Natural history of localised prostatic cancer. A population-based study in 223 untreated patients

Sensitizing the cytotoxic action of Docetaxel induced by Pentoxifylline in a PC3 prostate cancer cell line

BACKGROUND

Prostate cancer is one of the most frequently diagnosed types of cancers worldwide. In its initial period, the tumor is hormone-sensitive, but in advanced states, it evolves into a metastatic castration-resistant tumor. In this state, chemotherapy with taxanes such as Docetaxel (DTX) comprises the first line of treatment. However, the response is poor due to chemoresistance and toxicity. On the other hand, Pentoxifylline (PTX) is an unspecific inhibitor of phosphodiesterases; experimental, and clinically it has been described as sensitizing tumor cells to chemotherapy, increasing apoptosis and decreasing senescence. We study whether the PTX sensitizes prostate cancer cells to DTX for greater effectiveness.

METHODS

PC3 human prostate cancer cells were treated in vitro at different doses and times with PTX, DTX, or their combination. Viability was determined by the WST-1 assay by spectrophotometry, cell cycle progression, apoptosis, generic caspase activation and senescence by flow cytometry, DNA fragmentation and caspases-3, -8, and -9 activity by ELISA.

RESULTS

We found that PTX in PC3 human prostate cancer cells induces significant apoptosis per se and increases that generated by DTX, while at the same time it reduces the senescence caused by the chemotherapy and increases caspases-3,-8, and -9 activity in PTX + DTX-treated cells. Both treatments blocked the PC3 cell in the G1 phase.

CONCLUSIONS

Our results show that PTX sensitizes prostate tumor cells to apoptosis induced by DTX. Taken together, the results support the concept of chemotherapy with rational molecular bases.

Prostate MRI with PI-RADS v2.1: initial detection and active surveillance

The role of prostate MRI in clinical practice has continued to broaden over time. Multiple iterations of PI-RADS reporting have aided in improving detection and reporting of prostate cancer. In addition, recent recommendations from the PI-RADS Steering Committee promote an MRI-first approach with an MRI-directed prostate cancer diagnostic pathway. It is imperative for radiologists to be knowledgeable and familiar with prostate MRI and PI-RADS recommendations, as there is an increasing demand for prostate imaging by clinicians and patients alike.

Is Prostate Biopsy Recommended in Turkish Men with a Prostate-Specific Antigen Level between 2.5 and 4 ng/mL?

BACKGROUND

Prostate cancer is the most common solid tumor. The incidence of prostate cancer shows regional and racial differences. The ideal PSA threshold for prostate biopsy is still being debated.

OBJECTIVE

We aimed to investigate cancer detection rates in Turkish men who underwent transrectal ultrasound-guided prostate biopsy (TRUSPB) who had prostate-specific antigen (PSA) levels in the range of 2.5 to 4.0 ng/mL and compare them with the rates of cancer in patients with PSA levels in the range of 4.0 to 10.0 ng/mL.

METHODS

All Turkish men who underwent TRUSPB in our clinic between January 2012 and May 2014 were included; that is, 101 patients (Group 1) with PSA level in the range of 2.5 to 4.0 ng/mL and 522 patients (Group 2) with PSA level in the range of 4.0 to 10.0 ng/mL. Mean PSA level, age, prostate volume, and cancer detection rates were evaluated.

RESULTS

The mean age was 60.5 and 64 years in Group 1 and Group 2, respectively (P = 0.06). The mean PSA level was determined as 3.1 and 6.8 ng/mL in Group 1 and Group 2, respectively (P = 0.03). The cancer detection rate was 12.7% in Group 1 (n = 13) and 30.8% in Group 2 (n = 161), which revealed a statistically significant difference between the 2 groups (P = 0.001). In Group 1, 9 of 13 patients (69%) had Gleason score of 6, 3 (23%) had Gleason score of 7, and 1 (8%) had a Gleason score of 8.

CONCLUSIONS

The cancer detection rate is lower in Turkish men with PSA level in the range of 2.5 to 4.0 ng/mL when compared with men with PSA level in the range of 4.0 to 10.0 ng/mL. Furthermore, most patients in whom cancer was detected who have a PSA level in the range of 2.5 to 4.0 ng/mL are low risk. Therefore, the benefit of TRUSBP in Turkish men with PSA level between 2.5 and 4 ng/mL is low.

Association of PITX2 mRNA down-regulation in prostate cancer with promoter hypermethylation and poor prognosis

BACKGROUND

Hypermethylation of the PITX2 (paired-like homeodomain transcription factor 2) gene promoter is strongly associated with recurrence after radical prostatectomy. We hypothesized that PITX2 hypermethylation leads to PITX2 silencing and that decreased PITX2 expression is likewise associated with poor prognosis in prostate cancers. Moreover, it is unknown so far how PITX2 hypermethylation relates to other molecular changes in prostate cancer, such as ERG oncogenic activation in about half of all cases.

OBJECTIVE

To investigate how PITX2 expression and methylation are related, whether biochemical recurrence after radical prostatectomy can be predicted by PITX2 mRNA levels, and how changes in PITX2 relate to ERG overexpression.

MATERIAL AND METHODS

We measured PITX2 and ERG expression in 45 cancerous and 13 benign tissues from patients undergoing radical prostatectomy (age range: 59-74 years). Methylation of the PITX2 gene was analyzed in an extended series of 93 cancers. Follow-up was performed for all patients for a 98-month median period. Additionally, expression and methylation changes of PITX2 were investigated in prostate carcinoma cell lines. Gene expression and methylation were determined by quantitative RT-PCR and methylation-specific PCR, respectively. Biochemical recurrence defined as a total PSA of >0.2 ng/ml on 2 consecutive tests was considered as the surrogate endpoint for survival analysis.

