%, 95% CI 41-53) levels, which were within normal ranges.

CONCLUSIONS

As more men are placed on CC for infertility or hypogonadism, characterising the safety effect profile becomes important. Our study found that CC significantly increased testosterone levels without changing PSA or Hct values. Because the biochemical response to CC can vary, we suggest scheduling laboratory evaluation at regular intervals; however, ordering routine assessment of PSA and Hct may not be necessary.

Immunochemical Assays and Nucleic-Acid Detection Techniques for Clinical Diagnosis of Prostate Cancer

Prostate cancer (PCa) is a significant cause of morbidity and mortality and the most common cancer in men in Europe, North America, and some parts of Africa. The established methods for detecting PCa are normally based on tests using Prostate Specific Antigen (PSA) in blood, Prostate cancer antigen 3 (PCA3) in urine and tissue Alpha-methylacyl-CoA racemase (AMACR) as tumour markers in patient samples. Prior to the introduction of PSA in clinics, prostatic acid phosphatase (PAP) was the most widely used biomarker. An early diagnosis of PCa through the detection of these biomarkers requires the availability of simple, reliable, cost-effective and robust techniques. Immunoassays and nucleic acid detection techniques have experienced unprecedented growth in recent years and seem to be the most promising analytical tools. This growth has been driven in part by the surge in demand for near-patient-testing systems in clinical diagnosis. This article reviews immunochemical assays, and nucleic-acid detection techniques that have been used to clinically diagnose PCa.

Prostate cancer markers: An update

As the most common noncutaneous malignancy in American men, prostate cancer currently accounts for 29% of all diagnosed cancers, and ranks second as the cause of cancer fatality in American men. Prostatic cancer is rarely symptomatic early in its course and therefore disease presentation often implies local extension or even metastatic disease. Thus, it is extremely critical to detect and diagnose prostate cancer in its earliest stages, often prior to the presentation of symptoms. Three of the most common techniques used to detect prostate cancer are the digital rectal exam, the transrectal ultrasound, and the use of biomarkers. This review presents an update regarding the field of prostate cancer biomarkers and comments on future biomarkers. Although there is not a lack of research in the field of prostate cancer biomarkers, the discovery of a novel biomarker that may have the advantage of being more specific and effective warrants future scientific inquiry.

Prospective investigation of change in the prostate-specific antigens after various urologic procedures

PURPOSE

Prostate-specific antigen (PSA) is the most important marker in the diagnosis and follow-up of patients with prostate cancer. The primary objective of this study was to evaluate the effect of various urologic procedures in prostatic area on serum free and total PSA levels.

SUBJECTS AND METHODS

A series of 62 patients (8 after digital rectal examination [DRE], 12 after transrectal ultrasonography [TRUS], 11 after rigid cystoscopy, 13 after prostatic massage, 8 after TRUS-guided prostate biopsy, and 10 after transurethral resection of prostate [TURP]) were enrolled in the study. Blood samples were taken from each patient before procedure and at 10, 30, 60, and 120 minutes after procedures.

RESULTS

Prostate massage, rigid cystoscopy, TURP, and TRUS-guided prostate biopsy caused statistically significant rise in total and free PSA levels in the serum. There was no significant increase in total and free PSA levels in the serum after DRE and TRUS. The mean differences were greater for free PSA level in the serum for TURP, TRUS-guided prostate biopsy, prostate massage, and rigid cystoscopy.

CONCLUSION

Total and free PSA levels in the serum are altered by prostate massage, rigid cystoscopy, TRUS-guided prostate biopsy, and TURP. The PSA rises were related to the stimulation strength of the procedures. The total and free PSA levels were increased significantly from 10 minutes after procedures, except DRE and TRUS, and were increased to maximal level at 60 minutes after procedures.

Prostate-specific antigen kinetic profiles during androgen deprivation therapy as prognostic factors in castration-resistant prostate cancer

OBJECTIVE

To identify pretreatment prognostic factors for patients with castration-resistant prostate cancer (CRPC) undergoing docetaxel (DCT) chemotherapy.

MATERIALS AND METHODS

We retrospectively analyzed 102 patients with CRPC who underwent DCT chemotherapy (dosage: 60-75 mg/m(2)) from December 2001 to August 2013. The parameters evaluated as prognostic factors were as follows: age, body mass index, Gleason score, clinical TNM stage, prior radical prostatectomy, prior radiation therapy, performance status, presence of pain, laboratory results at the start of DCT, and prostate-specific antigen (PSA) kinetics during prior androgen deprivation therapy (ADT), including PSA level at the start of ADT (PSA-ADT), PSA half-time (PSAT1/2), time to nadir, PSA level at nadir (PSA-Nadir), duration of nadir, PSA doubling time (PSADT), and PSA level at the start of DCT (PSA-DCT). Univariate and multivariate analyses were performed to identify independent prognostic factors.

RESULTS

Median cancer-specific survival (CSS) duration following CRPC diagnosis was 28.0 months. In univariate analyses, performance status, serum albumin, serum creatinine, PSAT1/2, time to nadir, PSA-Nadir, duration of nadir, PSADT, and PSA-DCT showed a potential association with prognosis (P<0.001-0.077). Multivariate analyses of these parameters showed that performance status (hazard ratio [HR] = 0.046; P = 0.046), serum creatinine (HR = 3.028; P = 0.036), PSAT1/2 (HR = 0.172; P = 0.007), PSA-Nadir (HR = 4.884; P = 0.033), PSADT (HR = 0.148; P<0.001), and PSA-DCT (HR = 5.222; P = 0.004) remained independent predictors of CSS in CRPC.

