Changing trends in U.S. prostate cancer incidence rates

Prostate-Specific Antigen Screening According to Health Professional Counseling and Age in the United States

Background

In 2018, the US Preventive Services Task Force recommended that PSA screening for prostate cancer involve men aged 55–69, based on a personal decision following consultation with a health professional. PSA screening in men aged 70 or older should only occur if symptoms exist. This study identifies the association between having a PSA test in the past two years and whether or not there was consultation with a health professional about the benefits and/or harms of PSA screening.

Methods

Analyses were based on data involving men aged 40 years or older, who responded to PSA related questions in the 2018 BRFSS survey.

Results

Approximately 32.0% (14.6% for ages 40–54, 41.7% for ages 55–69, and 49.8% for ages 70 years and older) of respondents had a PSA test in the past two years. Approximately 81.7% of these men had talked with a health professional about the benefits and/or harms of PSA screening, with 42.4% having discussed the benefits and harms, 54.6% having discussed the benefits only, and 3.0% having discussed the harms only. The odds of a PSA test in the past two years in men having talked with a health professional about the benefits and harms of the test versus no talk are 10.1 (95% CI 9.3–10.8), in men who talked with a health professional about the benefits only versus no talk are 10.8 (95% CI 10.0–11.6), and in men who talked with a health professional about the harms only versus no talk are 3.9 (95% CI 2.9–5.1).

Conclusion

PSA screening is most common in men aged 70 or older, which is counter to the US Preventive Task Force recommendation. Most men having a PSA test have talked with a health professional about the test, but the talks tended to focus on just the benefits of screening and not both potential benefits and harms.

The diminishing role of transurethral resection of the prostate

BACKGROUND

This study provides an update of patterns in transurethral resection of the prostate (TURP) rates in the United States and the extent of TURP-detected prostate cancer incidence rates.

METHODS

Analyses are based on data from the National Hospital Discharge Survey, the Surveillance, Epidemiology, and End Results Program, and the U.S. Census Bureau for the years 1996 through 2006.

RESULTS

TURP procedure rates were 6, 14, and 18 times greater in men aged 60 to 69, 70 to 79, and >or=80 years compared with men aged 50 to 59, respectively. During 1996-2006, the estimated annual percentage change in TURP rates was -10.5 (95% confidence interval [95% CI] -14.1 to -6.7) for ages 50 to 59, -7.4 (95% CI -9.2 to -5.6) for ages 60 to 69, -6.2 (95% CI -7.6 to -4.8) for ages 70 to 79, and -7.7 (95% CI -9.5 to -5.8) for ages >or=80 years. TURP-detected prostate cancer incidence rates were 2, 7, and 17 times greater in men aged 60 to 69, 70 to 79, and >or=80 years compared with men aged 50 to 59, respectively. The estimated annual percentage change in trend was -17.8 (-20.6, -15.0) for ages 50 to 59, -14.8 (-16.6, -13.0) for ages 60 to 69, -10.8 (-12.0, -9.7) for ages 70 to 79, and -8.2 (-10.0, -6.5) for ages >or=80 years. Trends in prostate cancer incidence rates peaked in 2002 and decreased thereafter. Some of the decreasing trend in rates among older age groups is because of a decrease in TURPs and consequently a decrease in incidental TURP-detected cases.

CONCLUSIONS

TURP procedure rates and incidental TURP-detected prostate cancer incidence rates have declined and will likely continue to decline in the future.

Improving therapeutic outcomes in BPH through diagnosis, treatment and patient compliance

The percentage of men with symptoms of benign prostatic hyperplasia (BPH) increases markedly with age. In the United States, although evidence that racial/ethnic minorities are more likely to develop BPH remains controversial, it is clear that there are generalized differences in access to healthcare for a large portion of the minority population. These differences in healthcare access could in turn influence the way minorities are treated for symptoms of BPH. Given both the sensitive nature of the disease and the variety of treatment options, communication between healthcare professionals and the patient needs to be improved for optimal care. Communication between the healthcare provider and a minority patient can be even more challenging, considering the potential differences in language, education, and culture. Improving patient education is crucial to healthcare communication and can be accomplished through a variety of methods, including visual decision aides and fine-tuning the literacy level of educational material, to most appropriately target the desired patient population. Further steps can be taken with minorities to overcome language barriers such as the use of interpreters, or promotoras in the case of the Latino population. Finally, improving the cultural competence of the healthcare provider could have profound impacts on the treatment of not only BPH but all diseases in minority populations.

A population-based survey of prostate-specific antigen testing among California men at higher risk for prostate carcinoma

BACKGROUND

Despite the lack of evidence demonstrating a survival benefit from prostate-specific antigen (PSA) screening, its use has become widespread, organizations have encouraged physicians to discuss early detection of prostate carcinoma, and two higher risk groups have been recognized. In the current study, the authors examined whether African-American men and men who had a family history of prostate carcinoma underwent PSA testing preferentially, and patterns of test use were examined according to age, race, and other factors.

METHODS

Data regarding self-reported PSA test use in the past year among men age 50 years and older without a history of prostate carcinoma (n = 8713 men) were analyzed from the 2001 California Health Interview Survey.

RESULTS

The overall rate of PSA use was 43.0%. Older age, higher socioeconomic status, having a usual source of healthcare, and a family history of prostate carcinoma were the strongest predictors of testing. Higher risk African-American men age 50 years and older were no more likely to be tested than white men. Men at higher risk who had a family history of prostate carcinoma were more likely to have been tested than men who had no such family history.

CONCLUSIONS

Rates of PSA use among higher risk men who had a family history of prostate carcinoma were higher compared with the rates among men without such a family history. However, PSA testing rates among higher risk African-American men were no different than the rates among lower risk white men, suggesting that some risk factors for prostate carcinoma (but not others) are associated with preferential testing. Testing in all groups was associated with access to care variables, highlighting the importance of removing barriers to preventive healthcare services.

