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Trends in Prostate Specific Antigen (PSA) testing and prostate cancer incidence and mortality in Australia: A critical analysis. Cancer Epidemiol 2022; 77:102093. [PMID: 35026706 DOI: 10.1016/j.canep.2021.102093] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Population trends in PSA testing and prostate cancer incidence do not perfectly correspond. We aimed to better understand relationships between trends in PSA testing, prostate cancer incidence and mortality in Australia and factors that influence them. METHODS We calculated and described standardised time trends in PSA tests, prostate biopsies, treatment of benign prostatic hypertrophy (BPH) and prostate cancer incidence and mortality in Australia in men aged 45-74, 75-84, and 85 + years. RESULTS PSA testing increased from its introduction in 1989 to a peak in 2008 before declining in men aged 45-84 years. Prostate biopsies and cancer incidence fell from 1995 to 2000 in parallel with decrease in trans-urethral resections of the prostate (TURP) and, latterly, changes in pharmaceutical management of BPH. After 2000, changes in biopsies and incidence paralleled changes in PSA screening in men 45-84 years, while in men ≥85 years biopsy rates stabilised, and incidence fell. Prostate cancer mortality in men aged 45-74 years remained low throughout. Mortality in men 75-84 years gradually increased until mid 1990s, then gradually decreased. Mortality in men ≥ 85 years increased until mid 1990s, then stabilised. CONCLUSION Age specific prostate cancer incidence largely mirrors PSA testing rates. Most deviation from this pattern may be explained by less use of TURP in management of BPH and consequent less incidental cancer detection in TURP tissue specimens. Mortality from prostate cancer initially rose and then fell below what it was when PSA testing began. Its initial rise and fall may be explained by a possible initial tendency to over-attribute deaths of uncertain cause in older men with a diagnosis of prostate cancer to prostate cancer. Decreases in mortality rates were many fold smaller than the increases in incidence, suggesting substantial overdiagnosis of prostate cancer after introduction of PSA testing.
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Aronowitz R. Prostate Cancer: People Transforming A Diagnosis, A Diagnosis Transforming People. SCIENCE TECHNOLOGY AND SOCIETY 2021. [DOI: 10.1177/0971721820960254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Prostatic specific antigen (PSA) screening has been controversial since its inception. Controversy has persisted despite more and higher quality clinical evidence. Attention to lead and length time biases, overdiagnosis, overtreatment, medicalisation, iatrogenesis and financial conflict of interest has had limited impact. I undertook a social history of the prostate cancer diagnosis to reassess the causes of controversy and suggest different clinical and policy responses. For much of the twentieth century, clinicians were uninterested in early detection and radical treatment, believing that cancers revealed after obstruction-relieving surgery or autopsy could be ignored. In 1985, the FDA approved PSA diagnostic tests, which rapidly catalysed two self-reinforcing cycles of action and perception. One occurred when the increased diagnoses made the disease more prevalent and feared, and efforts at prevention and treatment seem more efficacious, leading to more screening, and so on. The other cycle occurred among men with screening detected cancer who initially eschewed radical treatments or imagined doing so, whose lives were often consumed with fear and surveillance, increasing demand for radical cures. This history underscores the need for novel clinical and policy responses to the looping effects—self-reinforcing cycles of action and perception—which can radically transform so much of what we believe and do about disease.
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Klotz L. Overdiagnosis in urologic cancer : For World Journal of Urology Symposium on active surveillance in prostate and renal cancer. World J Urol 2021; 40:1-8. [PMID: 33492425 DOI: 10.1007/s00345-020-03523-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 11/09/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Cancer, which historically was diagnosed at late and incurable stages, has expanded to a heterogeneous group of conditions that vary from clinically insignificant to rapidly aggressive and lethal. This evolution is due to the widespread use of screening tests for early detection of cancer, both directed (i.e., PSA, mammography, colonoscopy) and undirected (abdominal imaging). The use of these tests has resulted in both benefits and harms. The benefits are a reduction in survival and mortality, due to significant cancers being diagnosed at a more curable stage. The harms are an increase, in some cases dramatic, in the diagnosis of clinically insignificant disease. These are called 'cancer' but not destined to affect the patient's life, even in the absence of treatment. METHODS Non-explicit summary of the literature on overdiagnosis of cancer. RESULTS The phenomenon of overdiagnosis requires two factors: the presence of a common reservoir of microfocal disease and a screening test to find it. These factors exist for breast, prostate, skin, renal, and thyroid cancers, and to a lesser degree for lung cancer. The problem of cancer overdiagnosis and overtreatment is complex, with numerous etiologies and many tradeoffs. It is a particular problem in prostate cancer but is a major issue in many other cancer sites. Screening for prostate cancer based on the best data from prospective randomized trials significantly reduces cancer mortality. However, reducing overtreatment in patients diagnosed with indolent disease is critical to the success of screening. CONCLUSION Active surveillance, the focus of this series of articles, is an important strategy to reduce overtreatment. This article reviews the pathological, clinical, social, and psychological aspects of overdiagnosis in cancer.
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Affiliation(s)
- Laurence Klotz
- Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave. #MG408, Toronto, ON, M4N 3M5, Canada.
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Cayuela L, Lendínez-Cano G, Chávez-Conde M, Rodríguez-Domínguez S, Cayuela A. Recent trends in prostate cancer in Spain. Actas Urol Esp 2020; 44:483-488. [PMID: 32600879 DOI: 10.1016/j.acuro.2020.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/04/2020] [Accepted: 05/07/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To assess recent trends in prostate cancer incidence, survival and mortality in Spain using updated data. SUBJECTS AND METHOD Prostate cancer mortality data have been obtained from the National Institute of Statistics (INE). Incidence cases have been obtained from the databases Cancer Incidence in Five Continents (CI5) and European Cancer Information System. Joinpoint regression models were used for trend analysis. The results show the duration (years) of each trend, as well as the Annual Percent Change (APC) for each of them. The direction and magnitude of recent trends (last 5 years available) were evaluated using the percentages of Average Annual Percent Change (AAPC). RESULTS Incidence rates increased significantly from 16.4 in 1980 to 61.3 in 2014. The joinpoint analysis shows three periods: two initial periods of significant rise (1980-1990; 3.5% and 1990-2004; 8.4%) followed by a final one in which rates stabilize (2004-2014; -0.5%, non-significant). Mortality rates drop from 12.9 in 1980 to 7.9 in 2018, with an AAPC of -1.2% (p<0.05). However, the joinpoint analysis identified three time periods: an initial period of statistically significant rise (1980-1998; APC: 0.6%, p<0.05) and two periods of decreasing rates (1992-2008; APC: -3.3%, p<0.05 and 2008-2018; APC: -2.4%, p<0.05). CONCLUSION Recent trends (last 5 years) show that mortality rates have decreased and incidence rates have stabilized or even decreased in some age groups.
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Affiliation(s)
- H Gilbert Welch
- From the Center for Surgery and Public Health, Brigham and Women's Hospital, Boston (H.G.W.); and the Division of Urology, Department of Surgery, University of Connecticut Health Center, Farmington (P.C.A.)
| | - Peter C Albertsen
- From the Center for Surgery and Public Health, Brigham and Women's Hospital, Boston (H.G.W.); and the Division of Urology, Department of Surgery, University of Connecticut Health Center, Farmington (P.C.A.)