CONCLUSIONS

PSA kinetic parameters measured during prior ADT are significant surrogate markers predicting CSS in patients undergoing DCT chemotherapy for CRPC.

A lab-in-a-briefcase for rapid prostate specific antigen (PSA) screening from whole blood

We present a new concept for rapid and fully portable prostate specific antigen (PSA) measurements, termed "lab-in-a-briefcase", which integrates an affordable microfluidic ELISA platform utilising a melt-extruded fluoropolymer microcapillary film (MCF) containing an array of 10 200 μm internal diameter capillaries, a disposable multi-syringe aspirator (MSA), a sample tray pre-loaded with all of the required immunoassay reagents, and a portable film scanner for colorimetric signal digital quantification. Each MSA can perform 10 replicate microfluidic immunoassays on 8 samples, allowing 80 measurements to be made in less than 15 minutes based on semi-automated operation, without the need of additional fluid handling equipment. The assay was optimised for the measurement of a clinically relevant range of PSA of 0.9 to 60.0 ng ml(-1) in 15 minutes with CVs on the order of 5% based on intra-assay variability when read using a consumer flatbed film scanner. The PSA assay performance in the MSA remained robust in undiluted or 1 : 2 diluted human serum or whole blood, and the matrix effect could simply be overcome by extending sample incubation times. The PSA "lab-in-a-briefcase" is particularly suited to a low-resource health setting, where diagnostic labs and automated immunoassay systems are not accessible, by allowing PSA measurement outside the laboratory using affordable equipment.

Screening for prostate cancer: an updated review

Prostate cancer is the most frequently diagnosed malignancy in men and its incidence has been increasing in the last decades. Diagnosis and treatment of prostate cancer were radically improved after the discovery of prostatic-specific antigen. Early detection rates increased, especially in asymptomatic individuals, confirmed by recent published randomized trials. The impact of screening in overdiagnosis and overtreatments is discussed, since benefits in overall mortality rates were not clearly demonstrated. Perhaps younger patients with a longer life expectancy would be the ones with the most benefits from screening. This study presents an update of the most important screening methods for prostate cancer as well as the recent recommendations for screening.

Limited PSA testing in indigent men in South Texas: an appropriate care or missing a prevention opportunity?

BACKGROUND

No previous study has examined racial ethnic differences in prostate-specific antigen (PSA) testing and followup in primary care practices serving an indigent population.

METHODS

From electronic medical records of primary care practices affiliated with one health care system in San Antonio, we identified 9,267 men aged 50 to 74 with 2+ clinic visits from 2008 through 2010 and no prior prostate cancer diagnosis. Logistic regression was used to examine the association of race ethnicity with the use of PSA testing and, if tested, with an abnormal result (≥4 ng/mL) adjusted for demographics, health care, and clinical factors. Time to a follow-up activity after an abnormal PSA was assessed using Cox proportional models.

RESULTS

The race ethnicity of this cohort was 63% Hispanic, 27% non-Hispanic white, 7% African-American, and 3% other. In a 3-year period, 26.8% of men had at least one PSA test. Compared with African-Americans, non-Hispanic whites were less likely to be tested [OR, 0.68; 95% confidence interval (CI), 0.55-0.83] but Hispanics did not differ (OR = 0.95; 95% CI 0.79-1.15). African-Americans were more likely to have an abnormal PSA than others (12.4% vs. 5.2%, P < 0.001) and the shortest adjusted time to follow-up (P = 0.004).

CONCLUSIONS

In this 3-year indigent cohort, about one quarter had a PSA test, approximately half of the national testing rate.

IMPACT

African-Americans were more likely to be tested than non-Hispanic whites but had more abnormal results, raising concerns about missed prevention opportunities. African-Americans with high PSA results had the shortest time until follow-up, reflecting awareness of the threat of prostate cancer for African-Americans by physicians.

Correlation of hepatitis C and prostate cancer, inverse correlation of basal cell hyperplasia or prostatitis and epidemic syphilis of unknown duration

PURPOSE

The accuracy of prostate specific antigen (PSA) to detect prostate cancer has not yet been determined. Autopsy evidence suggests one-third of men have evidence of prostate cancer. Correlation between prostate cancer and sexually transmitted infection is indeterminate.

MATERIALS AND METHODS

A retrospective database was created of all men who underwent transrectal ultrasound guided prostate biopsy over 3 years. Men were 49% African or African Caribbean, and 51% Central or South American. Information about prostate specific antigen, cholesterol, hepatitis A, B and C, human immunodeficiency virus, syphilis, tuberculin skin testing and histology were collected.

RESULTS

Hepatitis C antibody detection correlated with prostate cancer OR 11.2 (95% CI 3.0 to 72.4). The odds of prostate cancer increased annually (p = 0.0003). However, no correlation was found between prostate cancer and the following: PSA, biopsy date, repeat biopsy, more than 12 cores at biopsy, total cholesterol, high density lipoprotein, triglycerides, low density lipoprotein, risk measure reported with free and total PSA, hepatitis B surface antibody, high grade prostatic intraepithelial neoplasia or atypical small acinar proliferation. Histologic prostatitis and basal cell hyperplasia were inversely correlated with prostate cancer. Syphilis of unknown duration occurred in 17% of men with indeterminate correlation to prostate cancer.