Prostate cancer screening

Prostate cancer is the leading noncutaneous cancer in men of the Western world. Because of its prevalence and ability to cause morbidity and mortality,prostate cancer screening continues to be an important area of focus in health care. This article covers the sensitivity and specificity of prostate-specific antigen and current techniques used to improve the test's validity, the importance of detecting clinically important cancers with screening, as well as the downward stage migration, decreased disease-specific mortality, and decreased metastases rate seen inpatients screened and treated for prostate cancer.

Screening for prostate cancer: current recommendations

Recent studies have questioned the efficacy of PSA as a marker for the early detection of prostate cancer, but techniques are being investigated to improve the sensitivity and specificity of screening. It is hoped that new methods can differentiate between lethal and nonlethal cancers, thereby avoiding lead-time bias. Even with the current limitations of PSA, the combination of stage migration seen with screening, the recent Scandinavian study showing decrease of disease progression following surgical extirpation, and the known mortality in patients presenting with advanced disease help support PSA screening for prostate cancer. It is hoped that prospective, randomized, long-term screening studies, such as the PLCO and ERSCP trials, will show improved survival using the admittedly imperfect PSA marker in prostate cancer screening.

Screening for Prostate Cancer

Prostate cancer is a highly prevalent disease in the Western world. In the United States alone, prostate cancer affects approximately 230,000 men and causes the death of 30,000 American men annually. Several theoretical health care measures may be implemented to decrease the morbidity and mortality of any disease. These measures include prevention, screening, improved curative treatment, and the transformation of an acute lethal disease to a chronic, tolerable one. This summary focuses on the screening aspects of prostate cancer.

Screening decreases prostate cancer mortality: 11-year follow-up of the 1988 Quebec prospective randomized controlled trial

PURPOSE

This clinical trial is aimed at evaluating the impact of prostate cancer screening on cancer-specific mortality.

SUBJECTS AND METHODS

Forty-six thousand four hundred and eighty-six (46,486) men aged 45-80 years registered in the electoral roll of the Quebec city area were randomized in 1988 between screening and no screening. Screening included measurement of serum prostatic specific antigen (PSA) using 3.0 ng/ml as upper limit of normal and digital rectal examination (DRE) at first visit. At follow-up visits, serum PSA only was used.

RESULTS

Seventy-four (74) deaths from prostate cancer occurred in the 14,231 unscreened controls while 10 deaths were observed in the screened group of 7,348 men during the first 11 years following randomization. Median follow-up of screened men was 7.93 years. A Cox proportional hazards model of the age at death from prostate cancer shows a 62% reduction (P < 0.002, Fisher's exact test) of cause-specific mortality in the screened men (P = 0.005). These results are in agreement with the continuous decrease of prostate cancer mortality observed in North America.

WITHDRAWN:Epidemiology of prostate cancer and its precursors

Ahead of Print article withdrawn by publisher.

Human prostate cancer risk factors

Prostate cancer has the highest prevalence of any nonskin cancer in the human body, with similar likelihood of neoplastic foci found within the prostates of men around the world regardless of diet, occupation, lifestyle, or other factors. Essentially all men with circulating androgens will develop microscopic prostate cancer if they live long enough. This review is a contemporary and comprehensive, literature-based analysis of the putative risk factors for human prostate cancer, and the results were presented at a multidisciplinary consensus conference held in Crystal City, Virginia, in the fall of 2002. The objectives were to evaluate known environmental factors and mechanisms of prostatic carcinogenesis and to identify existing data gaps and future research needs. The review is divided into four sections, including 1) epidemiology (endogenous factors [family history, hormones, race, aging and oxidative stress] and exogenous factors [diet, environmental agents, occupation and other factors, including lifestyle factors]); 2) animal and cell culture models for prediction of human risk (rodent models, transgenic models, mouse reconstitution models, severe combined immunodeficiency syndrome mouse models, canine models, xenograft models, and cell culture models); 3) biomarkers in prostate cancer, most of which have been tested only as predictive factors for patient outcome after treatment rather than as risk factors; and 4) genotoxic and nongenotoxic mechanisms of carcinogenesis. The authors conclude that most of the data regarding risk relies, of necessity, on epidemiologic studies, but animal and cell culture models offer promise in confirming some important findings. The current understanding of biomarkers of disease and risk factors is limited. An understanding of the risk factors for prostate cancer has practical importance for public health research and policy, genetic and nutritional education and chemoprevention, and prevention strategies.

FGF8 isoform b expression in human prostate cancer

Overexpression of fibroblast growth factor 8 (FGF8) mRNA has been previously described in prostate cancer. Of its four isoforms, FGF8b is thought to be the most important in carcinogenesis. We hypothesised that immunodetection of FGF8b in archival prostate cancer specimens is of potential prognostic value. Using a selected cohort of prostate tumours from transurethral (n=30) and radical prostatectomies (n=59), an optimised protocol for FGF8b immunoreactivity was used to corroborate expression with clinical parameters. No expression was observed in benign prostates (n=10). In prostate cancer, immunoreactivity was localised to the malignant epithelium with weak signals in the adjacent stroma. Expression of FGF8b in stage T1 and T2 cancers were 40 and 67%, respectively. In contrast, FGF8b expression was present in 94% of T3 and 100% of T4 cancers. By histological grade, FGF8b was found in 41% of low-grade cancers (Gleason score 4-6), 60% of intermediate-grade cancers (Gleason score 7 and 92% of high-grade cancers (Gleason score 8-10). The intensity of expression was significantly associated with stage (P=0.0004) and grade (P<0.0001) of disease. We further hypothesised that FGF8b overexpression resulted from enhanced transcription and translation rather than from abnormalities involving the FGF8 gene locus. This was tested by means of fluorescent in situ hybridisation in 20 cancer specimens to map the FGF8 gene locus. FGF8 gene copy number in benign and malignant nuclei was found to be similar (2.33+/-0.57 and 2.0+/-0.81, respectively P=0.51). Based on these findings, we propose a multicentre study on cohorts of patients to further evaluate FGF8b as a potential prognostic marker in prostate cancer.

Toward a better understanding of the comparatively high prostate cancer incidence rates in Utah

BACKGROUND

This study assesses whether comparatively high prostate cancer incidence rates among white men in Utah represent higher rates among members of the Church of Jesus Christ of Latter-day Saints (LDS or Mormons), who comprise about 70% of the state's male population, and considers the potential influence screening has on these rates.