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Jegerlehner S, Chiolero A, Aujesky D, Rodondi N, Germann S, Konzelmann I, Bulliard JL. Recent incidence and surgery trends for prostate cancer: Towards an attenuation of overdiagnosis and overtreatment? PLoS One 2019; 14:e0210434. [PMID: 30716740 PMCID: PMC6361620 DOI: 10.1371/journal.pone.0210434] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 12/22/2018] [Indexed: 12/31/2022] Open
Abstract
Background Screening for prostate cancer is frequent in high-income countries, including Switzerland. Notably due to overdiagnosis and overtreatment, various organisations have recently recommended against routine screening, potentially having an impact on incidence, mortality, and surgery rates. Our aim was therefore to examine whether secular trends in the incidence and mortality of prostate cancer, and in prostatectomy rates, have recently changed in Switzerland. Methods We conducted a population-based trend study in Switzerland from 1998 to 2012. Cases of invasive prostate cancer, deaths from prostate cancer, and prostatectomies were analysed. We calculated changes in age-standardised prostate cancer incidence rates, stratified by tumor stage (early, advanced), prostate cancer-specific mortality, and prostatectomy rates. Results The age-standardised incidence rate of prostate cancer increased greatly in men aged 50–69 years (absolute mean annual change +4.6/100,000, 95% CI: +2.9 to +6.2) between 1998 and 2002, and stabilised afterwards. In men aged ≥ 70 years, the incidence decreased slightly between 1998 and 2002, and more substantially since 2003. The incidence of early tumor stages increased between 1998 and 2002 only in men aged 50–69 years, and then stabilised, while the incidence of advanced stages remained stable across both age strata. The rate of prostatectomy increased markedly until 2002, more so in the 50 to 69 age range than among men aged ≥ 70 years; it leveled off after 2002 in both age strata. Trends in surgery were driven by radical prostatectomy. Since 1998, the annual age-standardised mortality rate of prostate cancer slightly declined in men aged 50–69 years (absolute mean annual change -0.1/100,000, 95% CI: -0.2 to -0.1) and ≥ 70 years (absolute mean annual change -0.5/100,000, 95% CI: -0.7 to -0.3). Conclusions The increases in the incidence of early stage prostate cancer and prostatectomy observed in Switzerland among men younger than 70 years have concomitantly leveled off around 2002/2003. Given the decreasing mortality, these trends may reflect recent changes in screening and clinical workup practices, with a possible attenuation of overdiagnosis and overtreatment.
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Affiliation(s)
- Sabrina Jegerlehner
- Division of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Arnaud Chiolero
- Division of Chronic Diseases, IUMSP, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Observatoire valaisan de la santé (OVS), Sion, Switzerland
- Department of Epidemiology, McGill University, Montreal, Canada
| | - Drahomir Aujesky
- Division of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicolas Rodondi
- Division of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Simon Germann
- Division of Chronic Diseases, IUMSP, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Observatoire valaisan de la santé (OVS), Sion, Switzerland
| | | | - Jean-Luc Bulliard
- Division of Chronic Diseases, IUMSP, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- * E-mail:
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Liu FC, Hua KC, Lin JR, Pang ST, Yu HP. Prostate resected weight and postoperative prostate cancer incidence after transurethral resection of the prostate: A population-based study. Medicine (Baltimore) 2019; 98:e13897. [PMID: 30653095 PMCID: PMC6370121 DOI: 10.1097/md.0000000000013897] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
To analyze whether different volumes of tissue resected during transurethral resection of the prostate (TURP) would associate with the subsequent development of prostate cancer.This population-based retrospective cohort study recruited 49,206 patients with benign prostate hyperplasia (BPH) undergoing TURP between 2005 and 2012. Patients were recruited from the Taiwan National Health Insurance Research Database. Patients were separated into three groups, based on different volumes of tissue resected during TURP (5-15 g, 15-50 g, >50 g).Of the 49,206 patients, 633 patients were diagnosed with new onset of prostate cancer following TURP. Older age was a risk factor contributing to the onset of prostate cancer (P = .0196) and different volumes of tissue resected were significantly related to the incidence of postoperative prostate cancer (P = .0399). The group of patients with a smaller volume of prostate resected had a higher risk of prostate cancer with a hazard ratio (HR) of 1.221 (95% confidence interval [CI]: 1.035, 1.440; P = .0179). However, the risk in the group of patients with a larger volume of prostrate resected was not significantly different, with an HR of 1.277 (95% CI: 0.981, 1662; P = .0690). The incidence of prostate cancer in Taiwanese males over 30 years of age has previously been reported to be 0.0560%; the mean incidence was 0.2282% in our present study.This study shows that BPH patients who had a smaller volume of tissue resected during TURP show a higher incidence of prostate cancer postoperatively. Currently, no clear mechanism is shown to demonstrate the relationship between resected prostate weight and the incidence of tumors. Patients with a larger prostate volume might have lower urinary tract symptoms earlier and then seek professional help. It is possible that surgical procedures might remove the potentially carcinogenic prostate tissue and thus reduce the risk of an aggressive tumor developing in the future.
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Affiliation(s)
- Fu-Chao Liu
- The Department of Anesthesiology, Chang Gung Memorial Hospital
- College of Medicine
| | - Kuo-Chun Hua
- The Department of Anesthesiology, Chang Gung Memorial Hospital
- College of Medicine
| | - Jr-Rung Lin
- Clinical Informatics and Medical Statistics Research Center and Graduate Institute of Clinical Medicine, Chang Gung University
| | - See-Tong Pang
- Department of Urology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Huang-Ping Yu
- The Department of Anesthesiology, Chang Gung Memorial Hospital
- College of Medicine
- Department of Anesthesiology, Xiamen Chang Gung Hospital, Xiamen, China
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Fleshner K, Carlsson SV, Roobol MJ. The effect of the USPSTF PSA screening recommendation on prostate cancer incidence patterns in the USA. Nat Rev Urol 2017; 14:26-37. [PMID: 27995937 PMCID: PMC5341610 DOI: 10.1038/nrurol.2016.251] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Guidelines regarding recommendations for PSA screening for early detection of prostate cancer are conflicting. In 2012, the United States Preventive Services Task Force (USPSTF) assigned a grade of D (recommending against screening) for men aged ≥75 years in 2008 and for men of all ages in 2012. Understanding temporal trends in rates of screening before and after the 2012 recommendation in terms of usage patterns in PSA screening, changes in prostate cancer incidence and biopsy patterns, and how the recommendation has influenced physician's and men's attitudes about PSA screening and subsequent ordering of other screening tests is essential within the scope of prostate cancer screening policy. Since the 2012 recommendation, rates of PSA screening decreased by 3-10% in all age groups and across most geographical regions of the USA. Rates of prostate biopsy and prostate cancer incidence have declined in unison, with a shift towards tumours being of higher grade and stage upon detection. Despite the recommendation, some physicians report ongoing willingness to screen appropriately selected men, and many men report intending to continue to ask for the PSA test from their physician. In the coming years, we expect to have an improved understanding of whether these decreased rates of screening will affect prostate cancer metastasis and mortality.
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Affiliation(s)
- Katherine Fleshner
- Schulich School of Medicine and Dentistry, University of
Western Ontario, Canada
| | - Sigrid V. Carlsson
- Department of Surgery; and Department of Epidemiology and
Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
- Institute of Clinical Sciences, Department of Urology,
Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Monique J. Roobol
- Department of Urology, Erasmus Medical Center, Rotterdam,
The Netherlands
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9
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Trends in the Incidence of Fatal Prostate Cancer in the United States by Race. Eur Urol 2016; 71:195-201. [PMID: 27476048 DOI: 10.1016/j.eururo.2016.05.011] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 05/08/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Prostate-specific antigen (PSA) testing has dramatically changed the composition of prostate cancer (PCa), making it difficult to interpret incidence trends. New methods are needed to examine temporal trends in the incidence of clinically significant PCa and whether trends vary by race. OBJECTIVE To conduct an in-depth analysis of incidence trends in clinically significant PCa, defined as cases in which PCa was the underlying cause of death within 10 yr of diagnosis. DESIGN, SETTING, AND PARTICIPANTS We extracted incident PCa cases during the period 1975-2002 and associated causes of death and survival through 2012 from nine cancer registries in the population-based Surveillance Epidemiology and End Results program database. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We applied joinpoint regression analysis to identify when significant changes in trends occurred and age-period-cohort models to examine longitudinal and cross-sectional trends in the incidence of fatal PCa. RESULTS AND LIMITATIONS Among 51 680 fatal PCa cases, incidence increased 1% per year prior to 1992, declined 15% per year from 1992 to 1995, and further declined by 5% per year through 2002. Age-specific incidence rates of fatal disease decreased >2% per year among men aged ≥60 yr, yet rates remained relatively stable among men aged ≤55 yr. Fatal disease rates were >2-fold higher in black men compared with white men, a racial disparity that increased to 4.2-fold among younger men. CONCLUSIONS The incidence of fatal PCa substantially declined after widespread PSA screening and treatment advances. Nevertheless, rates of fatal disease among younger men have remained relatively stable, suggesting the need for additional attention to early onset PCa, especially among black men. The persistent black-to-white racial disparity observed in fatal PCa underscores the need for greater understanding of the causes of this difference so that strategies can be implemented to eliminate racial disparities. PATIENT SUMMARY We assessed how the incidence of ultimately fatal prostate cancer (PCa) changed over time. We found that the incidence of fatal PCa declined by >50% since the introduction of prostate-specific antigen testing and advances in treatment options; however, incidence rates among younger men remained relatively stable, and younger black men exhibited a 4.2-fold higher risk for fatal disease compared with white men.