CONCLUSION

In Inner City men of African and African-Caribbean, or Central and South American descent, prostate specific antigen levels did not correlate with prostate cancer. Hepatitis C antibody detection correlates significantly with prostate cancer. One prostate biopsy is sufficient to diagnose statistically significant prostate cancer. Histologic prostatitis and basal cell hyperplasia decrease odds of prostate cancer. Atypical small acinar proliferation may not correlate to prostate cancer and is pending further investigation. Men should be screened for epidemic syphilis of unknown duration.

Prostate cancer epidemiology in the United States

BACKGROUND

Prostate cancer is a significant public health issue in the United States. It is the most commonly diagnosed non-skin cancer and the second leading cause of cancer death. The American Cancer Society estimates that in 2011, 240,890 men were diagnosed with prostate cancer and 33,720 men died of it.

METHODS

A review of the peer-reviewed literature was conducted: American Cancer Society, National Cancer Institute Surveillance, Epidemiology and End Results. Program data were assessed to describe trends in incidence, mortality, and survival rates and look at other predictors of risk of prostate cancer diagnosis and death.

RESULTS

Since 1985, there have been significant changing trends in prostate cancer incidence, mortality, and survival rates, as well as changes in the age distribution of the population diagnosed and even in the distribution of pathologies at diagnosis. Major risk factors for diagnosis include age, family history, race, and screening behavior.

CONCLUSION

While prostate cancer remains largely a disease diagnosed in older men (over age 65), screening has increased risk of diagnosis among men in their 40s and 50s. The incidence rates and 5-year survival rates are heavily influenced by the introduction of serum prostate-specific antigen (PSA) and widespread screening. The effects of PSA usage and screening on mortality rates are less certain. Outcome studies among men treated with radical prostatectomy show that greater than 30% relapse rates are common. This suggests that many men who are diagnosed with "localized early stage disease" actually have "apparently localized early stage disease," which is really low volume metastatic disease.

Combining urinary detection of TMPRSS2:ERG and PCA3 with serum PSA to predict diagnosis of prostate cancer

OBJECTIVES

We sought to develop a clinical algorithm combining serum PSA with detection of TMPRSS2:ERG fusion and PCA3 in urine collected after digital rectal exam (post-DRE urine) to predict prostate cancer on subsequent biopsy.

MATERIALS AND METHODS

Post-DRE urine was collected in 48 consecutive patients before prostate biopsy at 2 centers; quantitative reverse transcription-polymerase chain reaction (qRT-PCR) was used to detect PCA3 and TMPRSS2:ERG fusion transcript expression. Serum PSA was measured by clinical assay. The performance of TMPRSS2:ERG fusion, PCA3, and serum PSA as biomarkers predicting prostate cancer at biopsy was measured; a clinically practical algorithm combining serum PSA with TMPRSS2:ERG and PCA3 in post-DRE urine to predict prostate cancer was developed.

RESULTS

Post-DRE urine sediment provided informative RNA in 45 patients; prostate cancer was present on subsequent biopsy in 15. TMPRSS2:ERG in post-DRE urine was associated with prostate cancer (OR = 12.02; P < 0.001). PCA3 had the highest sensitivity in predicting prostate cancer diagnosis (93%), whereas TMPRSS2:ERG had the highest specificity (87%). TMPRSS2:ERG had the greatest discriminatory value in predicting prostate cancer (AUC = 0.77 compared with 0.65 for PCA3 and 0.72 for serum PSA alone). Combining serum PSA, PCA3, and TMPRSS2:ERG in a multivariable algorithm optimized for clinical utility improved cancer prediction (AUC = 0.88; specificity = 90% at 80% sensitivity).

CONCLUSIONS

A clinical algorithm specifying biopsy for all patients with PSA ≥ 10 ng/ml, while restricting biopsy among those with PSA <10 ng/ml to only those with detectable PCA3 or TMPRSS2:ERG in post-DRE urine, performed better than the individual biomarkers alone in predicting prostate cancer.

The implementation of screening for prostate cancer

The objective of this study was to determine whether screening for prostate cancer (PC) reduces PC mortality and, if so, whether the required criteria to be introduced as a population-based screening program are satisfied. A literature review was conducted through electronic scientific databases. The screening tests, that is, PSA and digital rectal examination, have limited sensitivity and specificity for detecting PC; screening produces a beneficial stage shift and reduces PC mortality. Nevertheless, PC screening causes a large increase in the cumulative incidence, and the understanding of the economic cost and quality-of-life parameters are limited. PC screening cannot be justified yet in the context of a public health policy.

Urine cytology and urine-based markers for bladder urothelial carcinoma detection and monitoring: developments and future prospects

Bladder cancer is currently diagnosed using cystoscopy and cytology in patients with suspicious signs and symptoms. These tests are also used to monitor patients with a history of bladder cancer. The recurrence rate for bladder cancer is high, thus necessitating long-term follow-up. Urine cytology has a high sensitivity and specificity for the detection of high-grade urothelial carcinoma, but lacks the sensitivity to detect low-grade tumors. Recently, multiple noninvasive urine-based bladder cancer tests have been developed. Many markers (BTA stat®, BTA TRAK®, ImmunoCyt™, NMP22® and UroVysion™) have already been approved by the US FDA for bladder cancer surveillance, while other markers are still undergoing development, preclinical and clinical investigation. An ideal bladder cancer test would be noninvasive, highly sensitive and specific, inexpensive, easy to perform and yield highly reproducible results. Many of the tests reviewed herein meet some, but not all, of these criteria.

