Stage-specific mortality and survival trends of prostate cancer patients in Finland before and after introduction of PSA

Periodic trends in geographical variation of prostate cancer incidence and mortality in Finland between 1985 and 2019

BACKGROUND

Evaluation of regional variation of prostate cancer (PCa) incidence and PCa-specific mortality is essential in the assessment of equity in a national healthcare system. We evaluated PCa incidence and PCa-specific mortality between different municipalities and hospital districts in Finland over 1985-2019.

MATERIAL AND METHODS

Men diagnosed with PCa in Finland from 1985 through 2019 were retrieved from Finnish Cancer Registry. Age-standardized PCa incidence and mortality rates were estimated by municipality and hospital district as well as municipality urbanization, education, and income level using hierarchical Bayesian modeling. Standard deviations (SD) of the regional rates were compared between periods from 1985-1989 to 2015-2019.

RESULTS

We identified 123,185 men diagnosed with any stage PCa between 1985 and 2019. SD of PCa incidence rate (per 100,000 person-years) showed that the total variation of PCa incidence between different municipalities was substantial and varied over time: from 22.2 (95% CI, 17.1-27.8) in 1985-1989 to 56.5 (95% CI, 49.8-64.5) in 2000-2004. The SD of PCa mortality rate between all municipalities was from 9.0 (95% CI, 6.6-11.8) in 2005-2009 to 2.4 (95% CI, 0.9-4.8) in 2015-2019. There was a trend toward a lower PCa-specific mortality rate in municipalities with higher education level.

DISCUSSION

Regional variation in the incidence rate of PCa became more evident after initiation of PSA testing in Finland, which indicates that early diagnostic practice (PSA testing) of PCa has been different in different parts of the country. Variation in the national PCa mortality rate was indeed recognizable, however, this variation diminished at the same time as the mortality rate declined in Finland. It seems that after the initiation period of PSA testing, PSA has equalized PCa mortality outcomes in Finland.

Individualised non-contrast MRI-based risk estimation and shared decision-making in men with a suspicion of prostate cancer: protocol for multicentre randomised controlled trial (multi-IMPROD V.2.0)

INTRODUCTION

European Association of Urology and UK National Institute for Health and Care Excellence guidelines recommend that all men with suspicions of prostate cancer should undergo prebiopsy contrast enhanced, that is, multiparametric prostate MRI. Subsequent prostate biopsies should also be performed if MRI is positive, that is, Prostate Imaging-Reporting and Data System (PI-RADS) scores 3-5. However, several retrospective post hoc analyses have shown that this approach still leads to many unnecessary biopsy procedures. For example, 88%-96% of men with PI-RADS, three findings are still diagnosed with clinically non-significant prostate cancer or no cancer at all.

METHODS AND ANALYSIS

This is a prospective, randomised, controlled, multicentre trial, being conducted in Finland, to demonstrate non-inferiority in clinically significant cancer detection rates among men undergoing prostate biopsies post-MRI and men undergoing prostate biopsies post-MRI only after a shared decision based on individualised risk estimation. Men without previous diagnosis of prostate cancer and with abnormal digital rectal examination findings and/or prostate-specific antigen between 2.5 ug/L and 20.0 ug/L are included. We aim to recruit 830 men who are randomised at a 1:1 ratio into control (all undergo biopsies after MRI) and intervention arms (the decision to perform biopsies is based on risk estimation and shared decision-making). The primary outcome of the study is the proportion of men with clinically significant prostate cancer (Gleason 4+3 prostate cancer or higher). We will also compare the overall biopsy rate, benign biopsy rate and the detection of non-significant prostate cancer between the two study groups.

ETHICS AND DISSEMINATION

The study (protocol V.2.0, 4 January 2021) was approved by the Ethics Committee of the Hospital District of Southwest Finland (IORG number: 0001744, IBR number: 00002216; trial number: 99/1801/2019). Participants are required to provide written informed consent. Full reports of this study will be submitted to peer-reviewed journals, mainly urology and radiology.

TRIAL REGISTRATION NUMBER

NCT04287088; the study is registered at ClinicalTrials.gov.

Spatial and temporal patterns of prostate cancer burden and their association with Socio-Demographic Index in Asia, 1990-2019

BACKGROUND

Prostate cancer is the second most frequently diagnosed cancer for males worldwide, but the spatial and temporal trends of prostate cancer burden remain unknown in Asia. This study aimed to investigate the changing spatial and temporal trends of incidence, prevalence, mortality, disability-adjusted life year (DALY), and mortality-to-incidence ratio (MIR) of prostate cancer, and their association with the Socio-Demographic Index (SDI) in 48 Asian countries from 1990 to 2019.

METHODS

Data were extracted from the Global Health Data Exchange query tool, covering 48 Asian countries from 1990 to 2019. The average annual percent change was calculated to evaluate temporal trends. Spatial autocorrelation analysis was used to obtain spatial patterns, and the association between SDI and prostate cancer burden was estimated using a spatial panel model.