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Dickinson J, Shane A, Tonelli M, Connor Gorber S, Joffres M, Singh H, Bell N. Trends in prostate cancer incidence and mortality in Canada during the era of prostate-specific antigen screening. CMAJ Open 2016; 4:E73-9. [PMID: 27280117 PMCID: PMC4866930 DOI: 10.9778/cmajo.20140079] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Widespread use of prostate-specific antigen (PSA) to screen for prostate cancer began in the early 1990s. Advocates for screening assert that this has caused a decrease in prostate cancer mortality. We sought to describe secular changes in prostate cancer incidence and mortality in Canada in relation to the onset of PSA screening. METHODS Age-standardized and age-specific prostate cancer incidence (1969-2007) and mortality (1969-2009) from Public Health Agency of Canada databases were analyzed by joinpoint regression. Changes in incidence and mortality were related to introduction of PSA screening. RESULTS Prior to PSA screening, prostate cancer incidence increased from 54.2 to 99.8 per 100 000 between 1969 and 1990. Thereafter, incidence increased sharply (12.8% per year) to peak at 140.8/100 000 in 1993. After decreasing in all age groups between 1993 and 1996, incidence continued to increase for men aged less than 70 years, but decreased for older men. Age-standardized mortality was stable from 1969 to 1977, increased 1.4% per year to peak in 1995 and subsequently decreased at 3.3% per year; the decline started from 1987 in younger men (age < 60 yr). INTERPRETATION Incidence was increasing before PSA screening occurred, but rose further after it was introduced. Reductions in prostate cancer mortality began before PSA screening was widely used and were larger than could be anticipated from screening alone. These findings suggest that screening caused artifactual increase in incidence, but no more than a part of reductions in prostate cancer mortality. The reduction may be due to changing treatment or certification of death.
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Affiliation(s)
- James Dickinson
- University of Calgary Medical Centre, Family Medicine; University of Calgary, Community Health Sciences (Dickinson), Calgary, Alta.; Public Health Agency of Canada (Shane) Ottawa, Ont.; University of Calgary, Cumming School of Medicine; University of Calgary, Office of the Vice President (Research) (Tonelli), Calgary, Alta.; Public Health Agency of Canada, Preventive Health Care Division (Connor Gorber), Ottawa, Ont.; Simon Fraser University (Joffres), Faculty of Health Sciences, Vancouver, BC; Department of Internal Medicine (Singh), University of Manitoba, Winnipeg, Man.; Family Medicine/Public Health Sciences (Bell), University of Alberta, Edmonton, Alta
| | - Amanda Shane
- University of Calgary Medical Centre, Family Medicine; University of Calgary, Community Health Sciences (Dickinson), Calgary, Alta.; Public Health Agency of Canada (Shane) Ottawa, Ont.; University of Calgary, Cumming School of Medicine; University of Calgary, Office of the Vice President (Research) (Tonelli), Calgary, Alta.; Public Health Agency of Canada, Preventive Health Care Division (Connor Gorber), Ottawa, Ont.; Simon Fraser University (Joffres), Faculty of Health Sciences, Vancouver, BC; Department of Internal Medicine (Singh), University of Manitoba, Winnipeg, Man.; Family Medicine/Public Health Sciences (Bell), University of Alberta, Edmonton, Alta
| | - Marcello Tonelli
- University of Calgary Medical Centre, Family Medicine; University of Calgary, Community Health Sciences (Dickinson), Calgary, Alta.; Public Health Agency of Canada (Shane) Ottawa, Ont.; University of Calgary, Cumming School of Medicine; University of Calgary, Office of the Vice President (Research) (Tonelli), Calgary, Alta.; Public Health Agency of Canada, Preventive Health Care Division (Connor Gorber), Ottawa, Ont.; Simon Fraser University (Joffres), Faculty of Health Sciences, Vancouver, BC; Department of Internal Medicine (Singh), University of Manitoba, Winnipeg, Man.; Family Medicine/Public Health Sciences (Bell), University of Alberta, Edmonton, Alta
| | - Sarah Connor Gorber
- University of Calgary Medical Centre, Family Medicine; University of Calgary, Community Health Sciences (Dickinson), Calgary, Alta.; Public Health Agency of Canada (Shane) Ottawa, Ont.; University of Calgary, Cumming School of Medicine; University of Calgary, Office of the Vice President (Research) (Tonelli), Calgary, Alta.; Public Health Agency of Canada, Preventive Health Care Division (Connor Gorber), Ottawa, Ont.; Simon Fraser University (Joffres), Faculty of Health Sciences, Vancouver, BC; Department of Internal Medicine (Singh), University of Manitoba, Winnipeg, Man.; Family Medicine/Public Health Sciences (Bell), University of Alberta, Edmonton, Alta
| | - Michel Joffres
- University of Calgary Medical Centre, Family Medicine; University of Calgary, Community Health Sciences (Dickinson), Calgary, Alta.; Public Health Agency of Canada (Shane) Ottawa, Ont.; University of Calgary, Cumming School of Medicine; University of Calgary, Office of the Vice President (Research) (Tonelli), Calgary, Alta.; Public Health Agency of Canada, Preventive Health Care Division (Connor Gorber), Ottawa, Ont.; Simon Fraser University (Joffres), Faculty of Health Sciences, Vancouver, BC; Department of Internal Medicine (Singh), University of Manitoba, Winnipeg, Man.; Family Medicine/Public Health Sciences (Bell), University of Alberta, Edmonton, Alta
| | - Harminder Singh
- University of Calgary Medical Centre, Family Medicine; University of Calgary, Community Health Sciences (Dickinson), Calgary, Alta.; Public Health Agency of Canada (Shane) Ottawa, Ont.; University of Calgary, Cumming School of Medicine; University of Calgary, Office of the Vice President (Research) (Tonelli), Calgary, Alta.; Public Health Agency of Canada, Preventive Health Care Division (Connor Gorber), Ottawa, Ont.; Simon Fraser University (Joffres), Faculty of Health Sciences, Vancouver, BC; Department of Internal Medicine (Singh), University of Manitoba, Winnipeg, Man.; Family Medicine/Public Health Sciences (Bell), University of Alberta, Edmonton, Alta
| | - Neil Bell
- University of Calgary Medical Centre, Family Medicine; University of Calgary, Community Health Sciences (Dickinson), Calgary, Alta.; Public Health Agency of Canada (Shane) Ottawa, Ont.; University of Calgary, Cumming School of Medicine; University of Calgary, Office of the Vice President (Research) (Tonelli), Calgary, Alta.; Public Health Agency of Canada, Preventive Health Care Division (Connor Gorber), Ottawa, Ont.; Simon Fraser University (Joffres), Faculty of Health Sciences, Vancouver, BC; Department of Internal Medicine (Singh), University of Manitoba, Winnipeg, Man.; Family Medicine/Public Health Sciences (Bell), University of Alberta, Edmonton, Alta
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Abstract
In the United States, prostate cancer is the most commonly diagnosed non-skin cancer and the second leading cause of cancer death. The American Cancer Society estimates that 241 740 American men will be diagnosed with the disease and 28 170 men will die of it in 2012. Prostate cancer demographics have changed dramatically over the past 30 years. The prostate cancer age-adjusted incidence rate increased through the 1980s and peaked in the early to mid-1990s. The incidence rate has declined since. American mortality rates rose through the 1980s and peaked in 1991. Today, the American incidence rates are below 1975 levels. Both the incidence rate and the 5-year survival rates are heavily influenced by the introduction of serum prostate-specific antigen test and the widespread use of it in cancer screening. The effect of screening on prostate cancer mortality is less certain. Screening has caused a dramatic increase in the number and proportion of men diagnosed with localized disease. Outcomes studies among men treated with radical prostatectomy show that greater than 30% serum prostate-specific antigen relapse rates are common. This suggests that many men who are diagnosed with "localized early stage disease" actually have "apparently localized early stage disease," which is really low-volume metastatic disease.