Prostate-specific antigen and prostate cancer: prediction, detection and monitoring

Testing for prostate-specific antigen (PSA) has profoundly affected the diagnosis and treatment of prostate cancer. PSA testing has enabled physicians to detect prostate tumours while they are still small, low-grade and localized. This very ability has, however, created controversy over whether we are now diagnosing and treating insignificant cancers. PSA testing has also transformed the monitoring of treatment response and detection of disease recurrence. Much current research is directed at establishing the most appropriate uses of PSA testing and at developing methods to improve on the conventional PSA test.

Impact of improvement in specificity of primary screening test on total cost of prostate cancer mass screening

OBJECTIVES

Improvement in the specificity of primary screening tests, without significant cost elevation of the assay, provides cost savings in prostate cancer screening programs by reducing unnecessary secondary screening procedures. The purpose of this study was to evaluate the economic impact of improvement in the specificity of primary screening tests and to estimate the socially acceptable cost elevation for improved specificity.

METHODS

A decision-analytic model was designed to evaluate the total costs of prostate cancer mass screening according to the changes in the specificity and the cost of the primary screening test. All assumed factors were tested by three-way sensitivity analyses incorporating cost and specificity.

RESULTS

The base case analysis showed that a 1% improvement in the specificity of the primary screening test provides a $1.19 cost reduction per participant. Sensitivity analyses showed that an acceptable cost elevation for a 1% improvement in the specificity ranged from 0.68 to 2.90 $/% with respect to changes in several factors in the screening program.

CONCLUSIONS

The specificity and cost of the primary screening test has a significant economical impact on prostate cancer mass screening. For each screening program, it should be taken into consideration whether the cost of the new test deserves the specificity.

Prostate specific antigen changes as related to the initial prostate specific antigen: data from the prostate, lung, colorectal and ovarian cancer screening trial

PURPOSE

Annual screening with PSA, although of unproven benefit, is currently used for prostate cancer early detection. A large fraction of screened men have low (less than 2 ng/ml) initial PSA. The yield over time of positive PSA screens (ie more than 4 ng/ml) in these men has not been well characterized in large cohorts in the United States.

MATERIALS AND METHODS

Men in the screening arm of the PLCO received baseline PSA and annual tests for 5 years. 30,495 of these men had baseline PSA 4 ng/ml or less. We estimated the cumulative probability of converting to PSA greater than 4 at years 1 through 5 as a function of baseline PSA.

RESULTS

Among men with baseline PSA less than 1 ng/ml, 1.5% converted by year 5 (95% CI 1.2-1.7). Among men with baseline PSA of 1.0 to 1.99 ng/ml, 1.2% (95% CI 0.9-1.3) and 7.4% (95% CI 6.8-8.1) converted by year 1 and 5, respectively. A total of 33.5% and 79% of men with initial PSA of 2.0 to 2.99 and 3.0 to 4.0, respectively, converted by year 5. Of men with baseline PSA less than 1 ng/ml converting to PSA more than 4 ng/ml, 8% were diagnosed with cancer within 2 years of conversion. About 10% of men with baseline PSA less than 1 ng/ml and negative baseline DRE had a positive DRE within 3 years.

CONCLUSIONS

For men choosing PSA screening, screening every 5 years for baseline PSA less than 1 ng/ml and every 2 years for PSA 1 to 2 ng/ml could result in a 50% reduction in PSA tests and in less than 1.5% of men missing earlier positive screens, but with an unknown effect on prostate cancer mortality.

Male BRCA1 and BRCA2 mutation carriers: a pilot study investigating medical characteristics of patients participating in a prostate cancer prevention clinic

BACKGROUND

Male BRCA1 and BRCA2 mutation carriers are at an increased risk to develop prostate cancer and are subject to screening protocols for high-risk men. The utility of targeted screening, and the clinical and pathological features associated with prostate cancer, have received little attention in this population.

METHODS

We report on the clinical screening and pathological characteristics of a group of 19 men with BRCA1 or BRCA2 mutation, as compared to an age-matched group of men with a family history of prostate cancer.

RESULTS

Mutation carriers were significantly more likely to have an elevated PSA at first visit (P = 0.03). Prostate cancer was twice as likely to be diagnosed in mutation carriers although this difference was not statistically significant (P = 0.55).

CONCLUSIONS

Prostate cancer surveillance of BRCA1 and BRCA2 mutation carriers is warranted. Further research on larger cohorts is needed to evaluate whether unique pathological prostate cancer characteristics exist in these men.

Prostate Cancer Screening in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial: findings from the initial screening round of a randomized trial

BACKGROUND

The benefit of screening for prostate cancer using prostate-specific antigen (PSA) testing and digital rectal examination (DRE) is uncertain and is under evaluation in a randomized prospective trial, the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial. Although the final results are several years away, the initial round of screening is complete. We describe the population enrolled in the PLCO trial, their baseline PSA and DRE screening results, and diagnostic follow-up results during the first year of follow-up.

METHODS

A total of 38,350 men were randomly assigned to the screening arm of the PLCO trial from November 1993 through June 2001. Men were advised to seek diagnostic follow-up from their primary care provider if their DRE was suspicious for cancer and/or if their serum PSA level was higher than 4 ng/mL. PLCO trial staff obtained records related to diagnostic follow-up.