RESULTS

PITX2 expression was significantly and strongly decreased in prostate cancer compared to benign tissues. Cases with decreased PITX2 experienced significantly earlier biochemical recurrences. PITX2 down-regulation was associated with PITX2 promoter hypermethylation in tumor samples and cell lines. PITX2 hypermethylation was more pronounced in cases with ERG overexpression.

CONCLUSIONS

PITX2 down-regulation is associated with promoter hypermethylation and is a good predictor of clinical outcomes after radical prostatectomy. PITX2 methylation might be influenced by oncogenic ERG.

What is the risk posed by prostate cancer?

Prostate cancer carries an extraordinarily varied prognosis. Previously, most men presented with clinical symptoms often succumbed to their disease several years following treatment with hormonal manipulation. With the advent of prostate-specific antigen (PSA) testing, most men are now diagnosed with localized, well- to moderately differentiated disease. The most powerful predictor of long-term outcome is the Gleason score, followed by tumor volume. Over the past two decades, changes in the interpretation of Gleason patterns have resulted in the reclassification of many well-differentiated tumors as higher grade tumors. Men with well-differentiated disease have an excellent prognosis and often survive 10-20 years without intervention. Conversely, men with poorly differentiated disease often succumb to their cancer within a decade. PSA can estimate tumor volume, but poorly differentiated disease may not produce much PSA. We are unable to predict accurately the risk posed by a specific prostate cancer.

Role of histopathology and molecular markers in the active surveillance of prostate cancer

Surgery or radiation therapy remain the standard curative treatments for newly diagnosed prostate cancer patients. Nonetheless, these aggressive treatments are associated with decreased quality of life with altered sexual and urinary functions. The objective was a systematic review of active surveillance protocols to investigate the role of histopathology and molecular markers in the active surveillance of prostate cancer. Medline was searched using the following terms: prostate cancer, active surveillance and expectant management. Selection criteria, follow-up strategies and outcomes. Using modern risk stratification, several centres have gained significant experience in identifying patients with a low risk of prostate cancer progression and have adopted an active surveillance program with delayed curative therapy. Interestingly, only limited numbers of patients under active surveillance require additional treatment. Recent data suggest that delayed treatment does not appear to alter the clinical outcome among those highly selected patients. The future and conclusions. A better understanding of the molecular determinants of prostate cancer behaviour would not only enable healthcare professionals to identify which cases need aggressive treatment but, perhaps more importantly, would also indicate potential targets for the development of novel therapeutic strategies.

Use and assessment of PSA in prostate cancer

Since the introduction of prostate-specific antigen (PSA) screening in the late 1980s, more prostate cancers have been detected, and at an earlier stage. As a consequence, the majority of prostate cancers are now detected years before the emergence of clinically evident disease, which usually represents locally advanced or metastatic cancer. PSA screening has remained controversial, because many of the prostate cancers detected are low grade and slow growing. With this long natural history and a median survival without treatment that often approaches at least 15 to 20 years, many clinicians and researchers have questioned if prostate cancer screening and treatment actually improves survival, as many patients will die with prostate cancer rather than of prostate cancer. In this review, the authors discuss the rationale for prostate cancer screening and present the current guidelines for the use of PSA.

The prostate cancer pseudo-epidemic

Screening for prostate cancer with prostate-specific antigen (PSA), a simple blood test, is complex, controversial, intellectually challenging and ethically concerning. Sweden has contributed actively to the knowledge base for PSA screening in the last couple of years and a more informed debate is now possible. I will in this article summarize what we currently know about PSA testing. I discuss the closely related issues of the natural history of early-stage disease and the risks and benefits of radical local treatment. I propose that the mortality reduction following PSA screening is probably modest, whilst substantial harms are well documented. Furthermore, there is growing evidence that the PSA test is profoundly limited for screening purposes. I therefore concur with the growing number of health and professional agencies - notably outside the US - that advise against population screening with PSA. Through PSA screening the medical community has generated a pseudo-epidemic of over-diagnosed non-lethal prostate cancer. Molecular tools to distinguish innocent, over-diagnosed prostate cancer from lethal tumors that deserving curative treatment are necessary to improve screening test performance. To date, extensive attempts to identify molecular predictors of outcome have remained unsuccessful, and no ideal screening test is within sight.

The discovery of common recurrent transmembrane protease serine 2 (TMPRSS2)-erythroblastosis virus E26 transforming sequence (ETS) gene fusions in prostate cancer: significance and clinical implications

Recurrent gene fusions and chromosomal rearrangements were previously thought to be the primary oncogenic mechanism of hematological malignancies and sarcomas. The recent discovery of recurrent gene fusions in a majority of prostate cancers represents a paradigm shift in understanding the molecular mechanisms of one of the most prevalent epithelial malignancies, with important clinical and biologic implications. The prostate cancer gene fusions that have been identified so far are characterized by 5'-genomic regulatory elements, most notably the androgen-controlled prostate specific gene, transmembrane protease serine 2, fused to members of the erythroblastosis virus E26 transforming sequence family of transcription factors, most notably ERG, leading to the overexpression of oncogenic transcription factors. The erythroblastosis virus E26 transforming sequence gene fusions most likely define a distinct class of prostate cancer with potential implications for early diagnosis, prognosis, and rational therapeutic targeting. In this review, we summarize the bioinformatics approach that led to the discovery of gene fusions, the current state of the frequency, and diversity of gene fusions that define the molecular heterogeneity of prostate cancer, their associations with prostate cancer progression and clinical outcome, the subsequent morphological characteristics, and the potential application of gene fusions as biomarkers in the diagnosis and management of prostate cancer.