METHODS

Analyses are based on 14,693 histologically confirmed invasive prostate cancer cases among men aged 50 years and older identified through the Utah Cancer Registry between 1985 and 1999. Cancer records were linked to LDS Church membership records to determine LDS status. Poisson regression was used to derive rate ratios of LDS to nonLDS prostate cancer incidence, adjusted for age, disease stage, calendar time, and incidental detection.

RESULTS

LDS men had a 31% (95% confidence interval, 26%-36%) higher incidence rate of prostate cancer than nonLDS men during the study period. Rates were consistently higher among LDS men over time (118% in 1985-88, 20% in 1989-92, 15% in 1993-1996, and 13% in 1997-99); age (13% in ages 50-59, 48% in ages 60-69, 28% in ages 70-79, and 16% in ages 80 and older); and stage (36% in local/regional and 17% in unstaged). An age- and stage-shift was observed for both LDS and nonLDS men, although more pronounced among LDS men.

CONCLUSIONS

Comparatively high prostate cancer incidence rates among LDS men in Utah are explained, at least in part, by more aggressive screening among these men.

Prostate cancer in Italy before and during the 'PSA era': survival trend and prognostic determinants

The aim of the study was to investigate the variations in prostate cancer prognosis during a period of major diagnostic change, such as the introduction of the prostate-specific antigen (PSA) test. Data were provided by 14 Italian cancer registries (CRs). Incidence and follow-up information was collected for patients diagnosed from 1978 to 1994. Relative survival was computed taking into account incidence period, age, tumour stage and grade at diagnosis. A multivariate analysis was carried out to evaluate the independent simultaneous effect on survival of some prognostic determinants. A large geographical variability was observed: in 1993-1994 Italian survival rates ranged from 76% to 52%, with a north-south gradient. A striking prognostic improvement (up to +27 percentage points) between the late 1980s and the early 1990s occurred in almost all CRs, particularly with regard to younger patients. Multivariate analysis showed a strong influence of incidence period on survival, also after correction by tumour stage. The slowdown of metastatic cancers suggests that the survival improvement could be due both to the introduction of an effective opportunistic screening and to a quantitative change in the application of clinical treatment, even if the effect of the lead-time bias phenomenon has to be taken into account.

Differences in the epidemic rise and decrease of prostate cancer among geographical areas in Southern Europe. an analysis of differential trends in incidence and mortality in France, Italy and Spain

This is a population-based study aimed at evaluating incidence and mortality trends for prostate cancer in France, Italy and Spain, during the prostate-specific antigen (PSA) era, considering elderly people aged 70 years and over and younger adults aged between 40 and 69 years. Trends were estimated by a log-linear Poisson regression model and expressed as an Estimated Annual Percent Change (EAPC). Incidence increased sharply in almost all areas. Spain showed the lowest increases. Incidence started to rise around 1985 in France and after 1990 in Italy and Spain. Mortality increased until the late 1980s in all countries, then declined in France and Italy (-2.5% in 40-69 year age group), but not in Spain. Younger people showed a much higher rise in incidence than the elderly, while mortality decreased mainly in the younger adults. The decrease in mortality was more marked in those areas and the younger age group where the rise in incidence was higher and started earlier, i.e. in France and in younger people, suggesting that the PSA test may have had a positive effect on mortality, although other clinical advances also have to be taken into account.

Modeling the impact of the decline in distant stage disease on prostate carcinoma mortality rates

BACKGROUND

The incidence of distant stage prostate carcinoma was relatively flat until 1991 and then started declining rapidly. This decline probably was caused by the shift to earlier stage disease associated with the rapid dissemination of prostate specific antigen (PSA) screening. Prostate carcinoma mortality rates started falling at approximately the same time. In this article, the authors model the potential impact of this stage shift on prostate carcinoma mortality rates given various assumptions concerning the survival of patients with screen-detected local-regional disease.

METHODS

The authors used the CAN*TROL 2 computer model to shift each deficit in the number of patients with distant stage disease to local-regional stage disease and modeled the implications on mortality using a set of base, optimistic, and pessimistic survival assumptions. A base survival assumes that a patient with screen-detected local-regional disease of a certain histologic grade has the same prognosis as a patient with clinically detected local-regional disease of same grade (i.e., an assumption of no length bias for patients with screen-detected disease), whereas the optimistic and pessimistic scenarios assume that survival is better or worse, respectively, than the base survival (i.e., complete cure for patients with favorable grade for the optimistic scenario and no improvements in survival for patients with unfavorable grade for the pessimistic scenario).

RESULTS

Model results were compared with observed mortality trends. Rising age-adjusted mortality rates peaked in 1991 for white males and in 1993 for black males and then fell 21% and 13% for white males and black males, respectively, from 1990 through 1999. Under the modeled stage-shift intervention, mortality rates would fall 18%, 8%, and 19% for both white males and black males under the base, pessimistic, and optimistic assumptions, respectively.

CONCLUSIONS

It is impossible to know what the mortality trends would have been in the absence of the introduction of PSA screening. However, under the base assumption, it appears that the decline in distant stage disease can have a fairly sizable and rapid impact on population mortality. The optimistic scenario is not much improved over the base scenario, which is indicative of the facts that the survival of patients diagnosed with clinical local-regional prostate carcinoma is quite good and that further survival improvements can have only a marginal impact. Under the pessimistic scenario, it appears that something else must be responsible for much of the decline in mortality. Screening trial results from the United States and Europe may verify and isolate the size of any mortality benefit associated with PSA screening. Trial results eventually can be put back into these population models to help quantify the impact of screening, treatment, and other factors on population trends.