RESULTS

Compliance with both screening tests was high (more than 89%). At screening, 7.5% of men had a positive DRE (i.e., suspicious for cancer) and 7.9% had a PSA level higher than 4 ng/mL. Of the men with positive screening tests, 74.2% underwent additional diagnostic testing, and 31.5% underwent a prostatic biopsy within 1 year. Overall, 1.4% of the men in the screening arm were diagnosed with prostate cancer, the majority of whom had clinically localized cancer. These compliance, biopsy, and cancer detection rates appear to be representative of contemporary practice patterns.

CONCLUSION

The PLCO trial is evaluating PSA- and DRE-based screening for prostate cancer in a clinically valid manner. Whether such screening will result in a reduction of prostate cancer mortality cannot be answered until the randomized comparison is completed.

Colonoscopy effects on serum prostate specific antigen levels

INTRODUCTION

To evaluate the colonoscopy effects on serum levels of prostate specific antigen (PSA) and PSA ratio.

SUBJECTS AND METHODS

Thirty men were studied (median age 68 years, range 32-89). All of them had their serum PSA (total and free) measured 24 hours prior to colonoscopy and also 24 hours, 7 and 30 days after procedure.

RESULTS

14 of 30 (47%) patients, had significantly (p = 0.045) increased Total PSA levels 24 hours after the procedure, 14 (47%) patients had insignificantly (p = 0.139) increased levels 7 days after, while 13 (43%) of them had insignificantly (p = 0.061) increased levels 30 days after colonoscopy. In 7 patients (23%), with total PSA levels in the "gray zone" (4-10 ng/ml) before colonoscopy, a near significant (p = 0.063) raise in PSA ratio was also observed 24 hours after.

CONCLUSION

Flexible colonoscopy affect serum PSA (free and total) levels in certain patients. Special attention must be given to those patients with PSA levels in the "gray zone" before colonoscopy.

Cumulative probability of PSA increase above 4.0 NG/ML in population-based screening for prostate cancer

Routine screening for prostate cancer remains controversial. However, it is very important to show how the optimal rescreening interval should be set for men who want to be screened after informed consent. To solve this issue, the risk of prostate-specific antigen (PSA) increase above 4.0 ng/ml relative to baseline PSA levels and age was investigated. Between 1988 and 2000, 7,757 subjects screened twice or more and also with baseline PSA levels of 4.0 ng/ml or lower were enrolled in our study. All serum PSA levels were measured by E-test Tosoh II PA assay at one center. Interval PSA levels for men undergoing screening with a greater than 1 year interval were calculated on the assumption that PSA levels changed over time in a simple exponential fashion. Then, the cumulative rate of freedom from PSA increase above 4.0 ng/ml was estimated using the Kaplan-Meier technique stratified by baseline PSA ranges of 0.0 to 1.0, 1.1 to 2.0, 2.1 to 3.0 and 3.1 to 4.0 ng/ml and every 10 years of age ranges. Of the 7,757 subjects, 559 (7.2%) were expected to have had PSA levels increase above 4.0 ng/ml within 5 years after the baseline PSA measurements. The cumulative rate of freedom from the PSA increase above 4.0 ng/ml at 5 years was 98.7%, 92.9%, 70.3% and 38.5% in cases of baseline PSA levels of 1.0 ng/ml or lower, 1.1 to 2.0 ng/ml, 2.1 to 3.0 ng/ml and 3.1 to 4.0 ng/ml, respectively. The cumulative rates of freedom from the PSA increase were significantly decreased with the baseline PSA ranges being higher regardless of age range. Re-screening interval should be set stratified by baseline PSA levels, regardless of age and race. Rescreening interval should be set at 1, 1 to 2 and 3 to 5 years for men with baseline PSA ranges of 2.1 to 4.0 ng/ml, 1.1 to 2.0 ng/ml and 0.0 to 1.0 ng/ml, respectively, in individual-based screening. In mass screening system using PSA alone, rescreening interval should be set in the same manner as in individual-based screening, except for men with baseline PSA levels of 1.1 to 2.0 ng/ml, which should be set at 1 year to avoid developing incurable prostate cancer.

Assessment of ethnic variation in serum levels of total, complexed and free prostate specific antigen. Comparison of Maori, Pacific Island and New Zealand European populations

AIMS

To determine whether age-adjusted levels of serum total (tPSA) and complexed (cPSA) prostate specific antigen and the ratio of free to tPSA (%fPSA) differ by ethnic group independent of symptomatic disease.

METHODS

The serum levels of tPSA, cPSA, and %fPSA in relation to age, ethnicity and obstructive urinary symptoms were examined in 1405 Maori, Pacific Island and New Zealand European men in the Wellington region of New Zealand, and indicative reference range estimates produced. Participants were non-randomly selected from two study populations.

RESULTS

tPSA and cPSA increased with age while %fPSA decreased with age in all ethnic groups. Maori showed higher tPSA values in the 60-69 age group than other ethnic groups. cPSA increased more rapidly with age in Maori than in New Zealand Europeans or Pacific Islanders. %fPSA differed according to age across all three ethnic groups. The median and 5th percentile Pacific Island %fPSA values were higher in comparison to the %fPSA reference ranges of all other ethnic groups and were also higher than those reported in other studies. Once adjusted for urinary symptom score, only %fPSA in Pacific Island subjects remained significantly higher than that in New Zealand Europeans (P<0.001).

CONCLUSIONS

Our study indicates that %fPSA differs by ethnicity independent of symptomatic prostate disease.

Current bladder cancer tests: unnecessary or beneficial?