Estrogen-dependent signaling in a molecularly distinct subclass of aggressive prostate cancer

BACKGROUND

The majority of prostate cancers harbor gene fusions of the 5'-untranslated region of the androgen-regulated transmembrane protease serine 2 (TMPRSS2) promoter with erythroblast transformation-specific transcription factor family members. The common fusion between TMPRESS2 and v-ets erythroblastosis virus E26 oncogene homolog (avian) (ERG) is associated with a more aggressive clinical phenotype, implying the existence of a distinct subclass of prostate cancer defined by this fusion.

METHODS

We used complementary DNA-mediated annealing, selection, ligation, and extension to determine the expression profiles of 6144 transcriptionally informative genes in archived biopsy samples from 455 prostate cancer patients in the Swedish Watchful Waiting cohort (1987-1999) and the United States-based Physicians(') Health Study cohort (1983-2003). A gene expression signature for prostate cancers with the TMPRSS2-ERG fusion was determined using partitioning and classification models and used in computational functional analysis. Cell proliferation and TMPRSS2-ERG expression in androgen receptor-negative (NCI-H660) prostate cancer cells after treatment with vehicle or estrogenic compounds were assessed by viability assays and quantitative polymerase chain reaction, respectively. All statistical tests were two-sided.

RESULTS

We identified an 87-gene expression signature that distinguishes TMPRSS2-ERG fusion prostate cancer as a discrete molecular entity (area under the curve = 0.80, 95% confidence interval [CI] = 0.792 to 0.81; P < .001). Computational analysis suggested that this fusion signature was associated with estrogen receptor (ER) signaling. Viability of NCI-H660 cells decreased after treatment with estrogen (viability normalized to day 0, estrogen vs vehicle at day 8, mean = 2.04 vs 3.40, difference = 1.36, 95% CI = 1.12 to 1.62) or ERbeta agonist (ERbeta agonist vs vehicle at day 8, mean = 1.86 vs 3.40, difference = 1.54, 95% CI = 1.39 to 1.69) but increased after ERalpha agonist treatment (ERalpha agonist vs vehicle at day 8, mean = 4.36 vs 3.40, difference = 0.96, 95% CI = 0.68 to 1.23). Similarly, expression of TMPRSS2-ERG decreased after ERbeta agonist treatment (fold change over internal control, ERbeta agonist vs vehicle at 24 hours, NCI-H660, mean = 0.57- vs 1.0-fold, difference = 0.43-fold, 95% CI = 0.29- to 0.57-fold) and increased after ERalpha agonist treatment (ERalpha agonist vs vehicle at 24 hours, mean = 5.63- vs 1.0-fold, difference = 4.63-fold, 95% CI = 4.34- to 4.92-fold).

CONCLUSIONS

TMPRSS2-ERG fusion prostate cancer is a distinct molecular subclass. TMPRSS2-ERG expression is regulated by a novel ER-dependent mechanism.

[A study of the progression of the incidental prostate cancer depending on the kind of treatment performed]

INTRODUCTION AND OBJECTIVES

Prostate cancer is a common neoplasm, with a significant burden of mortality. Since it's diagnosed at old ages and usually growths slowly, agresive treatment of localised cancer of prostate could be of little benefit. The study of the evolution of incidental prostate cancer diagnosed 20 years ago could give directions for present decision-making.

METHODS

We performed a time survival analysis of patients diagnosed of incidental prostate cancer between 1980 and 2000, and followed them until april 2005. We analysed overall and disease-specific mortality, related to the kind of treatment and some anatomopathological characteristics.

RESULTS

We included 80 cases. Treatment was hormonotherapy in 34 cases, surgery in 4, radiotherapy in 3 and watchful waiting in 39. Overall average survival was 8.87 years. Disease-specific survival in low risk group (Gleason lower than 6) was 16 years, and in high risk group (Gleason higher than 7) was 6 years. No differences were found between hormonotherapy and watchful waiting.

CONCLUSIONS

While in low risk patients watchful waiting represents an acceptable aproaching, it could not be adequate in high risk cases. Hormonotherapy showed no benefit in incidental prostate cancer.

Heterogeneity of TMPRSS2 gene rearrangements in multifocal prostate adenocarcinoma: molecular evidence for an independent group of diseases

Recurrent gene fusions between the androgen-regulated gene TMPRSS2 and the ETS family transcription factors ERG, ETV1, and ETV4 have been identified in the majority of prostate adenocarcinomas (PCA). PCA is often multifocal with histologic heterogeneity of different tumor foci. As TMPRSS2 is a common 5' partner of ETS gene fusions, we monitored TMPRSS2 rearrangement by fluorescence in situ hybridization (FISH) to study the origin and molecular basis of multifocal PCA heterogeneity. TMPRSS2 rearrangement was evaluated by FISH on a tissue microarray representing 93 multifocal PCAs from 43 radical prostatectomy resections. Overall, 70% (30 of 43) of the cases showed TMPRSS2 rearrangement, including 63% through deletion (loss of the 3' TMPRSS2 signal), 27% through translocation (split of 5' and 3' TMPRSS2 signals), and 10% through both mechanisms in different tumor foci. Of the 30 TMPRSS2 rearranged cases, 30% showed concordance in all tumor foci, whereas 70% were discordant in at least one focus. In TMPRSS2 rearranged cases, the largest (index) tumor was rearranged 83% of the time. Pathologic stage, size, or Gleason grade of the multifocal PCA did not correlate with overall TMPRSS2 rearrangement. Our results suggest that multifocal PCA is a heterogeneous group of diseases arising from multiple, independent clonal expansions. Understanding this molecular heterogeneity is critical to the future development and utility of diagnostic and prognostic PCA biomarkers.