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12
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Walter LC, Fung KZ, Kirby KA, Shi Y, Espaldon R, O'Brien S, Freedland SJ, Powell AA, Hoffman RM. Five-year downstream outcomes following prostate-specific antigen screening in older men. JAMA Intern Med 2013; 173:866-73. [PMID: 23588999 PMCID: PMC3712749 DOI: 10.1001/jamainternmed.2013.323] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Despite ongoing controversies surrounding prostate-specific antigen (PSA) screening, many men 65 years or older undergo screening. However, few data exist that quantify the chain of events following screening in clinical practice to better inform decisions. OBJECTIVE To quantify 5-year downstream outcomes following a PSA screening result exceeding 4.0 ng/mL in older men. DESIGN AND SETTING Longitudinal cohort study in the national Veterans Affairs health care system. PARTICIPANTS In total, 295,645 men 65 years or older who underwent PSA screening in the Veterans Affairs health care system in 2003 and were followed up for 5 years using national Veterans Affairs and Medicare data. MAIN OUTCOME MEASURES Among men whose index screening PSA level exceeded 4.0 ng/mL, we determined the number who underwent prostate biopsy, were diagnosed as having prostate cancer, were treated for prostate cancer, and were treated for prostate cancer and were alive at 5 years according to baseline characteristics. Biopsy and treatment complications were also assessed. RESULTS In total, 25,208 men (8.5%) had an index PSA level exceeding 4.0 ng/mL. During the 5-year follow-up period, 8313 men (33.0%) underwent at least 1 prostate biopsy, and 5220 men (62.8%) who underwent prostate biopsy were diagnosed as having prostate cancer, of whom 4284 (82.1%) were treated for prostate cancer. Performance of prostate biopsy decreased with advancing age and worsening comorbidity (P < .001), whereas the percentage treated for biopsy-detected cancer exceeded 75% even among men 85 years or older, those with a Charlson-Deyo Comorbidity Index of 3 or higher, and those having low-risk cancer. Among men with biopsy-detected cancer, the risk of death from non-prostate cancer causes increased with advancing age and worsening comorbidity (P < .001). In total, 468 men (5.6%) had complications within 7 days after prostate biopsy. Complications of prostate cancer treatment included new urinary incontinence in 584 men (13.6%) and new erectile dysfunction 588 men (13.7%). CONCLUSIONS AND RELEVANCE Performance of prostate biopsy is uncommon in older men with abnormal screening PSA levels and decreases with advancing age and worsening comorbidity. However, once cancer is detected on biopsy, most men undergo immediate treatment regardless of advancing age, worsening comorbidity, or low-risk cancer. Understanding downstream outcomes in clinical practice should better inform individualized decisions among older men considering PSA screening.
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Affiliation(s)
- Louise C Walter
- Division of Geriatrics, San Francisco VA Medical Center, Mail Code 181G, 4150 Clement St, San Francisco, CA 94121, USA.
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13
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Fontes F, Severo M, Castro C, Lourenço S, Gomes S, Botelho F, La Vecchia C, Lunet N. Model-based patterns in prostate cancer mortality worldwide. Br J Cancer 2013; 108:2354-66. [PMID: 23660943 PMCID: PMC3681014 DOI: 10.1038/bjc.2013.217] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: Prostate cancer mortality has been decreasing in several high income countries and previous studies analysed the trends mostly according to geographical criteria. We aimed to identify patterns in the time trends of prostate cancer mortality across countries using a model-based approach. Methods: Model-based clustering was used to identify patterns of variation in prostate cancer mortality (1980–2010) across 37 European, five non-European high-income countries and four leading emerging economies. We characterised the patterns observed regarding the geographical distribution and gross national income of the countries, as well as the trends observed in mortality/incidence ratios. Results: We identified three clusters of countries with similar variation in prostate cancer mortality: pattern 1 (‘no mortality decline'), characterised by a continued increase throughout the whole period; patterns 2 (‘later mortality decline') and 3 (‘earlier mortality decline') depict mortality declines, starting in the late and early 1990s, respectively. These clusters are also homogeneous regarding the variation in the prostate cancer mortality/incidence ratios, while are heterogeneous with reference to the geographical region of the countries and distribution of the gross national income. Conclusion: We provide a general model for the description and interpretation of the trends in prostate cancer mortality worldwide, based on three main patterns.
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Affiliation(s)
- F Fontes
- Institute of Public Health of the University of Porto, Porto, Portugal
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Grivas N, Hastazeris K, Kafarakis V, Tsimaris I, Xousianitis Z, Makatsori A, Raptis P, Aspiotis S, Ioachim E, Ntemou A, Kitsiou E, Malamou-Mitsi V, Sofikitis N, Kordela V, Papandreou C, Agnantis NJ, Stavropoulos NE. Prostate cancer epidemiology in a rural area of North Western Greece. Asian Pac J Cancer Prev 2012; 13:999-1002. [PMID: 22631687 DOI: 10.7314/apjcp.2012.13.3.999] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Epirus is a rural area of North-Western Greece. We reviewed data from 4 hospitals for 4.975 patients who underwent prostate biopsy in Epirus in the twelve year period from 1999 to 2010. Two six-year periods were compared (1999-2004 and 2004-2010). All cases of prostate cancer confirmed by biopsy were recorded and age-standardized incidence rates per 100,000 males were calculated. We also recorded the clinical stage for patients diagnosed in our hospital and correlated this with PSA and Gleason scores. Percentage of positive prostate biopsies was also calculated. There were a total of 1714 new cases during 1999-2010 and the mean annual age-adjusted incidence was 34/100,000. The mean incidences during 1999-2004 and 2005-2010 were 26/100,000 and 42/100,000, respectively. The mean age at diagnosis was 74. The most common Gleason score was 6 and the prevalent clinical stage was T2. Median PSA at diagnosis was 10.8 ng/ml. There was a significant difference between stage cT4 and all other stages regarding PSA value (p=0.000). A positive correlation was found between Gleason score and PSA (p=0.013). These results are in accordance with the incidence rise recorded in neighboring countries of South-East Europe. However we should keep in mind the risk of overdiagnosis and the detection of low-risk cancers that would not have caused morbidity or death during a man's lifetime anyway.
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Affiliation(s)
- N Grivas
- Department of Urology, Hatzikosta General Hospital of Ioannina, Greece.
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15
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Neppl-Huber C, Zappa M, Coebergh JW, Rapiti E, Rachtan J, Holleczek B, Rosso S, Aareleid T, Brenner H, Gondos A. Changes in incidence, survival and mortality of prostate cancer in Europe and the United States in the PSA era: additional diagnoses and avoided deaths. Ann Oncol 2012; 23:1325-1334. [PMID: 21965474 DOI: 10.1093/annonc/mdr414] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND We describe changes in prostate cancer incidence, survival and mortality and the resulting impact in additional diagnoses and avoided deaths in European areas and the United States. METHODS Using data from 12 European cancer registries and the Surveillance, Epidemiology and End Results program, we describe changes in prostate cancer epidemiology between the beginning of the PSA era (USA: 1985-1989, Europe: 1990-1994) and 2002-2006 among patients aged 40-64, 65-74, and 75+. Additionally, we examine changes in yearly numbers of diagnoses and deaths and variation in male life expectancy. RESULTS Incidence and survival, particularly among patients aged <75, increased dramatically, yet both remain (with few exceptions in incidence) lower in Europe than in the United States. Mortality reductions, ongoing since the mid/late 1990 s, were more consistent in the United States, had a distressingly small absolute impact among patients aged 40-64 and the largest absolute impact among those aged 75+. Overall ratios of additional diagnoses/avoided deaths varied between 3.6 and 27.6, suggesting large differences in the actual impact of prostate cancer incidence and mortality changes. Ten years of remaining life expectancy was reached between 68 and 76 years. CONCLUSION Policies reflecting variation in population life expectancy, testing preferences, decision aids and guidelines for surveillance-based management are urgently needed.
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Affiliation(s)
- C Neppl-Huber
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - M Zappa
- Tuscany Cancer Registry, Clinical and Descriptive Epidemiology Unit, CSPO, Florence, Italy
| | - J W Coebergh
- Department of Public Health, Erasmus MC Rotterdam, Rotterdam, The Netherlands
| | - E Rapiti
- Geneva Cancer Registry, Geneva, Switzerland
| | - J Rachtan
- Cracow Cancer Registry, Cracow, Poland
| | - B Holleczek
- Saarland Cancer Registry, Saarbrücken, Germany
| | - S Rosso
- Piedmont Cancer Registry, Turin, Italy
| | - T Aareleid
- Department of Epidemiology and Biostatistics, National Institute for Health Development, Tallinn, Estonia
| | - H Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - A Gondos
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.