Regulation of FGF8 expression by the androgen receptor in human prostate cancer

Fibroblast growth factor 8 (FGF8) has been shown to play a key role in prostate carcinogenesis. It was initially cloned as an androgen induced protein in mouse mammary cancer SC3 cells. In this study, we examined if FGF8 was also regulated by the androgen receptor in human prostate cancer. FGF8b protein expression in resected clinical prostate cancer correlated closely with expression of the androgen receptor (AR). In the androgen sensitive CWR22 prostate xenograft, we observed up-regulation of FGF8b immunoreactivity in testosterone supplemented mice while castration markedly reduced its signal. Furthermore, FGF8b protein expression in AR positive LNCaP cells was similarly enhanced by androgens. The proximal promoter of the human FGF8 gene was cloned into a luciferase reporter construct (FGF8.luc). FGF8.luc activity in AR positive LNCaP and SC3 cells was increased 2.5-fold by androgens. In AR negative DU145 cells, maximal induction of FGF8.luc required both co-transfection of the AR and the presence of androgens. The anti-androgen bicalutamide completely abolished AR mediated FGF8.luc induction. Deletion constructs from FGF8.luc have further defined an active promoter region and an androgen responsive region. Nucleotide analysis of this androgen responsive region has revealed putative androgen response elements. Finally, using ChIP assays we confirmed in vivo interaction between the AR and the androgen responsive region of the FGF8 promoter. Taken together these data provide first evidence that expression of the mitogen FGF8 in prostate cancer is, at least in part, regulated by the androgen receptor at the transcriptional level.

Molecular characterization of canine prostaglandin G/H synthase-2 and regulation in prostatic adenocarcinoma cells in vitro

Induction of PG G/H synthase-2 (PGHS-2), a key rate-limiting enzyme in the PG biosynthetic pathway, has been implicated in prostatic adenocarcinomas in humans and dogs in vivo, but the molecular control of PGHS-2 expression in prostate cancer remains poorly understood. Using the dog model, the specific objectives of this study were to clone and characterize canine PGHS-2, and to study the regulation of its transcript, protein, and activity in a canine prostatic adenocarcinoma (CPA) cell line in vitro. The canine PGHS-2 cDNA was cloned by a combination of cDNA library screening and 5'-rapid amplification of cDNA ends, and shown to contain a 5'-untranslated region of 28 bp, an open reading frame of 1815 bp, and a 3'-untranslated region of 1655 bp. The open reading frame encodes a 604-amino acid protein that is 89% identical to the human homolog. The regulation of PGHS-2 protein and PGE(2) synthesis was studied in CPA cells cultured in the absence or presence of graded doses of phorbol 12-myristate 13-acetate (PMA), TNFalpha, and lipopolysaccharides. Results from immunoblots, immunocytochemistry, and RIAs showed that PGHS-2 protein and PGE(2) were present at low levels in control cells and were significantly induced after agonist treatment (P < 0.05), with PMA being the strongest inducer. Northern blot analyses also revealed a significant increase of PGHS-2 mRNA by PMA, TNFalpha, and lipopolysaccharides treatment (P < 0.05). Agonist-dependent induction of PGHS-2 mRNA was not dependent on new protein synthesis (coincubation with cycloheximide; 10 microg/ml) but was blocked by transcription inhibitor actinomycin D (5 microg/ml), suggesting that PGHS-2 acts an immediate early-response gene in prostatic epithelial cells. Thus, this study characterizes for the first time the structure of canine PGHS-2 and provides an in vitro model to unravel the molecular basis of PGHS-2 expression in prostatic adenocarcinomas.

Changing face and different countenances of prostate cancer: racial and geographic differences in prostate-specific antigen (PSA), stage, and grade trends in the PSA era

The purpose of this investigation was to examine changes in pretreatment prostate-specific antigen (PSA), stage, and grade over the past decade as a function of race and geographic region. A multiinstitutional database representing 6,790 patients (1,417 African-American, 5,373 white) diagnosed with nonmetastatic prostate cancer between 1988 and 1997 was constructed. PSA, stage, and grade data were tabulated by calendar year and region, and time trend analyses based on race and region were performed. There was an overall decline of PSA of 0.8%/year, which was significant (P = 0.0001), with a faster rate of decline in African-Americans (1.9%/year) than for whites (0.6%/year). The odds ratio (OR) for a stage shift was 1.09, which was significant (P < 0.0001), and this shift was greater in whites. The OR for an overall grade shift was 1.15, which was significant (P < 0.0001). Although grade and PSA trends were similar for the different regions, there were significant regional differences in stage trends. The implications are that the face of prostate cancer has changed over the past decade; i.e., the distributions of stage, grade, and PSA (the most important prognosticators) have changed. In addition, the countenances of that face are different for whites and African-Americans. For African-Americans, this is good news: the stage, grade, and PSA distributions are more favorable now than before. For whites, the trends are more complex and more dependent on region. These findings should be used for future clinical and health-policy decisions in the screening and treatment of prostate cancer.

Demographics and health-related factors of men receiving prostate-specific antigen screening in Utah

BACKGROUND

Identifying who is pursuing prostate-specific antigen (PSA) screening for prostate cancer is prerequisite to effectively influencing participation in PSA screening and educating people about potential screening implications and personal risk. This paper describes the relationship between select demographic and health-related factors with PSA screening.

METHODS

Analysis was based on 1,293 men age 40 years or older who responded to a cross-sectional random telephone survey involving 12 health districts in the state of Utah from June 1 to August 31, 1996. Independent variables were current age, race, marital status, education, household income, medical insurance, level of physical activity, intake of fruits and vegetables, receipt of psychiatric help, religious preference, church attendance, general health status, and employment.

RESULTS

Forty-eight percent of respondents reported having had a PSA in the past year. PSA screening in the previous year significantly increased and leveled off with age: 23.9% for ages 40-49, 51.4% for ages 50-59, 67.4% for ages 60-69, and 67.0% for ages 70+. After adjusting for age, only marital status and medical insurance were significantly related to PSA screening, with medical insurance having the largest effect. Approximately 50.6% married men and 33.5% unmarried men had a PSA in the past year. Percentages for insured and uninsured men were 49.4 and 16.6%, respectively.

CONCLUSION

A substantial portion of elderly men, particularly those who are married and medically insured, have had a PSA test in the past year. This information makes it possible to more effectively influence participation in PSA screening and educate people about potential screening implications and personal risk.