Quality of analgesic treatment in patients with advanced prostate cancer: do we do a better job now? The Swiss Group for Clinical Cancer Research (SAKK) experience

GOALS OF WORK

The aim of this study was to evaluate pain intensity and the application of the WHO guidelines for cancer pain treatment in patients with prostate cancer treated at Swiss cancer centers.

MATERIALS AND METHODS

We analyzed a series of five multicenter phase II clinical trials which examined the palliative effect of different chemotherapies in patients with advanced hormone-refractory prostate carcinoma. Of 170 patients, 1,018 visits were evaluable for our purpose, including ratings of pain intensity by patients and prescribed analgesics.

MAIN RESULTS

No or mild pain was indicated by patients in 36 to 55% of the visits, more than mild pain in 30 to 46%. In 21% of the visits, the WHO pain treatment criteria (treatment according to one of the three steps; oral, rectal or transdermal application of the main dose; administration on a regular schedule) were fulfilled, and the Cleeland index was positive according to all recommendations. In 6% of the visits, neither the WHO criteria were fulfilled nor was the Cleeland index positive. This indicates insufficient pain treatment not following the WHO guidelines and that the prescribed analgesics were not sufficiently potent for the rated pain intensity.

CONCLUSIONS

In this selective Swiss sample, the standard of analgesic treatment is high. However, there is still scope for improvement. This cannot solely be solved by improving the knowledge of the physicians. Programs to change the patients' attitude towards cancer pain, training to improve the physicians' communication skills, and institutional changes may be promising strategies.

TMPRSS2:ERG gene fusion associated with lethal prostate cancer in a watchful waiting cohort

The identification of the TMPRSS2:ERG fusion in prostate cancer suggests that distinct molecular subtypes may define risk for disease progression. In surgical series, TMPRSS2:ERG fusion was identified in 50% of the tumors. Here, we report on a population-based cohort of men with localized prostate cancers followed by expectant (watchful waiting) therapy with 15% (17/111) TMPRSS2:ERG fusion. We identified a statistically significant association between TMPRSS2:ERG fusion and prostate cancer specific death (cumulative incidence ratio=2.7, P<0.01, 95% confidence interval=1.3-5.8). Quantitative reverse-transcription-polymerase chain reaction demonstrated high ets-related [corrected] gene (ERG) expression to be associated with TMPRSS2:ERG fusion (P<0.005). These data suggest that TMPRSS2:ERG fusion prostate cancers may have a more aggressive phenotype, possibly mediated through increased ERG expression.

Watchful waiting for prostate cancer: a review article

As earlier detection of prostate cancer increases because of prostate-specific antigen (PSA) testing, appropriate use for watchful waiting warrants re-evaluation. We have drawn together the significant watchful waiting literature and used it to evaluate the use of watchful waiting in the PSA era. We conducted literature searches for studies examining outcomes of watchful waiting and examined new literature emerging about the use of PSA for the follow-up of watchful waiting patients. Watchful waiting has the potential to play an increasingly important role in prostate cancer as less advanced disease is detected and methods are refined for identifying low-risk patients.

Recall of pretreatment symptoms among men treated with radiotherapy for prostate cancer

To determine the accuracy of patient recall of disease-specific symptoms and quality of life (QoL) in men treated with external beam radiotherapy (EBRT) for localized prostate cancer (LPC). One hundred and five patients enrolled in a prospective study of bladder, bowel, and sexual function, and QoL after radiotherapy for PC were requested to assess their baseline QoL and symptoms before treatment. About one year (mean 14.1 months; range 7-21 months) after treatment, they were asked to recall their baseline QoL and symptoms. Baseline and recall data were compared. Both QoL and symptoms were measured with established instruments, the European Organization for Research and Treatment of Cancer (EORTC) group's QLQ-C30 questionnaire and the Prostate Cancer Symptom Scale (PCSS). Eighty-five of 105 patients (81%) returned the questionnaires. Altogether, the recall of symptoms was poor. Urinary and intestinal symptoms were scored worse at recall than they had actually been at baseline. By contrast, patients tended to remember their baseline sexual function as having been better than it had actually been. The recall of QoL was good. The only QoL domain with a difference between recall and baseline data was that measured in the global health status/QoL scale of the QLQ-C30 questionnaire. The effect did not vary with age or time of follow-up since baseline. Men treated with EBRT for LPC do not accurately recall their pretreatment symptoms or QoL about 1 year after treatment. The accuracy of recall was not affected by time since EBRT (7-21 months). Age did not influence the recall bias. More precise data on impairments in QoL after EBRT in patients with LPC are therefore obtained from baseline and prospective follow-up studies.

Effects of spatial and temporal resolution for MR image-guided thermal ablation of prostate with transurethral ultrasound

PURPOSE

To describe approaches for determining optimal spatial and temporal resolutions for the proton resonance frequency shift method of quantitative magnetic resonance temperature imaging (MRTI) guidance of transurethral ultrasonic prostate ablation.