RESULTS

In Asia, the age-standardized incidence and prevalence of prostate cancer increased in almost all countries, and its mortality and DALY also increased in over half of the countries. Significantly regional disparities were found in Asia, and the hot spots for incidence, prevalence, mortality, and DALY were all located in Western Asia, the hot spots of percent change also occurred in Western Asia for incidence and DALY. Furthermore, SDI had a positive association with mortality (coef = 2.51, 95% confidence interval [CI]: 2.13-2.90) and negative association with DALY (coef = -14.99, 95% CI: -20.37 to -9.60) and MIR (coef = -0.95, 95%CI: -0.99 to -0.92).

CONCLUSIONS

Prostate cancer burden increased rapidly throughout Asia and substantial disparities had persisted between countries. Geographically targeted interventions are needed to reduce the prostate cancer burden throughout Asia and in specific countries.

All-Cause Mortality Risk in National Prostate Cancer Cohort: An Impact of Population-Based Prostate Cancer Screening

The aim of this study is to evaluate all-cause mortality risk differences before and during prostate cancer screening, with a profound focus on the differences between screened and not-screened patient groups. Prostate cancer cases diagnosed between 1998 and 2016 were identified from the population-based Lithuanian Cancer Registry and linked with screening status in the National Health Insurance Fund database. The analysis was stratified by a period of diagnosis and screening status. Standardized mortality ratios (SMRs) were used to assess all-cause and cause-specific mortality risk. The SMRs were calculated by dividing the observed number of deaths among prostate cancer patients by the expected number of deaths from the general population. All-cause SMR (1.45 (95% CI 1.42-1.48)) in the pre-screening period was higher compared to the screening period (SMR = 1.17 (95% CI 1.15-1.19)). An increased all-cause mortality risk among prostate cancer patients was observed in the not-screened patient population (SMR = 1.76 (95% CI 1.71-1.82)), while all-cause mortality risk in the screened patient population was similar to the general population (SMR = 1.00 (95% CI 0.97-1.02)). Screened patients with localized stage of disease had lower all-cause mortality risk than the general population (SMR = 0.72 (95% CI 0.70-0.75)). In conclusion, men with prostate cancer in Lithuania had excess all-cause mortality risk compared to the general population. The all-cause mortality risk among screened patients was not higher than expected.

Variation in Prostate-Specific Antigen Testing Rates and Prostate Cancer Treatments and Outcomes in a National 20-Year Cohort

IMPORTANCE

The diagnostic activity for prostate cancer has increased during the past decades. However, the benefit and harm of the increased diagnostic activity have not been quantified in detail for a country or a large region.

OBJECTIVE

The aim of this study was to evaluate and quantify the association between increases in diagnostic activity driven by prostate-specific antigen testing and incidence of prostate cancer diagnosis, treatment, and mortality.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used the Proxy-Based Risk-Stratified Incidence Simulation Model-Prostate Cancer to examine observed data on all Swedish men with prevalent prostate cancer and compare them with a corresponding, hypothetical, simulated scenario with more restrictive diagnostic activity. All men aged 40 to 100 years living in Sweden during the time period 1996 to 2016 with incident and prevalent prostate cancer were included. The second scenario is the corresponding, hypothetical, simulated scenario where diagnostic activity remained constant as of 1996 (the beginning of the prostate-specific antigen testing era) throughout the study period.

EXPOSURES

High or low diagnostic activity for prostate cancer.

MAIN OUTCOMES AND MEASURES

Incidence of prostate cancer diagnosis, treatment (deferred treatment, curative treatment, and hormonal treatment), and prostate cancer mortality.

RESULTS

During the study period from 1996 to 2016, 188 884 men were diagnosed with prostate cancer at a median (interquartile range) age of 71 (64-77) years. Compared with the low-diagnostic activity scenario, in the high-diagnostic activity scenario, the number of men diagnosed with prostate cancer was 48% higher (423 vs 286 [95% CI, 271-302] per 100 000 men per year), 148% more men were diagnosed with low- or intermediate-risk cancer (221 vs 89 [95% CI, 73-105] per 100 000 men per year), and 108% more men received curative treatment (152 vs 73 [95% CI: 66-85] per 100 000 men per year). There were up to 15% fewer prostate cancer deaths in the scenario with high-diagnostic activity (incidence rate ratio, 0.85; 95% CI, 0.82-0.88).

CONCLUSIONS AND RELEVANCE

This study's results suggest that increased prostate-specific antigen testing and diagnostic activity are associated with a larger number of men being diagnosed with prostate cancer, predominately with low- and intermediate-risk disease. The increased diagnostic activity was associated with a 2-fold increase in curative treatment and a modest decrease in mortality.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Vasectomy and the risk of prostate cancer in a Finnish nationwide population-based cohort

INTRODUCTION & OBJECTIVES

There are conflicting reports on the association of vasectomy and the risk of prostate cancer (PCa). Our objective was to evaluate the association between vasectomy and PCa from a nationwide cohort in Finland.

MATERIALS & METHODS

Sterilization registry of Finland and the Finnish Cancer Registry data were utilized to identify all men who underwent vasectomy between years 1987-2014 in Finland. Standard incidence ratio (SIR) for PCa as well as all-cause standardized mortality ratios (SMR) were calculated.