Cancer survival increases in Europe, but international differences remain wide

The EUROCARE project analysed cancer survival data from 45 population-based cancer registries in 17 European countries, revealing wide international differences in cancer survival. We calculated 5-year relative survival for 1836287 patients diagnosed with one of 13 cancers during the period 1978-1989. The data, from 20 cancer registries in 13 countries, were grouped into four regions: Finland, Sweden, Iceland (Northern Europe); Denmark, England and Scotland (UK and Denmark); France, The Netherlands, Germany, Italy and Switzerland (Western Europe); Estonia and Poland (Eastern Europe), and broken down into four periods (1978-1980, 1981-1983, 1984-1986, 1987-1989). For each cancer, mean European and regional survival was estimated as the weighted mean of 5-year relative survival in each country. Survival increased with time for all tumours, particularly for cancers of testis (12% increase, i.e. from 79.9 to 91.9%), breast, large bowel, skin melanoma (approximately 9-10%), and lymphomas (approximately 7%). For most solid tumours, survival was highest in Northern Europe and lowest in Eastern Europe, and also low in the UK and Denmark. Regional variation was less marked for the lymphomas. Survival improved more in Western than Northern Europe, and the differences between these regions fell for bowel cancer (from 8.0% for those diagnosed in 1978-1980 to 2% for those diagnosed in 1987-1989), breast cancer (from 7.4% to 3.9%), skin melanoma (from 13.4% to 11.0%) and Hodgkin's disease (from 7.2 to 0.6%). For potentially curable malignancies such as Hodgkin's disease, large bowel, breast and testicular cancers, there were substantial increases in survival, suggesting an earlier diagnosis and more effective treatment. The persisting regional differences suggest there are corresponding differences in the availability of diagnostic and therapeutic facilities, and in the effectiveness of healthcare systems.

Comparative studies of prostate cancer in Japan versus the United States. A review

This article reviews the available data on prostate cancer in Japan compared with that in the United States, with emphasis on epidemiologic, pathologic, and molecular aspects. Previous studies have demonstrated ethnic/racial differences in the incidence of prostate cancer between the two countries. Recent investigations indicate that different genetic alterations or polymorphisms are related to carcinogenesis in the prostate. Comparative geographic-pathologic autopsy studies suggest that different promoting factors including genetic, epigenetic, and environmental influences may be responsible for ethnic variations in the postinduction progression of prostate cancer.

Evaluation of prostatic specific antigen and digital rectal examination as screening tests for prostate cancer

BACKGROUND

The 11,811 first visits and 46,751 annual follow-up visits performed since 1988 were analyzed in order to assess the efficacy of serum prostatic specific antigen (PSA) and digital rectal examination (DRE) for diagnosis of prostate cancer.

METHODS

At first visit, screening included DRE and measurement of PSA using 3.0 ng/ml as upper limit of normal, demonstrated as optimal value in the course of the study. Transrectal echography of the prostate (TRUS) was performed only if PSA and/or DRE was abnormal. For elevated PSA, biopsy was performed only if PSA was above the value predicted from prostatic volume measured by TRUS. At follow-up visits, it was decided during the course of the study to use PSA alone.

RESULTS

PSA was above 3.0 ng/ml in 16.6% and 15.6% of men at first and follow-up visits, respectively. Prostate cancer was found in 2.9% of men invited for screening at first visit and in only 0.4% of men at follow-up visits for a 7.1-fold decrease at follow-up visits done up to 11 years. PSA alone allowed to find 90.5% and 90. 0% of cancers at first and follow-up visits, respectively, compared to 41.1% and 25.0% by DRE alone. In the presence of normal PSA, 344 and 1,919 DREs are needed to find one prostate cancer at first and follow-up visits, respectively. A significant improvement in stage of the disease is found at follow-up (215 cancers) compared to first visits (337 cancers). Comparison made between men invited for screening and those who were not invited but screened showed no significant difference in terms of incidence and prevalence of prostate cancer as well as diagnosis of cancer as a function of age or as a function of PSA, DRE, and TRUS data. The cost for finding one case of prostate cancer is estimated at Can $2,420 and Can $7, 105 (first and follow-up visits, respectively, when PSA is used as prescreening).

CONCLUSIONS

PSA used as prescreening and followed by DRE and TRUS when PSA is abnormal is highly efficient in detecting prostate cancer at a localized (potentially curable) stage since 99% of the cancers diagnosed were at such a localized stage, thus practically eliminating the diagnosis of metastatic and noncurable prostate cancer. The approach used is highly reliable, sensitive, efficient, and acceptable by the general population. The detection of clinically nonsignificant cancer is an exception.

Prostate cancer incidence and mortality trends among elderly and adult Europeans

Prostate cancer is a common malignancy primarily of elderly men, with incidence rates rapidly increasing, owing to the population ageing and the introduction of more sensitive diagnostic procedures. Although the effectiveness of a screening test remains controversial, the decreasing mortality rates, which recently emerged in the USA, may be partly attributable to the changes of patterns of care, thus suggesting a potential effect of preventive measure. The object of this study is to examine time trends in incidence and mortality from prostate cancer in European Union (EU) countries, with particular attention to possible differences between the elderly (65 years old or over) and younger or middle age adults (35-64 years old). EUROCIM, the data base created by the European Network of Cancer Registries, provided the incidence and mortality data for the 12 EU Countries analysed (namely: Finland, Denmark, Scotland, England and Wales, Ireland and The Netherlands in Northern Europe; Austria, Germany and France in Central Europe; Italy, Spain and Portugal in Southern Europe), for the 1978-1994 period. Incidence and mortality time trends, expressed as mean difference per cent (MD%) per year, were estimated by a Poisson log-linear regression model. Higher resolution analyses were also carried out to check differences in time trends by age class within the two groups under study. Upward mortality trends occurred in several countries, excepting Ireland, Austria and Southern Europe, but only for younger and middle aged adults. Rates increased more rapidly in older age groups; a clear north-south gradient appeared both in the elderly and in younger adults; for the elderly, MD% higher than +1.5 for most countries of Northern Europe, MD% around +1 for Central Europe, and MD% less than +1 for Southern Europe were registered, with lower values for younger people. Incidence rates rose across the period considered, almost in all countries both for elderly and for younger and middle age adults, increasing more rapidly in younger age. Incidence trends showed a less clear geographic pattern than for mortality. In the younger group, high MD%, ranging in Northern Europe from +3.2 in Finland and England and Wales to +5.7 in The Netherlands, were observed, while in the South values ranged between +4.2 and +5.0. In Central Europe, very high MD%, ranging between +8.4 in France and +16.6 in Austria, were noted. No significant trends were observed for Denmark, Ireland and Portugal. For the elderly the increase was generally lower and no significant trend was observed in Germany and Portugal. Interaction between age and calendar period in the older group was observed for most of the considered countries. With reference to mortality, the MD% showed a tendency to rise, with increasing age, while no consistent pattern emerged for incidence. The observed incidence trends are probably a consequence of the different times in which the more recent detection methods were introduced in each country, and of the different policies adopted by each health care system towards the elderly. A comparison with the USA data suggests that in the next future a favourable downward mortality trend could be expected also in some EU Countries and, particularly, for younger age groups, even though prostatic cancer in old patients will remain a great burden, which National Health Care Systems will have to face in the next decades.