MATERIALS AND METHODS

Temperature distributions of two transurethral ultrasound applicators (90 degrees sectored tubular and planar arrays) for canine prostate ablation were measured via MRTI during in vivo sonication, and agree well with two-dimensional finite difference model simulations at various spatial resolutions. Measured temperature distributions establish the relevant signal-to-noise ratio (SNR) range for thermometry in an interventional MR scanner, and are reconstructed at different resolutions to compare resultant temperature measurements. Various temporal resolutions are calculated by averaging MRTI frames.

RESULTS

When noise is added to simulated temperature distributions for tubular and planar applicators, the minimum root mean squared (RMS) error is achieved by reconstructing to pixel sizes of 1.9 and 1.7 mm, respectively. In in vivo measurements, low spatial resolution MRTI data are shown to reduce the noise without significantly affecting thermal dose calculations. Temporal resolution of 0.66 frames/minute leads to measurement errors of more than 12 degrees C during rapid heating.

CONCLUSION

Optimizing MRTI pixel size entails balancing large pixel SNR gain with accuracy in representing underlying temperature distributions.

Expectant management: an option for localized prostate cancer

Localized prostate cancer demonstrates tremendous heterogeneity in the natural history of the disease. To this end, although prostate cancer may be present histologically in nearly 30% of all men above the age of 50 y, the lifetime risk of developing clinically significant disease is 18% (one in six). Furthermore, the lifetime risk of dying from prostate cancer is less than 4%. Therefore, in order to avoid unnecessarily treating potentially insignificant prostate cancer, the concept of expectant management has been considered for this disease. In this brief review, we discuss the evolution of expectant management for men with localized prostate cancer.

Decreased -Methylacyl CoA Racemase Expression in Localized Prostate Cancer is Associated with an Increased Rate of Biochemical Recurrence and Cancer-Specific Death

Alpha-methylacyl CoA racemase (AMACR) is overexpressed in prostate cancer relative to benign prostatic tissue. AMACR expression is highest in localized prostate cancer and decreases in metastatic prostate cancer. Herein, we explored the use of AMACR as a biomarker for aggressive prostate cancer. AMACR protein expression was determined by immunohistochemistry using an image analysis system on two localized prostate cancer cohorts consisting of 204 men treated by radical prostatectomy and 188 men followed expectantly. The end points for the cohorts were time to prostate-specific antigen (PSA) failure (i.e., elevation >0.2 ng/mL) and time to prostate cancer death in the watchful waiting cohort. Using a regression tree method, optimal AMACR protein expression cut-points were determined to best differentiate prostate cancer outcome in each of the cohorts separately. Cox proportional hazard models were then employed to examine the effect of the AMACR cut-point on prostate cancer outcome, and adjusted for clinical variables. Lower AMACR tissue expression was associated with worse prostate cancer outcome, independent of clinical variables (hazard ratio, 3.7 for PSA failure; P = 0.018; hazard ratio, 4.1 for prostate cancer death, P = 0.0006). Among those with both low AMACR expression and high Gleason score, the risk of prostate cancer death was 18-fold higher (P = 0.006). The AMACR cut-point developed using prostate cancer-specific death as the end point predicted PSA failures independent of Gleason score, PSA, and margin status. This is the first study to show that AMACR expression is significantly associated with prostate cancer progression and suggests that not all surrogate end points may be optimal to define biomarkers of aggressive prostate cancer.

Diagnostic précoce et traitement chirurgical du cancer de la prostate

Prostate cancer is a significant cause of morbidity and mortality in the United States and Europe. The natural ageing of the population as well as the continued and widespread use of diagnostic tests such as prostate specific antigen (PSA), has led to an increase in the numbers of men diagnosed with localised prostate cancer. Screening to identify organ-confined disease has provoked much public and scientific attention, but remains controversial. Radical prostatectomy is one of the most challenging urological procedures performed. Improvements in technique due to better understanding of pelvic anatomy have reduced complications, with acceptable standards and excellent results in high-volume institutions. Continual refinements in technique and the recent introduction of laparoscopic radical prostatectomy are likely to improve functional outcome further. However the effectiveness of surgery in improving survival and quality of life, in men with early prostate cancer remains to be determined. The results from large randomised controlled trials are eagerly awaited.

Can Prostate Specific Antigen Derivatives and Pathological Parameters Predict Significant Change in Expectant Management Criteria for Prostate Cancer?

PURPOSE

A prior report established that pretreatment criteria based on clinical and biopsy pathology parameters can predict men who harbor small volume prostate cancer who might be followed expectantly. However, some of these men will exhibit disease progression with time and will need definitive therapy. To detect those in whom disease may progress, repeat prostate biopsies are performed at yearly intervals. Therefore, we determined whether biomarkers could be used to determine those in whom disease is likely to progress and thus those who require definitive therapy.

MATERIALS AND METHODS

Initial and repeat biopsy information along with transrectal ultrasound measurements of gland volume, total prostate specific antigen (PSA), %free PSA (%fPSA) and total PSA velocity were evaluated in 78 men, 45 from the prior study, in whom disease was being managed expectantly. Univariate and multivariate logistic regression analyses determined variables that predicted a favorable tumor burden based on biopsy pathology status at each subsequent repeat biopsy. A Cox proportional hazards model was produced using 67 of 78 evaluable cases having adequate temporal data to predict hazard ratios for conversion from favorable to unfavorable tumor burden status.