Bladder cancer is currently diagnosed using cystoscopy and cytology in patients with suspicious signs and symptoms. These same tests are used to monitor patients with a history of bladder cancer for recurrence. The recurrence rate for bladder cancer is high, thus necessitating long-term follow-up. Urine cytology requires an experienced cytopathologist and is costly. It has high specificity, but low sensitivity for low-grade bladder tumors. Recently many non-invasive bladder cancer tests, utilizing markers found in the urine, have been developed. The FDA has approved several of these for the use is bladder cancer diagnosis, and many others are undergoing development and investigation. An ideal bladder cancer test would be non-invasive, highly sensitive and specific, inexpensive, easy to perform, and yield highly reproducible results. Many of the tests reviewed meet some, but not all, of these criteria.

The effect of colonoscopy on serum prostate specific antigen levels

OBJECTIVE

To evaluate, in a prospective trial, the effect of colonoscopy on serum prostate specific antigen (PSA) levels (which are known to increase after cystoscopy and prostatic needle biopsy) in men aged 50-70 years, as they commonly undergo colonoscopy and PSA screening together.

SUBJECTS AND METHODS

Twenty-four consecutive men (mean age 61 years, range 37-78) were enrolled in the study. All subjects had their serum PSA measured 24-72 h before undergoing colonoscopy. Further values were obtained 24 h, 7 and 30 days after the procedure. The values before and after colonoscopy were compared to evaluate the effect of colonoscopy on serum PSA levels.

RESULTS

Of 24 patients, seven (35%) had insignificant increases at 24 h after colonoscopy; 12 (50%) patients had an insignificant increase in PSA level 30 days after the procedure. None of the 24 patients had a significant increase after colonoscopy when compared with baseline values.

CONCLUSION

Flexible colonoscopy does not adversely affect serum PSA levels. Although individuals may have a 30% daily fluctuation in serum values, this study detected no significant change in serum PSA levels after prolonged transrectal prostatic manipulation with a colonoscope.

Efficiency of prostate-specific antigen and digital rectal examination in screening, using 4.0 ng/ml and age-specific reference range as a cutoff for abnormal values

BACKGROUND

The purpose of this study was to examine the diagnostic efficiency of prostate-specific antigen (PSA) and digital rectal examination (DRE) testing when using either 4.0 ng/ml or an age-specific reference range (ASRR) as an abnormal cutoff PSA value.

METHODS

Between 1992-1995, 116,073 men, aged 40-79 years, were screened during Prostate Cancer Awareness Week. When using a 4.0-ng/ml cutoff PSA value, 22,014 had either an abnormal PSA, an abnormal DRE, or both. When using an ASRR cutoff PSA value, 17,561 had either an abnormal PSA, an abnormal DRE, or both. The positive predictive value (PPV), sensitivity, and specificity of PSA, DRE, and combined PSA and DRE tests were evaluated.

RESULTS

When using a 4.0-ng/ml cutoff PSA value, the PPVs of abnormal PSA alone, abnormal DRE alone, and combined abnormal PSA and DRE tests were 27.7%, 17.7%, and 56.0%, respectively. Sensitivities were 34.9%, 27.1%, and 38.0%, respectively. Specificities were 63.1%, 49.0%, and 87.9%, respectively. When using an ASRR cutoff PSA value, the PPVs of each category were 31.8%, 20.8%, and 63.7%, respectively. Sensitivities were 27.1%, 41.0%, and 31.8%, respectively. Specificities were 75.0%, 32.8%, and 92.2%, respectively. The PPVs of the PSA test were higher than those of the DRE. The PPVs of combined tests were highest when using either a 4.0-ng/ml cutoff PSA value or an ASRR cutoff PSA value (all P < 0.001). When using an ASRR, the PPVs of PSA, DRE, and combined tests were higher than those when using a 4.0-ng/ml without statistical significance (all P > 0.05). Sensitivity of PSA when using an ASRR was lower than when using 4.0 ng/ml.

CONCLUSIONS

Significantly higher PPVs indicated that utilizing both a PSA test and a DRE is most effective in screening for the early detection of prostate cancer. Although higher PPVs when using an ASRR cutoff PSA value suggested fewer unnecessary biopsies, lower sensitivities resulted in fewer cancers detected. Thus, we recommend that the combination of a PSA test with a cutoff value of 4.0 ng/ml and a DRE should continue to be utilized in the screening programs.

Evaluation of the digital rectal examination as a screening test for prostate cancer. Rotterdam section of the European Randomized Study of Screening for Prostate Cancer

BACKGROUND

The utility of digital rectal examination (DRE) as a screening test for early detection of prostate cancer has not been established. Therefore, we evaluated the usefulness of DRE as a stand-alone screening test and in conjunction with measured serum prostate-specific antigen (PSA) levels of 0-3.9 ng/mL and transrectal ultrasonography (TRUS).

METHODS

Our study population consisted of 10,523 men aged 54-76 years who were randomly assigned to the screening arm of the Rotterdam, The Netherlands, section of the European Randomized Study of Screening for Prostate Cancer. The underlying prevalence of detectable prostate cancer was estimated by logistic regression analysis and used for calculating the sensitivity of DRE as a test. Pathologic characteristics of 105 radical prostatectomy specimens were used to determine the aggressiveness of the tumors diagnosed (and missed) by DRE.