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Prostate cancer epidemiology in the United States. World J Urol 2012; 30:195-200. [PMID: 22476558 DOI: 10.1007/s00345-012-0824-2] [Citation(s) in RCA: 216] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Accepted: 01/04/2012] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Prostate cancer is a significant public health issue in the United States. It is the most commonly diagnosed non-skin cancer and the second leading cause of cancer death. The American Cancer Society estimates that in 2011, 240,890 men were diagnosed with prostate cancer and 33,720 men died of it. METHODS A review of the peer-reviewed literature was conducted: American Cancer Society, National Cancer Institute Surveillance, Epidemiology and End Results. Program data were assessed to describe trends in incidence, mortality, and survival rates and look at other predictors of risk of prostate cancer diagnosis and death. RESULTS Since 1985, there have been significant changing trends in prostate cancer incidence, mortality, and survival rates, as well as changes in the age distribution of the population diagnosed and even in the distribution of pathologies at diagnosis. Major risk factors for diagnosis include age, family history, race, and screening behavior. CONCLUSION While prostate cancer remains largely a disease diagnosed in older men (over age 65), screening has increased risk of diagnosis among men in their 40s and 50s. The incidence rates and 5-year survival rates are heavily influenced by the introduction of serum prostate-specific antigen (PSA) and widespread screening. The effects of PSA usage and screening on mortality rates are less certain. Outcome studies among men treated with radical prostatectomy show that greater than 30% relapse rates are common. This suggests that many men who are diagnosed with "localized early stage disease" actually have "apparently localized early stage disease," which is really low volume metastatic disease.
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Larrañaga N, Galceran J, Ardanaz E, Franch P, Navarro C, Sánchez MJ, Pastor-Barriuso R. Prostate cancer incidence trends in Spain before and during the prostate-specific antigen era: impact on mortality. Ann Oncol 2010; 21 Suppl 3:iii83-89. [PMID: 20427365 DOI: 10.1093/annonc/mdq087] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- N Larrañaga
- Basque Country Cancer Registry, Public Health Department of Gipuzkoa, Basque Country Regional Authority, San Sebastián, Spain
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Abstract
This article summarizes the phenomenon of cancer overdiagnosis-the diagnosis of a "cancer" that would otherwise not go on to cause symptoms or death. We describe the two prerequisites for cancer overdiagnosis to occur: the existence of a silent disease reservoir and activities leading to its detection (particularly cancer screening). We estimated the magnitude of overdiagnosis from randomized trials: about 25% of mammographically detected breast cancers, 50% of chest x-ray and/or sputum-detected lung cancers, and 60% of prostate-specific antigen-detected prostate cancers. We also review data from observational studies and population-based cancer statistics suggesting overdiagnosis in computed tomography-detected lung cancer, neuroblastoma, thyroid cancer, melanoma, and kidney cancer. To address the problem, patients must be adequately informed of the nature and the magnitude of the trade-off involved with early cancer detection. Equally important, researchers need to work to develop better estimates of the magnitude of overdiagnosis and develop clinical strategies to help minimize it.
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Affiliation(s)
- H Gilbert Welch
- Department of Veterans Affairs Medical Center, White River Junction, VT 05009, USA.
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20
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Merrill RM, Hunter BD. The diminishing role of transurethral resection of the prostate. Ann Surg Oncol 2010; 17:1422-8. [PMID: 20091426 DOI: 10.1245/s10434-009-0896-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Ray M Merrill
- Department of Health Science, College of Life Sciences, Brigham Young University, Provo, UT, USA.
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Kilpeläinen TP, Tammela TLJ, Määttänen L, Kujala P, Stenman UH, Ala-Opas M, Murtola TJ, Auvinen A. False-positive screening results in the Finnish prostate cancer screening trial. Br J Cancer 2010; 102:469-74. [PMID: 20051951 PMCID: PMC2822946 DOI: 10.1038/sj.bjc.6605512] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND There is evidence that prostate cancer (PC) screening with prostate-specific antigen (PSA) serum test decreases PC mortality, but screening has adverse effects, such as a high false-positive (FP) rate. We investigated the proportion of FPs in a population-based randomised screening trial in Finland. METHODS Finland is the largest centre in the European Randomized Study of Screening for Prostate Cancer. We have completed three screening rounds with a 4-year screening interval (mean follow-up time 9.2 years) using a PSA cutoff level of 4.0 ng ml(-1); in addition, men with PSA 3.0-3.9 and a positive auxiliary test were referred. An FP result was defined as a positive screening result without cancer in biopsy within 1 year from the screening test. RESULTS The proportion of FP screening results varied from 3.3 to 12.1% per round. Of the screened men, 12.5% had at least one FP during three rounds. The risk of next-round PC following an FP result was 12.3-19.7 vs 1.4-3.7% following a screen-negative result (depending on the screening round), risk ratio 3.6-9.9. More than half of the men with one FP result had another one at a subsequent screen. Men with an FP result were 1.5 to 2.0 times more likely to not participate in subsequent rounds compared with men with a normal screening result (21.6-29.6 vs 14.0-16.7%). CONCLUSION An FP result is a common adverse effect of PC screening and affects at least every eighth man screened repeatedly, even when using a relatively high cutoff level. False-positive men constitute a special group that receives unnecessary interventions but may harbour missed cancers. New strategies are needed for risk stratification in PC screening to minimise the proportion of FP men.
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Affiliation(s)
- T P Kilpeläinen
- Department of Urology, University of Tampere and Tampere University Hospital, Box 2000, Tampere FIN-33521, Finland.
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Chefo S, Tsodikov A. Stage-specific cancer incidence: an artificially mixed multinomial logit model. Stat Med 2009; 28:2054-76. [PMID: 19452568 DOI: 10.1002/sim.3615] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Early detection of prostate cancer using the prostate-specific antigen test led to a sharp spike in the incidence of the disease accompanied by an equally sharp improvement in patient prognoses as evaluated at the point of advanced diagnosis. Observed outcomes represent age at diagnosis and stage, a categorical prognostic variable combining the actual stage and the grade of tumor. The picture is summarized by the stage-specific cancer incidence that represents a joint survival-multinomial response regressed on factors affecting the unobserved history of the disease before diagnosis (mixture). Fitting the complex joint mixed model to large population data is a challenge. We develop a stable and structured MLE approach to the problem allowing for the estimates to be obtained iteratively. Factorization of the likelihood achieved by our method allows us to work with only a fraction of the model dimension at a time. The approach is based on generalized self-consistency and the quasi-EM algorithm used to handle the mixed multinomial part of the response through Poisson likelihood. The model provides a causal link between the screening policy in the population and the stage-specific incidence.
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Affiliation(s)
- Solomon Chefo
- Takeda Global Research & Development Center, Inc., Analytical Sciences, 675 North Field Drive, Lake Forest, IL 60045, USA
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Welch HG, Albertsen PC. Prostate cancer diagnosis and treatment after the introduction of prostate-specific antigen screening: 1986-2005. J Natl Cancer Inst 2009; 101:1325-9. [PMID: 19720969 DOI: 10.1093/jnci/djp278] [Citation(s) in RCA: 423] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Although there is uncertainty about the effect of prostate-specific antigen (PSA) screening on the rate of prostate cancer death, there is little uncertainty about its effect on the rate of prostate cancer diagnosis. Systematic estimates of the number of men affected, however, to our knowledge, do not exist. METHODS We obtained data on age-specific incidence and initial course of therapy from the National Cancer Institute's Surveillance, Epidemiology, and End Results program. We then used age-specific male population estimates from the US Census to determine the excess (or deficit) in the number of men diagnosed and treated in each year after 1986-the year before PSA screening was introduced. RESULTS Overall incidence of prostate cancer rose rapidly after 1986, peaked in 1992, and then declined, albeit to levels considerably higher than those in 1986. Overall incidence, however, obscured distinct age-specific patterns: The relative incidence rate (2005 relative to 1986) was 0.56 in men aged 80 years and older, 1.09 in men aged 70-79 years, 1.91 in men aged 60-69 years, 3.64 in men aged 50-59 years, and 7.23 in men younger than 50 years. Since 1986, an estimated additional 1 305 600 men were diagnosed with prostate cancer, 1 004 800 of whom were definitively treated for the disease. Using the most optimistic assumption about the benefit of screening-that the entire decline in prostate cancer mortality observed during this period is attributable to this additional diagnosis-we estimated that, for each man who experienced the presumed benefit, more than 20 had to be diagnosed with prostate cancer. CONCLUSIONS The introduction of PSA screening has resulted in more than 1 million additional men being diagnosed and treated for prostate cancer in the United States. The growth is particularly dramatic for younger men. Given the considerable time that has passed since PSA screening began, most of this excess incidence must represent overdiagnosis.