Radical prostatectomy: geographic and demographic variation

OBJECTIVES

Previous reports have documented a geographic variation in the use of radical prostatectomy. We examined whether this phenomenon can be explained by factors other than geography alone.

METHODS

This study was based on the data from nine geographic regions of the Surveillance, Epidemiology, and End Results (SEER) program for the years 1983 through 1994. Patients with localized or regional prostate cancer were included in the analysis. Logistic regression analysis was used to investigate the influence of geographic and demographic factors on the use of radical prostatectomy. The squared multiple correlation coefficient R(2) was used to measure the proportion of variation in the selection of radical prostatectomy explained by each factor of interest.

RESULTS

As previously reported, the use of radical prostatectomy was significantly associated with geographic location; the degree of geographic variation varied as a function of age and was most dramatic in the youngest (younger than 45 years) and the oldest (75 years or older) groups. Overall, however, geography explained less than 2% of the total variation in the use of radical prostatectomy. Age was the most important factor that influenced the use of radical prostatectomy.

CONCLUSIONS

Geography explains only a small proportion of the variation in the use of radical prostatectomy. In fact, of the factors examined, only age appeared to meaningfully explain the variation in the use of radical prostatectomy. Overall, our ability to explain the variation in the use of radical prostatectomy remains meager, and new factors must be identified if we are to better understand how patients and physicians make clinical decisions.

Explaining the difference in prostate cancer mortality rates between white and black men in the United States

OBJECTIVES

Black men have a twofold increased risk of dying of prostate cancer compared to white men. We assessed the extent to which differences in stage and grade at diagnosis, age, multiple primary cancers, and the first course of cancer-directed therapy influence the likelihood of prostate cancer death among diagnosed cases.

METHODS

Incidence-based mortality (IBM) is a method that involves tracking disease cases from diagnosis to death, such that the mortality event is linked to factors identified with the disease at the time of diagnosis (eg, tumor stage and grade). We applied the IBM method to prostate cancer data from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute.

RESULTS

Of men diagnosed with prostate cancer, blacks have a significantly greater chance of dying from the disease than do whites. However, once adjustment has been made for stage and grade at diagnosis, age, number of primary cancers, and initial treatment, no difference in the likelihood of prostate cancer mortality between the two races was found. Differences in stage and grade at diagnosis, age, number of primary cancers, and initial treatment each contributed significantly to the greater chance of dying of prostate cancer for black men than for white men.

CONCLUSIONS

The results of IBM analysis suggest that black men do not have a statistically greater chance of prostate cancer mortality than white men after adjusting for differences in stage and grade, age, number of primary cancers, and treatment. Later stage at diagnosis is the primary reason for the higher likelihood of prostate cancer mortality among black men compared to white men.

Trends in the curative treatment of localized prostate cancer after the introduction of prostate-specific antigen: data from the Rotterdam Cancer Registry

OBJECTIVE

To investigate changes in the incidence and treatment of prostate cancer over the period in which new diagnostic tools were introduced and the attitude towards treatment was changing.

PATIENTS AND METHODS

Information on the extent of disease and treatment of patients diagnosed with prostate cancer within the Rotterdam region was retrieved from the Rotterdam Cancer Registry.

RESULTS

In the period 1989-95, 4344 patients were diagnosed with prostate cancer and the age-standardized incidence increased from 62 to 125 per 100 000 men. This increase mainly comprised tumours localized to the prostate, while the incidence of advanced cancers remained stable. The proportion of poorly differentiated tumours decreased from 33% in 1989 to 24% in 1995. In the same period the number of patients receiving radiotherapy increased from 80 to 258, while the annual number of radical prostatectomies rose from 17 to 159. Radiotherapy was the preferred type of treatment in patients over 70 years of age, whereas radical prostatectomy was used more frequently in younger patients with localized tumours.

CONCLUSION

While the value of screening for prostate cancer remains in debate, incidence and treatment patterns are changing rapidly. Information on patterns of care is needed to interpret future mortality data and to plan resources for adequate health care.

Cancer incidence trends in urban shanghai, 1972-1994: an update

Incidence rates for a number of cancers in urban Shanghai, China, have been changing markedly. Herein we update the trends using population-based data from the Shanghai Cancer Registry for 1972-1994. During 1993-1994, cancers of the lung, stomach, and liver were the 3 leading forms among men, with age-adjusted (world standard) incidence rates of 50.9, 39.2, and 26.5 per 100,000 person-years, respectively, followed by cancers of the colon (12.4) and esophagus (10.0). Among women, cancers of the breast (27.5), stomach (19.1), and lung (17.7) were the most common tumors, followed by cancers of the colon (11.3) and liver (9.4). Over the 23-year period, the rate for all cancers combined, excluding non-melanoma skin cancer, decreased from 247.5 to 215.2 among men and from 173.6 to 154.0 among women. However, trends for individual forms of cancer varied considerably. Rates doubled for cancers of the colon and biliary tract in both sexes, and they increased substantially for cancers of the brain and nervous system, kidney, pancreas, prostate, corpus uteri, female breast, and ovary, and for non-Hodgkin's lymphoma. Rates for cancers of the lung and rectum changed little. Rates declined by at least one-half for cancers of the esophagus and cervix, with notable decreases also for cancers of the stomach and liver. Some of these trends may reflect variations in diagnostic or screening practices, although changes in lifestyle and other environmental exposures are likely to play important roles. Further epidemiologic research in China is needed to identify risk factors influencing the cancer incidence trends.