RESULTS

At time zero for 78 patients %fPSA, total PSA, and gland volume univariately and multivariately differentiated unfavorable and favorable tumor burden groups (p <0.05). The receiver operator characteristic area under the curve (ROC-AUC) was 83%. At the first followup biopsy 17 of 67 (25.4%) men converted to unfavorable tumor burden status. The %fPSA, PSA velocity and gland volume univariately distinguished these 2 groups (p <0.05) with 82% ROC-AUC. At second repeat biopsy 6 of 36 (16.7%) men converted to unfavorable tumor burden status and the ROC-AUC was 76%. Of the 14 men who had a third repeat biopsy all demonstrated favorable tumor burden status. A Cox proportional hazards model stratified the 67 of 78 men into high (48) and low risk (19) groups based on %fPSA at a 20% cutoff (p <0.01). Classification and regression tree analysis using logistic regression multivariately selected variables predicted favorable tumor burden status with an accuracy that ranged from 75% to 84% during our study.

CONCLUSIONS

PSA velocity, %fPSA and gland volume information improves the prediction of men undergoing expectant management who are more likely to have small volume disease based on a 12-core biopsy interpretation within the time of our observations. %fPSA proved to be a valuable marker to stratify the 2 risk groups. Therefore, based on these factors it may be possible to consider deferment of repeat prostate biopsy until adverse results are detected. This rational approach to the management of prostate cancer in older men with small volume cancer seems to be a reasonable strategy.

Early diagnosis and surgical management of prostate cancer

Prostate cancer is a significant cause of morbidity and mortality in the United States and Europe. The natural ageing of the population as well as the continued and widespread use of diagnostic tests such as prostate specific antigen (PSA), has led to an increase in the numbers of men diagnosed with localised prostate cancer. Screening to identify organ-confined disease has provoked much public and scientific attention, but remains controversial. Radical prostatectomy is one of the most challenging urological procedures performed. Improvements in technique due to better understanding of pelvic anatomy have reduced complications, with acceptable standards and excellent results in high-volume institutions. Continual refinements in technique and the recent introduction of laparoscopic radical prostatectomy are likely to improve functional outcome further. However the effectiveness of surgery in improving survival and quality of life, in men with early prostate cancer remains to be determined. The results from large randomised controlled trials are eagerly awaited.

The natural history of prostate cancer

Predicting the long-term outcome of patients who choose watchful waiting as initial therapy for prostate cancer is difficult. The wide variation in disease progression, the impact of competing medical hazards, and the potential impact of early hormonal therapy that is characteristic of contemporary patients all conspire to compromise survival estimates dating from the pre-PSA era. The survival analysis figure developed by Albertsen et al (Fig. 1) estimates a 15-year survival rate based on patient age and Gleason score at diagnosis from patients diagnosed in the pre-PSA era. Although no effort was made to adjustfor competing medical hazards, patients and clinicians can adjust a patient's chronological age to match his "physiological" age. The advent of widespread PSA testing appears to have advanced the date of diagnosis by approximately 5 years and the onset of secondary treatment by at least as many years. Therefore, the figure describing the natural history of prostate cancer most likely underestimates rather than overestimates survival among men with newly diagnosed, localized prostate cancer who select watchful waiting as their treatment choice. As contemporary databases of men with localized prostate cancer mature, more data on the natural history of this disease will become available. Only time will tell how the use of PSA has altered the precision of historic case-series data.

Screening for prostate cancer

Epidemiologically, screening is justified by the importance of the disease and the lack of prospects for primary prevention, but evidence from natural history is unhelpful since men are more likely to die with, rather than from, prostate cancer. The available screening tests do not always detect men whose lesions could result in future morbidity or mortality. Evidence is limited for the benefits of treatment for localised cancers detected through screening, whereas the evidence for harm is clear. Observational evidence for the effect of population screening programmes is mixed, with no clear association between intensity of screening and reduced prostate cancer mortality. Screening for prostate cancer cannot be justified in low-risk populations, but the balance of benefit and harm will be more favourable after risk stratification. Prostate cancer screening can be justified only in research programmes designed to assess its effectiveness and help identify the groups who may benefit.

KAI1/CD82 protein expression in primary prostate cancer and in BPH associated with cancer

Current prognostic methods in primary prostate cancer cannot accurately identify patients with clinically significant disease at highest risk of developing metastases. This study examined KAI1/CD82 metastasis suppressor expression by quantitative immunohistochemical analysis of benign prostatic hyperplasia (BPH) and prostate cancer specimens. Altogether, prostate cancers exhibited significant KAI1 overexpression compared to BPH not associated with cancer (P = 0.022). Increased KAI1 expression in well and moderately differentiated cancers, above levels seen in BPH, with decreased expression in poorly differentiated cancers was observed. Interestingly, KAI1 expression in BPH associated with cancers was significantly higher than in BPH not associated with cancer (P = 0.009). Thus, KAI1 overexpression may restrain onset and early stage prostate cancer development, whilst its loss may predispose the patient to more aggressive cancer behaviour. Altered KAI1 expression in prostate cancers and BPH associated with cancer may have important diagnostic roles.

A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer

BACKGROUND

Radical prostatectomy is widely used in the treatment of early prostate cancer. The possible survival benefit of this treatment, however, is unclear. We conducted a randomized trial to address this question.

METHODS

From October 1989 through February 1999, 695 men with newly diagnosed prostate cancer in International Union against Cancer clinical stage T1b, T1c, or T2 were randomly assigned to watchful waiting or radical prostatectomy. We achieved complete follow-up through the year 2000 with blinded evaluation of causes of death. The primary end point was death due to prostate cancer, and the secondary end points were overall mortality, metastasis-free survival, and local progression.