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Affiliation(s)
- H Gilbert Welch
- VA Outcomes Group (111B), Department of Veterans Affairs Medical Center, White River Junction, VT 05009, USA.
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Beiki O, Ekbom A, Allebeck P, Moradi T. Risk of prostate cancer among Swedish-born and foreign-born men in Sweden, 1961-2004. Int J Cancer 2009; 124:1941-53. [DOI: 10.1002/ijc.24138] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Biers SM, Oliver HC, King AJ, Adamson AS. Does laser ablation prostatectomy lead to oncological compromise? BJU Int 2009; 103:454-7. [DOI: 10.1111/j.1464-410x.2008.08039.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Screening should allow for the anticipation of cancer diagnosis at an earlier stage, when curative treatment is possible. Screening for cervical, large bowel, and breast cancer were shown to be effective in reducing mortality. The wide acceptance of the screening concept led to the wide diffusion also of screening of uncertain benefit against prostate cancer and skin melanoma. Diagnostic technologies are continuously evolving, and new tests are proposed to improve existing screenings or as screening tests for additional cancer sites (e.g., lung cancer). Cancer screening, however, is a complex and costly intervention that does not result only in benefits but also may cause harm. A major emerging problem of screening is overdiagnosis, or the detection of cases that would have not progressed to the symptomatic phase in the absence of screening. Thus, both experimental and observational evaluation studies are needed to reduce harm caused by screenings and to select effective interventions among many proposed innovations. Finally, the research of markers to assess the aggressive nature of screen-detected lesions is of great importance to improve screenings ' harm/benefit ratio.
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Affiliation(s)
- Fabrizio Stracci
- Department of Surgical and Medical Specialties, and Public Health, University of Perugia, Perugia, Italy
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Probability of finding T1a and T1b (incidental) prostate cancer during TURP has decreased in the PSA era. Prostate Cancer Prostatic Dis 2008; 12:57-60. [PMID: 18379587 DOI: 10.1038/pcan.2008.14] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The purpose of this study is to assess the likelihood of detecting stage T1a and T1b cancer in transurethral prostatectomy specimens during the PSA era. Comparison was made of transurethral resection of prostate (TURP) cohorts in the pre-PSA era (1986-1987) and the PSA era (1994-2000), excluding patients with known PCa. A total of 228 men without a known history of prostate cancer underwent TURP during the pre-PSA era time frame and 501 underwent the procedure during the PSA era time frame. Malignancy diagnosed at the time of TURP decreased from 14.9 to 5.2% of patients in the pre-PSA and PSA eras, respectively. Stage T1a decreased from 4.4 to 2.4% and Stage T1b decreased from 10.5 to 2.8% of patients in the pre-PSA and PSA eras, respectively (P<0.001, Fisher's exact test). Prostate cancer newly identified during TURP has decreased significantly in the era of PSA screening in our study population, with the most significant drop being in clinically significant stage T1b. The decrease in TURP rates reduces the overall incidence of T1a/b cancer but cannot explain the lower risk of detecting previously unsuspected cancer at the time of any given TURP. Identification of many men with occult prostate cancer before TURP through screening and early detection is the most likely cause of this finding. These data suggest that men considering surgical or medical management of benign prostatic hyperplasia may be informed that it should be infrequent that men properly evaluated for prostate cancer will harbor clinically significant undetected malignancy.
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Rajinikanth A, Manoharan M, Soloway CT, Civantos FJ, Soloway MS. Trends in Gleason score: concordance between biopsy and prostatectomy over 15 years. Urology 2008; 72:177-82. [PMID: 18279938 DOI: 10.1016/j.urology.2007.10.022] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Revised: 09/12/2007] [Accepted: 10/19/2007] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To assess the changes in the concordance rate of prostate biopsy and radical prostatectomy (RP) Gleason score (GS) over 15 years. METHODS We reviewed 1670 consecutive patients who underwent RP between 1992 and 2006. We excluded patients who underwent neoadjuvant hormone therapy or salvage RP, or who had incomplete data. Patients who had RP during 1992 through 1996, 1997 through 2001, and 2002 through 2006 were assigned to groups 1, 2, and 3, respectively. All clinical and pathological data were collected retrospectively. We defined overgrading as a biopsy GS higher than the RP Gleason score. Undergrading was a biopsy GS less than the RP Gleason score. The GS concordance between biopsy and RP was evaluated by kappa coefficient. RESULTS A total of 1363 patients satisfied the inclusion criteria. Biopsy and RP Gleason score categories correlated exactly in 937 (69%) men. Gleason undergrading occurred in 361 (26%) men and overgrading in 65 (5%). The exact correlation of GS between biopsy and RP was 58%, 66%, and 75% in groups 1, 2, and 3, respectively. The most common discordant finding was undergrading of the biopsy specimen. The number of cases with exact correlation was highest in GS 7 (78%). Undergrading was more in GS 6 or less (35%) and overgrading was more in the GS 8 through 10 (35%) category. CONCLUSIONS This large, single institutional study confirms increasing concordance of Gleason scores in prostate needle biopsies and surgical specimens. This is reassuring for patients assessing various treatment options for prostate cancer.
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Affiliation(s)
- Ayyathurai Rajinikanth
- Department of Urology, University of Miami Miller School of Medicine, Miami, Florida 33101, USA
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Kvale R, Auvinen A, Adami HO, Klint A, Hernes E, Moller B, Pukkala E, Storm HH, Tryggvadottir L, Tretli S, Wahlqvist R, Weiderpass E, Bray F. Interpreting Trends in Prostate Cancer Incidence and Mortality in the Five Nordic Countries. J Natl Cancer Inst 2007; 99:1881-7. [DOI: 10.1093/jnci/djm249] [Citation(s) in RCA: 253] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Telesca D, Etzioni R, Gulati R. Estimating lead time and overdiagnosis associated with PSA screening from prostate cancer incidence trends. Biometrics 2007; 64:10-9. [PMID: 17501937 DOI: 10.1111/j.1541-0420.2007.00825.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The introduction of the prostate-specific antigen (PSA) test has led to dramatic changes in the incidence of prostate cancer in the United States. In this article, we use information on the increase and subsequent decline in prostate cancer incidence following the adoption of PSA to estimate the lead time associated with PSA screening. The lead time is a key determinant of the likelihood of overdiagnosis, one of the main costs associated with the PSA test. Our approach conceptualizes observed incidence as the sum of the secular trend in incidence, which reflects incidence in the absence of PSA, and the excess incidence over and above the secular trend, which is a function of population screening patterns and the unknown lead time. We develop a likelihood model for the excess incidence given the secular trend and use it to estimate the mean lead time under specified distributional assumptions. We also develop a likelihood model for observed incidence and use it to simultaneously estimate the mean lead time together with a smooth secular trend. Variances and confidence intervals are estimated via a parametric bootstrap. Our results indicate an average lead time of approximately 4.59 years (95% confidence interval [3.24, 5.93]) for whites and 6.78 years [5.42, 8.20] for blacks with a corresponding secular trend estimate that is fairly flat after the introduction of PSA screening. These estimates correspond to overdiagnosis frequencies of approximately 22.7% and 34.4% for screen-detected whites and blacks, respectively. Our results provide the first glimpse of a plausible secular trend in prostate cancer incidence and suggest that, in the absence of PSA screening, disease incidence would not have continued its historic increase, rather it would have leveled off in accordance with changes in prostate patterns of care unrelated to PSA.
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Affiliation(s)
- Donatello Telesca
- Department of Statistics, University of Washington, Seattle, WA 98195-4322, USA.