RESULTS

The overall detection rate for prostate cancer in this population when serum PSA measurement, DRE, and TRUS were used was 4.5%, and the detection rate with DRE alone was 2.5%. The positive predictive value of DRE ranged from 4% to 11% in men with PSA levels of 0-2.9 ng/mL and from 33% to 83% in men with PSA levels of 3.0-9.9 ng/mL or more. Most tumors detected by DRE in men with PSA levels of less than 4.0 ng/mL were small (mean volumes = 0.24-0.83 mL), and most were well differentiated (Gleason scores of 6 or less). Minimal, moderate, and advanced cancers were seen in 42%, 42%, and 16% of men, respectively, with a PSA level of 4.0 ng/mL or less. DRE alone allowed detection of 264 (55.8%) of 473 cancers; 82 (17.3%) of the 473 cancers would have remained undetected by PSA-based screening alone (i.e., no follow-up procedures for PSA values of 0-3.9 ng/mL).

CONCLUSIONS

For PSA values of 0-3.9 ng/mL, the positive predictive value and sensitivity of DRE, tumor volume, and tumor grade were strongly dependent on PSA level. DRE has a poor performance in low PSA ranges.

Influence of free-to-total prostate specific antigen variability on the early diagnosis of prostate cancer: a comparative study of three immunoassays

OBJECTIVE

To compare three immunoassays for total prostate specific antigen (tPSA), free PSA (fPSA), free-to-total PSA ratio (f/tPSA), and the f/tPSA thresholds for optimal differentiation between benign prostatic hypertrophy (BPH) and prostate cancer in 141 consecutive patients referred for prostatic disease.

PATIENTS AND METHODS

The study included 43 patients with prostate cancer and 98 with BPH, all confirmed histologically. PSA levels were assessed using the following assay kits just before histological analysis of the prostate; Hybritech (Tandem-R PSA, normal values, NV, < 4 ng/mL, and Tandem-R free PSA), Cis Bio (PSA-RIACT, NV < 2.5 ng/mL and fPSA-RIACT) and Immunocorp (PSA-IRMA, NV < 4 ng/mL and Free PSA-IRMA). The results were assessed to determine the sensitivity, specificity and threshold values of the different assays to differentiate patients with BPH and cancer.

RESULTS

The mean tPSA and f/tPSA ratio were statistically different in assays with different NVs. The mean fPSA values differed significantly between the Hybritech and Cis Bio, between the Hybritech and Immunocorp but not between the Cis Bio and Immunocorp assays. With receiver operator curve analysis, there were no statistically significant differences among the three immunoassays in f/tPSA (0.72 for Hybritech, 0.73 for Cis Bio and 0.64 for Immunocorp) or between the tPSA and fPSA curves for each manufacturer. With the sensitivity fixed at 90%, different f/tPSA thresholds were defined (0.22, 0.34 and 0.25 for Hybritech, Cis Bio and Immunocorp, respectively). The specificities (i.e. the percentage of unnecessary biopsies spared) were 22%, 21% and 31%, respectively (not significantly different).

CONCLUSION

Each immunoassay could be used to distinguish prostate cancer and BPH at different f/tPSA thresholds, with 21-30% of unnecessary biopsies spared. There was no difference in overall performance among the different assays. Further studies are needed to better define the exact use of the f/tPSA ratio in the routine diagnosis of prostate cancer.

Comparison of prostate-specific antigen corrected for total prostate volume and transition zone volume in a population-based screening study

OBJECTIVES

To compare the discriminatory potential between prostate cancer and benign conditions of the prostate in a population-based screening study, of serum prostate-specific antigen levels (PSA) and PSA corrected for both the total prostate volume (PSA-D) and the transition zone volume (PSA-T).

METHODS

In a randomized population-based screening study (Rotterdam section of the European Randomized Study of Screening for Prostate Cancer), in which 10,865 men have been screened, the biopsy results of 1202 men with PSA levels of 4 ng/mL or more were evaluated. Planimetric and prolate ellipsoid volumes of the total prostate as well as of the transition zone were measured. The measured volumes were compared with the volumes of 57 radical prostatectomy specimens through Spearman's rank correlation coefficient and agreement tests. A receiver operating characteristic (ROC) curve analysis was done of sensitivity and specificity of biopsy indications through PSA and PSA corrected for the volumes measured with transrectal ultrasound.

RESULTS

In the 1202 men studied, 361 cases of prostate cancer were diagnosed. Both PSA-D and PSA-T showed a significantly higher area under the ROC curve (0.77 and 0.79, respectively) than PSA alone (area 0.65). There was no significant difference between PSA-D and PSA-T. The use of a PSA-D threshold value of 0. 10 ng/mL/cc would have avoided 28% of biopsies at the cost of 10% of detectable cancers. A PSA-D threshold of 0.15 ng/mL/cc would have avoided 73.8% of biopsies at the cost of not diagnosing 43.8% of detectable cancers.

CONCLUSIONS

The planimetrically obtained prostate volume showed a more favorable agreement with the radical prostatectomy volume than the prolate ellipsoid volume. The discriminatory potential of the corrected PSA value is better at predicting the results of needle biopsy of the prostate when compared with PSA alone. The use of the transition zone volume for this correction results in a higher discriminatory potential when compared to the use of the total prostate volume; however, the observed difference was not statistically significant.

Prostate-specific antigen testing practices and outcomes

OBJECTIVES

To characterize prostate-specific antigen (PSA) testing practices in a hospital-based primary care clinic, and to determine the outcomes of PSA testing, including urology referrals, biopsies, cancers detected, and cancer treatments.