Quality of life in low-income patients with metastatic prostate cancer: divergent and convergent validity of three instruments

Few studies have evaluated Quality Of Life (QOL) among low-income patients with cancer. Information is needed about the feasibility and psychometric characteristics of QOL instruments in these populations. The purpose of this study was to examine the convergent and discriminant relationships between scales of three QOL instruments: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC), Functional Assessment of Cancer Therapy--General (FACT), and Quality of Life Index (QLI). Participants included 110 men with metastatic prostate cancer of whom 94% were low income and 62% were African-American. Interviewers administered the questionnaires. Cronbach alpha internal consistency reliabilities were 0.57 to 0.90 for the EORTC, 0.65 to 0.86 for the FACT, and 0.63 for the QLI. Convergent validity was supported for the EORTC and FACT scales measuring emotional, physical, and role/functional dimensions (r = 0.54 to 0.72), but not on scales measuring social function (r = 0.12). Divergent validity was supported between dissimilar scales (r = 0.14 to 0.38). Analysis with receiver operating characteristics curves provided empirical support for the EORTC and FACT as multidimensional measures. These findings suggest that, even in busy clinical settings with low literacy patients, interviewer-administered EORTC and FACT QOL instruments can provide valid and reliable information.

Cancer surveillance series: interpreting trends in prostate cancer--part I: Evidence of the effects of screening in recent prostate cancer incidence, mortality, and survival rates

BACKGROUND

The prostate-specific antigen test was approved by the U.S. Food and Drug Administration in 1986 to monitor the disease status in patients with prostate cancer and, in 1994, to aid in prostate cancer detection. However, after 1986, the test was performed on many men who had not been previously diagnosed with prostate cancer, apparently resulting in the diagnosis of a substantial number of early tumors. Our purpose is to provide insight into the effect of screening on prostate cancer rates. Detailed data are presented for whites because the size of the population allows for calculating statistically reliable rates; however, similar overall trends are seen for African-Americans and other races.

METHODS

Prostate cancer incidence data from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program and mortality data from the National Center for Health Statistics were analyzed.

RESULTS/CONCLUSIONS

The following findings are consistent with a screening effect: 1) the recent decrease since 1991 in the incidence of distant stage disease, after not having been perturbed by screening; 2) the decline in the incidence of earlier stage disease beginning the following year (i.e., 1992); 3) the recent increases and decreases in prostate cancer incidence and mortality by age that appear to indicate a calendar period effect; and 4) trends in the incidence of distant stage disease by tumor grade and trends in the survival of patients with distant stage disease by calendar year that provide suggestive evidence of the tendency of screening to detect slower growing tumors.

IMPLICATIONS

The decline in the incidence of distant stage disease holds the promise that testing for prostate-specific antigen may lead to a sustained decline in prostate cancer mortality. However, population data are complex, and it is difficult to confidently attribute relatively small changes in mortality to any one cause.

Trends in prostatectomy for benign prostatic hyperplasia among black and white men in the United States: 1980 to 1994

OBJECTIVES

To estimate the annual rate of discharge for prostatectomy for benign prostatic hyperplasia (BPH) in black and white men from 1980 to 1994 using the National Hospital Discharge Survey.

METHODS

Overall and race-, age-, and year-specific utilization rates were estimated for the civilian population in the United States. Length of stay was calculated for each discharge, and the results were plotted over time. An expected number of discharges based on the rates observed in 1980 was estimated to determine the impact of decreased prostatectomy rates on the number of procedures that would have been expected in this aging population.

RESULTS

Discharge rates for whites were within a narrow range (233.2 to 274.5 per 100,000) from 1980 through 1990 and then displayed a monotonic decline after 1991 to 131.3 per 100,000 in 1994. Rates for blacks were 10% to 24% lower from 1980 to 1991; the decline in discharge rates began in 1993 for blacks, and by 1994 the racial gap had closed. Length of stay decreased throughout the period but length of stay averaged 30% longer for blacks throughout. On the basis of the observed rates of 1980, there were more than 140,000 fewer prostatectomies performed for BPH in 1994 than would have been expected owing to the aging of the population.

CONCLUSIONS

These data demonstrate that the black/white differences in prostatectomy for BPH that were observed in the 1980s have disappeared in recent years. Furthermore, rates have declined dramatically in all age- and race-specific groups. Further work is needed to determine whether this convergence in discharge rates is due to equalization of access to medical care or to differences in utilization of alternative therapies.

Comparison of risk estimates for selected diseases and causes of death

BACKGROUND

Lifetime risk estimates of disease are limited by long-term data extrapolations and are less relevant to individuals who have already lived a period of time without the disease, but are approaching the age at which the disease risk becomes common. In contrast, short-term age-conditional risk estimates, such as the risk of developing a disease in the next 10 years among those alive and free of the disease at a given age, are less restricted by long-term extrapolation of current rates and can present patients with risk information tailored to their age. This study focuses on short-term age-conditional risk estimates for a broad set of important chronic diseases and nondisease causes of death among white and black men and women.

METHODS

The Feuer et al. (1993, Journal of the National Cancer Institute) [15] method was applied to data from a variety of sources to obtain risk estimates for select cancers, myocardial infarction, diabetes mellitus, multiple sclerosis, Alzheimer's, and death from motor vehicle accidents, homicide or legal intervention, and suicide.