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Jonsson E, Sigbjarnarson HP, Tomasson J, Benediktsdottir KR, Tryggvadottir L, Hrafnkelsson J, Olafsdottir EJ, Tulinius H, Jonasson JG. Adenocarcinoma of the prostate in Iceland: a population-based study of stage, Gleason grade, treatment and long-term survival in males diagnosed between 1983 and 1987. ACTA ACUST UNITED AC 2007; 40:265-71. [PMID: 16916765 DOI: 10.1080/00365590600750110] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To investigate adenocarcinoma of the prostate in a single population with an extended follow-up period. MATERIAL AND METHODS Using the Icelandic Cancer Registry, we identified all Icelandic men diagnosed with prostate cancer between 1983 and 1987. Disease stage, initial treatment and follow-up information were obtained from hospital records and death certificates. A critical evaluation was made of the accuracy of the death certificates regarding prostate cancer. All available histology information was reviewed and graded according to the Gleason grading system. RESULTS A total of 414 men were diagnosed with adenocarcinoma of the prostate. Of these, 370 were alive at the time of diagnosis and stage could be determined. Four stage groups were defined: focal incidental (n=50); localized (n=164); local advanced (n=32); and metastatic disease (n=124). The mean age at diagnosis was 74.4 years (range 53-94 years). The combined Gleason score was 2-5 in 89, 6-7 in 117, 8-10 in 117 and unknown in 47 cases. The median follow-up period for the group was 6.15 years (range 0.3-19.8 years). Thirty men received treatment with curative intent: radiation therapy, n=20; and radical prostatectomy, n=10. A total of 334 patients died during the follow-up period, of whom 168 (50%) died of prostate cancer. Prostate cancer-specific survival at 10 and 15 years was 100% and 90.6%, respectively for focal incidental cancer; 73.1% and 60.8% for men with localized disease; 23.4% and 11.7% for local advanced disease; and 6.81% and 5.45% for metastatic disease. A Cox multivariate analysis showed age, stage and Gleason score to be independent predictors of prostate cancer death. A total of 104 patients with localized disease and a Gleason score of <or=7 received deferred treatment. The cause-specific survival for this group was 95.6%, 86.5% and 79.2% at 5, 10 and 15 years, respectively. Death certificates were judged to be accurate with regard to prostate cancer in nearly all instances (96%). CONCLUSIONS During an extended follow-up period, half of all patients with prostate cancer died from the disease. Males with localized disease and a favorable tumor grade fared well with deferred treatment. However, a higher stage and grade were associated with substantial prostate cancer mortality. Death certificates were accurate as far as prostate cancer was concerned.
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Affiliation(s)
- E Jonsson
- Department of Urology, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland.
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33
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Abstract
Introduction of screening for prostate cancer using the prostate-specific antigen (PSA) marker of the disease led to remarkable dynamics of the incidence of the disease observed in the last two decades. A statistical model is used to provide a link between dissemination of PSA and the observed transient population responses. The model is used to estimate lead time, overdiagnosis and other relevant characteristics of prostate cancer screening.
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Affiliation(s)
- A Tsodikov
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, One Shields Avenue, Davis, CA 95616, USA.
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34
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Abstract
The interpretation of cancer incidence trends is complicated by short-term random variation, artifactual fluctuations introduced by screening, changes in diagnosis or disease classification, completeness of reporting, and by the multiplicity of factors that may affect risk for specific cancer sites. We analyzed trends in 56 different cancer sites and subsites in the U.S. SEER registries in the period 1975-2002 using join-point analysis. The increase in cancer incidence for all sites combined that became evident with the inception of the SEER registries in the mid-1970s has abated since the early 1990s. Among the 15 most common cancer sites in men, sites with increasing incidence rates during the most recent time period include melanoma of the skin and cancers of the prostate, kidney and renal pelvis (kidney), and esophagus. Among women, incidence rates are increasing for leukemia, non-Hodgkin's lymphoma, melanoma, and cancers of the breast, thyroid, urinary bladder, and kidney. Incidence rates for all childhood cancers combined increased 0.6% per year from 1975 to 2002. Cancer mortality rates have decreased in the United States since 1991 in both men and in women; site-specific death rates have decreased in the most recent time period for 12 of the top 15 cancer sites in men and 9 of the top 15 cancer sites in women. Similar trends in cancer incidence and mortality have been reported in other industrialized countries. Possible reasons for these trends are discussed.
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Affiliation(s)
- Elizabeth M Ward
- Department of Epidemiology and Surveillance Research, American Cancer Society, National Home Office, Atlanta, GA 30329-4251, USA.
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35
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Neutel CI, Gao RN, Blood PA, Gaudette LA. Trends in prostate cancer incidence, hospital utilization and surgical procedures, Canada, 1981-2000. Canadian Journal of Public Health 2006. [PMID: 16827401 DOI: 10.1007/bf03405579] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Numbers of new prostate cancer cases in Canada continue to increase because of increasing prostate cancer incidence, population growth, aging of the population, and earlier detection methods such as PSA (prostate-specific antigen) testing. Concern has been expressed that PSA-related increases in incidence will make unaffordable demands on Canadian hospital resources. Our objective is to relate increases in prostate cancer incidence to trends in hospitalizations and in- patient treatment. METHODS Hospitalizations with prostate cancer as primary diagnosis were obtained from the Hospital Morbidity Database, estimates of prostate cancer day surgery from the Discharge Abstract Database, newly diagnosed cases from the Canadian Cancer Registry, and prostate cancer deaths from the Vital Statistics Mortality Databases--all for the years 1981-2000. RESULTS Between 1981-2000, the number of new cases rose from 7,000 to 18,500 with a transient peak, 1991-1994. Hospitalizations rose parallel to the incidence until 1991 but then fell sharply in spite of further increasing incidence. The use of radical prostatectomy (RP) increased steadily, but transurethral prostatectomy and bilateral orchiectomy decreased in the 1990s. Decreases in length of stay and in number of hospitalizations resulted in considerably decreased annual hospital days for all prostate cancer in-patient procedures except RP, which remained level since 1993. CONCLUSIONS A net decrease in number of in-patient days occurred, despite the increasing number of new prostate cancer cases and the increasing use of radical prostatectomy. We concluded that increases in hospital utilization due to early detection programs, such as PSA testing, are unlikely to overwhelm in-patient services of Canadian hospitals.
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Affiliation(s)
- C Ineke Neutel
- Chronic Disease Management and Control Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, Ottawa, ON.
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36
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Sengupta S, Slezak JM, Blute ML, Leibovich BC, Sebo TJ, Myers RP, Cheville JC, Bergstralh EJ, Zincke H. Trends in distribution and prognostic significance of Gleason grades on radical retropubic prostatectomy specimens between 1989 and 2001. Cancer 2006; 106:2630-5. [PMID: 16703592 DOI: 10.1002/cncr.21924] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The objectives of the current study were to examine time trends in the prevalence of Gleason grades of prostate cancer on radical retropubic prostatectomy (RRP) specimens and to assess the resultant impact on prognosis. METHODS The authors examined the prevalence over time of each grade and Gleason score (GS) on RRP specimens from 8750 patients who were treated between 1989 and 2001. Biochemical recurrence-free survival (BRFS), which was estimated by using Kaplan-Meier methodology, was examined in subgroups of patients defined by tumor grade and era of surgery. RESULTS The prevalence of Grade 3 prostate cancers increased (86% vs. 49% for primary Gleason grade and 71% vs. 47% for secondary Gleason grade; 1999-2001 vs. 1989-1990, respectively), whereas the prevalence of Grade 2 tumors decreased (0.4% vs. 38% for primary Gleason grade and 1.3% vs. 28% for secondary Gleason grade, respectively) over the study period, leading to fewer GS 4 and 5 tumors and more GS 6 and 7 tumors. BRFS improved over time for patients who had GS 5 tumors (hazards ratio [HR], 0.92 per year; P = .003) and GS 6 tumors (HR, 0.93; P < .001) but remained unchanged for GS 7 tumors (HR 0.99; P = .462) and GS 8-10 tumors (HR 1.02; P = .360). Patients who were treated in the recent era (1997-2001) had greater differentiation of BRFS based on GS or Gleason grade compared with patients who were treated earlier (1989-1991). CONCLUSIONS The current results confirmed that there were changes in the prevalence of Gleason grades on RRP specimens between 1989 and 2001. A chronological change in pathologic grading classification is suggested by evolving prognostic implications, which must be accounted for when comparing outcomes from different eras.