DESIGN

Retrospective cohort study. Data were obtained from computerized Department of Veterans Affairs (VA) files and the statewide New Mexico Surveillance, Epidemiology, and End Results (SEER) tumor registry.

SETTING

Primary care clinics in a university-affiliated VA Medical Center.

PATIENTS

Subjects were 1,448 men without cancer undergoing PSA testing in 1993 with follow-up through 1994.

MAIN RESULTS

Twenty-one percent of clinic enrollees at least 40 years of age were tested with PSA, including 58 who were 75 years of age or older. By the end of 1994, 40.0% (95% confidence interval [CI] 37.2%, 42.8%) were retested; 25.6% (95% CI 21.7%, 29.5%) of initial retesting occurred within 6 months. Overall, 20.7% (95% CI 18.9%, 22.5%) of PSA tests in the cohort were for men aged 75 years or older and were repeated within 6 months. Among the 193 subjects with PSA values > or = 4.0 ng/mL, 86.0% (95% CI 81.1%, 90.9%) were followed-up in urology clinic, and 46.1% (95% CI 39.1%, 53.1%) underwent biopsy. Only 11 of 51 men aged 75 years or older who were referred to urologists for an elevated PSA underwent biopsy. Forty cancers were diagnosed-a detection rate of 2.8% (95% CI 2.0%, 3.6%). Of these, 28 were organ-confined, 7 had regional invasion, and 3 had distant metastases.

CONCLUSIONS

Primary care providers frequently ordered PSA tests, but a substantial proportion of testing occurred outside recommended age ranges and screening intervals. Older patients with elevated PSA values often did not complete diagnostic workups. Better adherence to screening guidelines may limit the number of both PSA tests and urology referrals.

Laparoscopic pelvic lymph node dissection for prostate cancer: comparison of the extended and modified techniques

PURPOSE

We compared the results of extended (obturator, hypogastric, common and external iliac nodes) to modified (obturator and hypogastric nodes only) laparoscopic pelvic lymph node dissection in patients with clinically localized prostate cancer.

MATERIALS AND METHODS

A total of 189 patients with stage T1 to T3 prostate cancer underwent modified (150) or extended (39) laparoscopic pelvic lymph node dissection for pelvic nodal assessment before definitive treatment.

RESULTS

Twice as many lymph nodes were removed via extended than modified laparoscopic pelvic lymph node dissection (mean 17:8 versus 9.3). The overall positivity rate was 23 of 189 lymph nodes (12.2%), including 14 of 150 (7.3%) for modified and 9 of 39 (23.1%) for extended dissection (p = 0.02). Two patients (22%) who underwent extended dissection had positive lymph nodes in the external iliac area. Patients who presented with the high risk features of prostate specific antigen (PSA) greater than 20 ng./ml., Gleason score 7 or greater, or stage T2b disease or greater had a 26.5% (p = 0.0002), 22% (p = 0.0006) or 16.4% (p = 0.003) likelihood of positive lymph nodes, respectively. For extended versus modified laparoscopic pelvic lymph node dissection node positivity in high risk patients was 27% versus 18.8% (p = 0.4), 30 versus 26.4% (p = 0.8) and 25.4 versus 14.6% (p = 0.17) for Gleason score 7 or greater, PSA greater than 20 ng./ml. and disease stage T2b to T3a, respectively. Patients who underwent the extended procedure had a higher complication rate (35.9 versus 2%, p < 0.0001). No laparotomy was required.

CONCLUSIONS

Despite yielding a 2-fold higher node count and higher node positivity rate, extended laparoscopic pelvic lymph node dissection offers no advantage over modified laparoscopic pelvic lymph node dissection for diagnosing positive lymph nodes when results are analyzed by prognostic factors. The extended procedure is associated with a much higher complication rate. In patients with the high risk features of PSA greater than 20 ng./ml., Gleason score 7 or greater and stage T2b to T3a disease modified laparoscopic pelvic lymph node dissection can be performed safely and effectively to help identify those who may benefit most from curative therapy.

Eight years of "Prostate Cancer Awareness Week": lessons in screening and early detection. Prostate Cancer Education Council

BACKGROUND

Prostate Cancer Awareness Week began in 1989 to raise public awareness of the disease and impact on its clinical dynamics. Prior to 1990, prostate carcinoma was usually diagnosed in symptomatic men as advanced and ipso facto incurable.

METHODS

A 5-year longitudinal study of screening and early detection was initiated in 1992, involving 250 centers that tested over 50,000 men annually. The study analyzed the following: 1) the efficacy of digital rectal examination and prostate specific antigen (PSA) tests for the early detection of prostate carcinoma, 2) the impact of serial screening on stage of disease at diagnosis and cancer detection, 3) age and race specific reference ranges for PSA, 4) prostate carcinoma risk factors, and 5) psychosocial variables that influence the appropriateness and acceptability of both screening and treatment.

RESULTS

Community-based screening for prostate carcinoma is as effective as programs conducted at academic centers, but annual testing may not be necessary for all men. Participants in community screening programs may require more prescreening information and education regarding the potential risks and benefits of screening, and also regarding the cascade of diagnostic and treatment decisions that follow an abnormal digital rectal examination or an elevated PSA finding.

CONCLUSIONS

Community-based prostate carcinoma screening programs have contributed to the shift in the diagnosis of prostate carcinoma at an earlier stage. They provide data that are useful in studying the natural course of prostate carcinoma and in designing studies of the effect that prostate carcinoma screening has on mortality from the disease.