RESULTS

During a median of 6.2 years of follow-up, 62 men in the watchful-waiting group and 53 in the radical-prostatectomy group died (P=0.31). Death due to prostate cancer occurred in 31 of 348 of those assigned to watchful waiting (8.9 percent) and in 16 of 347 of those assigned to radical prostatectomy (4.6 percent) (relative hazard, 0.50; 95 percent confidence interval, 0.27 to 0.91; P=0.02). Death due to other causes occurred in 31 of 348 men in the watchful-waiting group (8.9 percent) and in 37 of 347 men in the radical-prostatectomy group (10.6 percent). The men assigned to surgery had a lower relative risk of distant metastases than the men assigned to watchful waiting (relative hazard, 0.63; 95 percent confidence interval, 0.41 to 0.96).

CONCLUSIONS

In this randomized trial, radical prostatectomy significantly reduced disease-specific mortality, but there was no significant difference between surgery and watchful waiting in terms of overall survival.

Lessons learnt about early prostate cancer from large scale databases: population-based pearls of wisdom

Prostate cancer is one of most common solid tumors in men and poses some of the most difficult problems in clinical research. Although many clinical research hypotheses in this condition have been explored using single center cases series and multi-center clinical trials, the results of these studies have often been equivocal, leaving many questions unanswered. Recently, investigators have utilized large, administrative datasets for prostate cancer research. These databases tend to include large numbers of patients from different geographic regions increasing their generalizability and statistical power. The goal of this report is to review lessons learnt about early prostate cancer using these data sources. In particular, we focus on the application of large, population-based datasets to address issues concerning the natural history of prostate cancer, the impact of race on outcomes in prostate cancer and the effectiveness of various treatments for localized disease. Information gathered from large, administrative databases will be helpful when counseling patients regarding their treatments options for localized prostate cancer and in identifying future directions for prostate cancer research.

Prognostic value of the Gleason score in prostate cancer

OBJECTIVE

To investigate the prognostic value of the Gleason score in prostate cancer.

PATIENTS AND METHODS

A consecutive series of 305 men with prostate cancer diagnosed at transurethral resection (1975-1990) and with no curative treatment was analysed. There was no assessment of prostate-specific antigen level during this period. The mean (range) age at diagnosis was 73.7 (52-95) years and the mean follow-up was 6.4 (0-22) years. The influence of Gleason score and the percentage of the specimen area with tumour (% cancer) on disease-specific survival were assessed using Kaplan-Meier analyses.

RESULTS

Of 305 cancers, 22% had a Gleason score of 4-5, 29% of 6, 18% of 7 and 32% of 8-10. At the follow-up, 89% of the men had died, of whom 42% had died from prostate cancer. The disease-specific 10-year survival was 56%. The disease-specific mean survival (DSMS) for Gleason score 4-5, 6, 7 and 8-10 was 20, 16, 10 and 5 years, respectively (P < 0.001). The DSMS did not differ significantly between Gleason 4 and 5 or between 8-10. There was a trend towards shorter survival for Gleason 4 + 3=7 (DSMS 9 years) than GS 3 + 4=7 (DSMS 13 years; P = 0.16). Gleason score and % cancer were independent predictors of DSMS (P < 0.001).

CONCLUSION

The long-term prognosis of prostate cancer on deferred treatment is predicted well by the Gleason score. Four prognostic categories of prostate cancer are suggested, i.e. Gleason score 4-5, 6, 7 and 8-10.

Loss of p53 and c-myc overrepresentation in stage T(2-3)N(1-3)M(0) prostate cancer are potential markers for cancer progression

To determine whether genetic changes are markers of cancer progression and patient survival in Stage T(2-3)N(1-3)M(0) prostatic carcinoma, we compared 26 patients who died of tumor relapse after prostatectomy and lymphadenectomy (case group) with 26 matched patients who were alive at the time of the matched case's death (control group). Nine unmatched cases were also included in this study. In 37 cases, paired primary tumors (119 foci) and lymph node metastases (114 foci) were available for study. Fluorescence in situ hybridization (FISH) with centromere-specific probes for chromosomes 7, 8, and 17 and region-specific probes for D7S486 (7q31), c-myc (8q24), LPL (8p22), and p53 (17p13) was performed on available primary carcinomas and lymph node metastases. In primary tumor foci, +7q31, -8p22, +c-myc, substantial additional increases of myc (AI-c-myc), and -p53 were observed in 65%, 74%, 43%, 29%, and 31% of foci, respectively. AI-c-myc was strongly associated with higher cancer Gleason score (P =.003). Heterogeneity of genetic changes was frequently observed among multiple cancer foci. Lymph node metastases of prostate cancer usually shared genetic changes with paired primary tumors. In addition, the genetic change pattern with -8p, +c-myc or AI-c-myc, +7q, and +p53 was slightly higher in lymph node metastases (22%) than in primary tumors (6%) (P =.08). In matched case and control patients, simultaneous gain of 7q31 (+7q31) and CEP7 (+CEP7) was identified in 59% and 68% of specimens for case and control groups, respectively (P =.48). Loss of 8p22 (-8p22) was identified in 77% and 69% of specimens for case and control groups, respectively (P = 1.0). Simultaneous gain of c-myc (+c-myc) and CEP8 (+CEP8) without overt additional increase of c-myc copy number relative to CEP8 copy number, was identified in 38% and 54% of specimens for case and control groups, respectively (P =.27). AI-c-myc was identified in 54% and 23% of specimens for case and control groups, respectively (odds ratio = 3.0, P =.06). Loss of p53 (-p53) was identified in 46% and 15% of specimens for case and control groups, respectively (odds ratio = 4.0, P =.04). Our results indicate that FISH anomalies are very common in both primary tumors and lymph node metastases of Stage T(2-3)N(1-3)M(0) prostate cancer; that AI-c-myc is associated with higher cancer Gleason score; that AI-c-myc and -p53 are associated with prostate cancer progression and are potential markers of survival in Stage T(2-3)N(1-3)M(0) prostate cancer; and that lymph node metastases usually have similar or additional genetic changes compared with primary tumors, and multiple lymph node metastases usually have similar genetic changes.