RESULTS

Acute deaths from suicide, homicide or legal intervention, and fatal motor vehicle accidents dominate the risk picture for persons in their 20s, with only diabetes mellitus and end-stage renal disease therapy (for blacks only) having similar levels of risk in this age range. Late in life, cancer, acute myocardial infarction, Alzheimer's, and stroke become most common. The chronic diseases affecting the population later in life present the most likely diseases someone will face. Several interesting differences in disease and death risks were derived and reported among age-specific race and gender subgroups of the population.

CONCLUSION

Presentation of risk estimates for a broad set of chronic diseases and nondisease causes of death within short-term age ranges among population subgroups provides tailored information that may lead to better educated prevention, screening, and control behaviors and more efficient allocation of health resources.

Trends and black/white differences in treatment for nonmetastatic prostate cancer

OBJECTIVES

Controversy and uncertainty surround use of radical prostatectomy, radiation therapy, and conservative symptomatic management in treating elderly men with nonmetastatic prostate cancer. Prior studies have demonstrated variations in use of these therapies by patient age, race, and geographic region. This study examined trends in treatment for nonmetastatic prostate cancer in black and white men aged 65 and older during the period 1986 to 1993. The study also explored factors related to use of initial therapies in these men.

METHODS

A cohort of 52,915 men (48,410 white; 4,505 black) obtained from the linked SEER-Medicare dataset was used in an observational design. Various sociodemographic and clinical measures were incorporated in the analysis.

RESULTS

For both races, use of aggressive therapy had increased with time, although this trend appears to be slowing. Black men were less likely to undergo radical prostatectomy than were white men, but use of radiation therapy did not differ markedly by race. High socioeconomic status and a lack of comorbid conditions were among the factors predictive of aggressive therapy receipt. The relation between race and receipt of aggressive therapy was dependent on whether prostate cancer was detected by transurethral resection of the prostate. Sociodemographic and clinical characteristics explained approximately half the difference between black men and white men in radical prostatectomy use.

CONCLUSIONS

This study documents racial differences and changing practice patterns in the treatment of nonmetastatic prostate cancer in elderly men. Further research is required to more fully understand reasons for racial differences, as well as to promote rational use of health care resources.

Prostate-specific antigen testing in Australia and association with prostate cancer incidence in New South Wales

OBJECTIVE

To describe patterns and trends in prostate-specific antigen (PSA) testing in Australia and assess its role in the increasing incidence of prostate cancer.

DESIGN

Descriptive analysis of (i) Medicare records of PSA testing in Australia, and (ii) prostate cancer recorded incidence in New South Wales.

DATA

(i) Medicare data for all males who received a Medicare-reimbursed PSA test between August 1989 and December 1996. (ii) NSW Central Cancer Registry data for all males in NSW with prostate cancer diagnosed between 1988 and 1995.

MAIN OUTCOME MEASURES

(i) Number of PSA tests, age-standardised rates of PSA tests by State and Territory, and proportions of males who had a PSA test. (ii) Recorded incidence of prostate cancer in NSW.

RESULTS

(i) More than 2.2 million PSA tests were done on more than 1.1 million Australians between 1989 and 1996. The annual number of males tested increased fivefold in this period and peaked in 1995. Twenty-seven per cent of Australian men aged 50 years or over had at least one PSA test in 1995 or 1996; 33% of men aged 60-69 years had a test in this period. (ii) In NSW the number of PSA tests per quarter was highly correlated with the number of new cases of prostate cancer (R2 = 0.92).

CONCLUSIONS

Although no organised program for prostate cancer screening exists, and despite repeated advice against it, opportunistic screening has been occurring at high rates. There was a high correlation between PSA testing and prostate cancer incidence between 1990 and 1995 in NSW.

Population-based prostate cancer trends in the United States: patterns of change in the era of prostate-specific antigen

We reviewed prostate cancer trends prior to and during the prostate-specific antigen (PSA) era using data reported from population-based tumor registries in the United States. On the basis of a summary of reports from several population-based tumor registries, prostate cancer incidence rose abruptly during the PSA era, peaked in 1992, and then fell just as abruptly. Prostate cancer incidence in the United States now appears to be approaching levels seen in the pre-PSA era. The flux in prostate cancer incidence (in both magnitude and slope) during the years 1988-1995 is without precedent in oncology. As expected, an age and stage migration toward early age and early stage has been observed. Unexpectedly, grade has shifted heavily toward moderate differentiation, whereas rates of poorly and well-differentiated disease have remained relatively stable. Local treatment rates, particularly radical prostatectomy rates, have risen substantially. Mortality rates appear to have leveled or declined slightly since 1991 after years of steady rise.

Incidence, mortality and survival from prostate cancer in Vaud and Neuchâtel, Switzerland, 1974-1994

BACKGROUND

Prostate cancer incidence has been increasing in most developed countries in the absence of similar trends in mortality, and with variable patterns in different areas of the world.

MATERIALS AND METHODS

Trends in incidence and mortality from prostate cancer for the period 1974-1994 were analysed using data from the Cancer Registries of the Swiss Cantons of Vaud and Neuchâtel. Of 5,010 cases registered, 80% were histologically or cytologically confirmed.

RESULTS

Age-standardized incidence rates increased from 33.1 to 48.6 per 100,000 (+47%). The upward trends were greater in the most recent calendar periods, and in the younger age groups (+77% at age 45 to 54; +57% at age 55 to 64). In contrast, mortality was stable, with an overall increase of only 3% in age-standardized rates (from 20.4 to 21.0 per 100,000), due to some increase in men aged 65 or above. Consequently, the incidence/mortality rate ratios increased from 1.6 in 1974-1979 to 2.3 in 1990-1994. Five-year observed and relative survivals increased from 26% to 41% and from 46% to 58%, respectively. Ten-year observed and relative survival for cases diagnosed in 1985-1989 were 19% and 42%, respectively. Survival improvements were greater below age 75.

CONCLUSION

The pattern of trends in incidence, mortality and survival confirms the influence of improved diagnosis of prostate cancer over the last few years in this European population. Still, while Swiss prostatic cancer mortality rates are the highest in the world (20.3 per 100,000, world standard), i.e., about 30% higher than in the United States, all races combined, incidence rates are still half as much. On account of the steady increase of prostate-specific antigen testing in Switzerland, further incidence increases are likely.

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.