RESULTS

We identified 38,124 men with vasectomy with a total of 429,937 person-years follow-up data. The median age at vasectomy was 39.7 years (interquartile range [IQR] 35.9-44.0), after vasectomy PCa was diagnosed in 413 men (122 cases 0-10 years, 219 cases 10-20 years and 72 cases >20 years from vasectomy). SIR for PCa for the vasectomy cohort was 1.15 (95% CI: 1.04-1.27). By the end of follow-up, 19 men had died from PCa, while the expected number was 20.5 (SMR 0.93 [95%CI: 0.56-1.44]). The overall mortality was decreased (SMR 0.54 [95%CI: 0.51-0.58]) among men with vasectomy.

CONCLUSION

We found a small statistically significant increase in PCa incidence after vasectomy, but in contrast the mortality of vasectomized men was significantly reduced. This may be due to higher likelihood of vasectomized men to undergo prostate-specific antigen testing, having healthier general lifestyle and other biological factors e.g. high reproductive fitness.

Literature review of the burden of prostate cancer in Germany, France, the United Kingdom and Canada

BACKGROUND

Prostate cancer is the most frequently reported cancer in males in Europe, and is associated with substantial morbidity and mortality. The aim of the current review was to characterize the clinical, economic and humanistic burden of disease associated with prostate cancer in France, Germany, the UK and Canada.

METHODS

Literature searches were conducted using the PubMed, EMBASE and Cochrane Library databases to identify studies reporting incidence and/or mortality rates, costs and health state utilities associated with prostate cancer in the settings of interest. For inclusion, studies were required to be published in English in full-text form from 2006 onwards.

RESULTS

Incidence studies showed that in all settings the incidence of prostate cancer has increased substantially over the past two decades, driven in part by increased uptake of prostate specific antigen (PSA) screening leading to earlier identification of tumors, but which has also led to over-treatment, compounding the economic burden of disease. Mortality rates have declined over the same time frame, driven by earlier detection and improvements in treatment. Both prostate cancer itself, as well as treatment and treatment-related complications, are associated with reduced quality of life.

CONCLUSIONS

Prostate cancer is associated with a significant clinical and economic burden, whilst earlier detection and aggressive treatment is associated with improved survival, over-treatment of men with indolent tumors compounds the already significant burden of disease and treatment can lead to long-term side effects including impotence and impaired urinary and/or bowel function. There is currently an unmet clinical need for diagnostic and/or prognostic tools that facilitate personalized prostate cancer treatment, and potentially reduce the clinical, economic and humanistic burden of invasive cancer treatment.

Image-guided surgery in cancer: A strategy to reduce incidence of positive surgical margins

Primary treatment for many solid cancers includes surgical excision or radiation therapy, with or without the use of adjuvant therapy. This can include the addition of radiation and chemotherapy after primary surgical therapy, or the addition of chemotherapy and salvage surgery to primary radiation therapy. Both primary therapies, surgery and radiation, require precise anatomic localization of tumor. If tumor is not targeted adequately with initial treatment, disease recurrence may ensue, and if targeting is too broad, unnecessary morbidity may occur to nearby structures or remaining normal tissue. Fluorescence imaging using intraoperative contrast agents is a rapidly growing field for improving visualization in cancer surgery to facilitate resection in order to obtain negative margins. There are multiple strategies for tumor visualization based on antibodies against surface markers or ligands for receptors preferentially expressed in cancer. In this article, we review the incidence and clinical implications of positive surgical margins for some of the most common solid tumors. Within this context, we present the ongoing clinical and preclinical studies focused on the use of intraoperative contrast agents to improve surgical margins. This article is categorized under: Laboratory Methods and Technologies > Imaging.

A randomized trial of early detection of clinically significant prostate cancer (ProScreen): study design and rationale

The current evidence of PSA-based prostate cancer screening shows a reduction in cause-specific mortality, but with substantial overdiagnosis. Recently, new developments in detection of clinically relevant prostate cancer include multiple kallikreins as biomarkers besides PSA, and multiparametric magnetic resonance imaging (mpMRI) for biopsy decision. They offer opportunities for improving the outcomes in screening, particularly reduction in overdiagnosis and higher specificity for potentially lethal cancer. A population-based randomized screening trial will be started, with 67,000 men aged 55-67 years at entry. A quarter of the men will be allocated to the intervention arm, and invited to screening. The control arm will receive no intervention. All men in the screening arm will be offered a serum PSA determination. Those with PSA of 3 ng/ml or higher will have an additional multi-kallikrein panel and those with indications of increased risk of clinically relevant prostate cancer will undergo mpMRI. Men with a malignancy-suspect finding in MRI are referred to targeted biopsies. Screening interval is 6 years for men with baseline PSA < 1.5 ng/ml, 4 years with PSA 1.5-3.0 and 2 years if initial PSA > 3. The main outcome of the trial is prostate cancer mortality, with analysis at 10 and 15 years. The statistical power is sufficient for detecting a 28% reduction at 10 years and 22% at 15 years. The proposed study has the potential to provide the evidence to justify screening as a public health policy if mortality benefit can be sustained with substantially reduced overdiagnosis.