Quality of life and symptoms in a randomized trial of radiotherapy versus deferred treatment of localized prostate carcinoma

BACKGROUND

Treatment of localized prostate carcinoma (LPC) using radiotherapy (RT) can induce disturbances in a patient's quality of life (QOL) and urinary and intestinal function. Late symptoms and QOL were evaluated in a randomized trial between RT and deferred treatment (DT).

METHODS

Quality of life was evaluated with European Organization for Research and Treatment of Cancer's QLQ-C30 (+3) formula. Urinary and intestinal problems were evaluated with a validated symptom specific self-assessment questionnaire, QUFW94. The questionnaires were sent to 108 randomized patients with LPC and to an age-matched control group (n = 68). Mean age was 72 years. Mean total dose was 65 grays (Gy; 62.3-70 Gy). The median follow-up time from randomization was 40.6 months for the RT group and 30.4 months for the DT group.

RESULTS

Social functioning was the only QOL scale in which a significant difference was found between the two patient groups and compared with the control group. Multivariate regression analysis showed that hematuria, incontinence, mucus, and planning of daily activities in response to intestinal problems caused this decrease in QOL in the RT group. A significant increase of intestinal problems was observed in the RT versus DT groups regarding mucus, stool leakage, intestinal blood, and planning of daily activity in response to intestinal problems.

CONCLUSIONS

The RT patients showed increased levels of minor intestinal side effects compared with the DT patients and the controls, but the RT patients reported no decreased QOL except for decreased social functioning. This could be because this group developed coping skills or because of a low magnitude of side effects to influence the QOL.

Design of the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial

The objectives of the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial are to determine in screenees ages 55-74 at entry whether screening with flexible sigmoidoscopy (60-cm sigmoidoscope) can reduce mortality from colorectal cancer, whether screening with chest X-ray can reduce mortality from lung cancer, whether screening men with digital rectal examination (DRE) plus serum prostate-specific antigen (PSA) can reduce mortality from prostate cancer, and whether screening women with CA125 and transvaginal ultrasound (TVU) can reduce mortality from ovarian cancer. Secondary objectives are to assess screening variables other than mortality for each of the interventions including sensitivity, specificity, and positive predictive value; to assess incidence, stage, and survival of cancer cases; and to investigate biologic and/or prognostic characterizations of tumor tissue and biochemical products as intermediate endpoints. The design is a multicenter, two-armed, randomized trial with 37,000 females and 37,000 males in each of the two arms. In the intervention arm, the PSA and CA125 tests are performed at entry, then annually for 5 years. The DRE, TVU, and chest X-ray exams are performed at entry and then annually for 3 years. Sigmoidoscopy is performed at entry and then at the 5-year point. Participants in the control arm follow their usual medical care practices. Participants will be followed for at least 13 years from randomization to ascertain all cancers of the prostate, lung, colorectum, and ovary, as well as deaths from all causes. A pilot phase was undertaken to assess the randomization, screening, and data collection procedures of the trial and to estimate design parameters such as compliance and contamination levels. This paper describes eligibility, consent, and other design features of the trial, randomization and screening procedures, and an outline of the follow-up procedures. Sample-size calculations are reported, and a data analysis plan is presented.

Prostate cancer: to screen or not to screen?

The aim of screening is to identify cancers that are potentially curable; before a programme can be introduced, it must satisfy the requirement that it does more good than harm, particularly in terms of survival and quality of life. Prostate cancer is a common disease in older men and presents a significant burden to health services. Prostatic tumours range from small slow-growing lesions to aggressive tumours that metastasise rapidly, but because the natural history of prostate cancer is poorly understood, there is controversy about which screen-detected lesions will become clinically significant. Current methods of screening involve measurement of serum prostate specific antigen, followed by transrectal ultrasound scanning and biopsy, but these lack adequate specificity and sensitivity. There are three major treatment options for localised disease: radical prostatectomy, radical radiotherapy, and monitoring with treatment if required. There is no randomised controlled trial evidence to suggest a survival advantage of any of these treatments, and each has risks. There is intense speculation about future developments in diagnostic testing, molecular markers of progression, and early chemoprevention, but the central question that remains is whether radical treatments can improve survival and quality of life.

Screening for prostate cancer

Screening for prostate cancer has shown great promise in its ability to detect prostate cancer at a curable stage; however, significant problems exist with respect to our knowledge of its impact on prostate cancer mortality. For the properly informed patient with at least a 10-year life expectancy, it would seem that early detection efforts utilizing digital rectal examination (DRE) and serum prostate-specific antigen (PSA) determination are beneficial. Considerable controversy abounds about early detection and screening and will continue until definitive proof of decreased prostate cancer mortality as a result of effective early detection and treatment regimens is demonstrated. Until then, all men with at least a 10-year life expectancy should be counseled as to the potential benefits and risks. The salient literature is reviewed and commentary made as to the benefits of screening methods that can be invoked as well as their limitations and potential liabilities.