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Affiliation(s)
- Shomik Sengupta
- Department of Urology, Mayo Clinic, Rochester, Minnesota 55905, USA
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37
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Neutel CI, Gao RN, Wai E, Gaudette LA. Trends in in-patient Hospital Utilization and Surgical Procedures for Breast, Prostate, Lung and Colorectal Cancers in Canada. Cancer Causes Control 2005; 16:1261-70. [PMID: 16215877 DOI: 10.1007/s10552-005-0379-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2005] [Accepted: 06/24/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To analyse population-based trends of in-patient surgical procedures for breast (female), prostate, lung and colorectal cancers. METHODS The Hospital Morbidity Files supplied hospital data and the Canadian Cancer Registry, incidence data. Age-adjusted rates were standardized to the 1991 Canadian population. RESULTS All four cancers showed major changes in trends of surgical procedures. For breast cancer, the rate of in-patient breast conservation surgery (BCS) increased from 1981 to the early 1990s while the rate of mastectomy decreased. Because day surgery was not included, the subsequent in-patient BCS rate stayed level. For prostate cancer, the rate of transurethral prostatectomy was initially high but decreased after 1990, while the rate of radical prostatectomy increased rapidly, only minimally affected by the PSA-related peak in incidence. The lung cancer lobectomy rate in men remained at 10/100,000 after 1986, but in women rose from 3/100,000 to 7/100,000, reflecting increasing lung cancer incidence. For colorectal cancer, right hemicolectomies and anterior resections increased, especially in men. CONCLUSIONS Surgery trends reflected changes in incidence and treatment preferences. Canadian trends were generally similar to US trends, although the timing of some of the changes differed. Canadians tended to use less invasive procedures such as BCS and anterior resection.
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Affiliation(s)
- C Ineke Neutel
- Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 120 Colonnade Avenue, K1A 0K9, Ottawa, Canada.
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38
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Abstract
BACKGROUND Population-based Utah Cancer Registry data were linked with Latter-day Saint (LDS or Mormon) Church membership records to obtain site-specific cancer incidence for LDS and non-LDS populations in Utah during 1995-1999. METHODS Analyses were based on 27,631 incident cases of cancer identified among whites. Restriction to whites was made because of the small number of nonwhites, approximately 5%, in the state during the study period. The direct method was used to age-adjust the rates to the 2000 U.S. standard population. RESULTS Significantly lower cancer incidence rates per 100,000 were observed among LDS compared with non-LDS males (287.2 vs. 321.1) and females (247.7 vs. 341.0). The lower rates are primarily explained by smoking-related cancers and female breast cancer. If the overall cancer incidence rate in LDS had occurred in the non-LDS population, 2.9% or 421 fewer cases would have occurred among males and 7.9% or 1,025 fewer cases would have occurred among females during the study period. CONCLUSIONS Given our current knowledge of risk factors for cancer, differences between LDS and non-LDS in smoking for males and smoking and sexual and reproductive behaviors in females primarily explain the lower risk of cancer in LDS populations.
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Affiliation(s)
- Ray M Merrill
- Department of Health Science, College of Health and Human Performance, Brigham Young University, 229-A Richards Building, Provo, UT 84602, USA.
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39
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Feuer EJ, Etzioni R, Cronin KA, Mariotto A. The use of modeling to understand the impact of screening on U.S. mortality: examples from mammography and PSA testing. Stat Methods Med Res 2005; 13:421-42. [PMID: 15587432 DOI: 10.1191/0962280204sm376ra] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Surveillance data represent a vital resource for understanding the impact of cancer control interventions on the population cancer burden. However, population cancer trends are a complex product of many factors, and estimating the contribution of any one of these factors can be challenging. Surveillance modeling is a technique for estimating the contribution of one or more interventions of interest to trends in disease incidence and mortality. In this article, we present several approaches to surveillance modeling of cancer screening interventions. We classify models as biological or epidemiological, depending on whether they model the full unobservable aspects of disease onset and progression, or models which reduce the complex process to simpler terms by summarizing portions of the disease process using mostly observed population level measures. We also describe differences between macrolevel models, microsimulation models and mechanistic models. We discuss procedures for model calibration and validation, and methods for presenting model results which are robust with respect to certain types of biased model estimates. As examples, we present several models of the impact of mammography screening on breast cancer mortality, and PSA screening on prostate cancer mortality. Both these examples are appropriate uses of surveillance modeling, even though for mammography there is extensive (although somewhat controversial) randomized trial evidence, whereas for PSA this biomarker has seen extensive use as a screening test prior to any controlled trial evidence of its efficacy. Some of the models presented here were developed as part of the National Cancer Institute's Cancer Intervention and Surveillance Modeling Network.
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Affiliation(s)
- Eric J Feuer
- Statistical Research and Applications Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland, USA.
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40
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Merrill RM, Hilton SC, Wiggins CL, Sturgeon JD. Toward a better understanding of the comparatively high prostate cancer incidence rates in Utah. BMC Cancer 2003; 3:14. [PMID: 12720571 PMCID: PMC156634 DOI: 10.1186/1471-2407-3-14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2002] [Accepted: 04/29/2003] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Ray M Merrill
- Department of Health Science, College of Health and Human Performance, Brigham Young University, Provo, Utah, USA
- Department of Family and Preventive Medicine, University of Utah College of Medicine, USA
| | - Sterling C Hilton
- Department of Statistics, College of Physical and Mathematical Sciences, Brigham Young University, Provo, Utah, USA
| | - Charles L Wiggins
- Utah Cancer Registry, Department of Oncological Sciences, and Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Jared D Sturgeon
- Department of Statistics, College of Physical and Mathematical Sciences, Brigham Young University, Provo, Utah, USA
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Jemal A, Kulldorff M, Devesa SS, Hayes RB, Fraumeni JF. A geographic analysis of prostate cancer mortality in the United States, 1970-89. Int J Cancer 2002; 101:168-74. [PMID: 12209994 DOI: 10.1002/ijc.10594] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The recently published atlas of cancer mortality in the United States revealed that prostate cancer mortality rates were elevated among white men in the Northwest, the Rocky Mountain states, the north-central area, New England and the South Atlantic area, and among black men in the South Atlantic area. Here we determine whether the elevated regional rates were statistically different from rates in the rest of the country and whether the pattern can be explained by selected regional characteristics. A spatial scan statistic was applied to county-based mortality data from 1970 through 1989 to identify geographic clusters of the elevated rates for prostate cancer. Five clusters of elevated mortality were detected in white men (p < 0.005) and 3 in black men (p = 0.0001-0.056). For white men, the primary cluster was in the northwestern quadrant, followed by clusters in New England, the eastern part of the north-central area, the mid-Atlantic states and the South Atlantic area, whereas for black men the primary cluster was in the South Atlantic area, followed by clusters in Alabama and the eastern part of the north-central area. Further analyses of these clusters revealed several significant subclusters (p < 0.05). None of the selected demographic and socioeconomic factors, separately or collectively, accounted for the primary clusters in the U.S. white and black populations. The patterns observed could not be attributed to selected demographic or socioeconomic characteristics but should provide leads for further study into the risk factors and the medical or reporting practices that may contribute to geographic variation in mortality from prostate cancer.
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Affiliation(s)
- Ahmedin Jemal
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA.
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42
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Merrill RM, Wiggins CL. Incidental detection of population-based prostate cancer incidence rates through transurethral resection of the prostate. Urol Oncol 2002; 7:213-9. [PMID: 12644219 DOI: 10.1016/s1078-1439(02)00193-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To provide an updated assessment of the influence transurethral resection of the prostate (TURP) has on incidental detection of prostate cancer and to characterize stage, histologic grade, and treatment patterns among these cases. METHODS Analyses were based on 17,310 histologically confirmed prostate cancer cases ages 45 years and older recorded in the Utah Cancer Registry between 1980 and 1999 and 6426 TURP procedures recorded in the Utah Hospital Discharge Database from 1992 through 1999. An algorithm was developed for identifying TURP-detected prostate cancer incidence. RESULTS Age-specific TURP-detected prostate cancer incidence rates tended to be flat between 1980 and 1990, decline through 1994, and then level off. Much of the decrease corresponds to the prostate-specific antigen (PSA) screening induced peak and subsequent fall in total prostate cancer incidence rates. Leveling off in the TURP-detected rates between 1994 and 1999 corresponds with a leveling off in the total prostate cancer incidence rates. The percentage of prostate cancer detected by TURP significantly increases with age, within each age group, but decreases over calendar years. For ages 45 years and older, the percentage of TURP-detected cases was 39.0% in 1980 to 1984, 33.9% in 1985 to 1989, 12.2% in 1990 to 1994, and 7.4% in 1995 to 1999. TURP-detected cases were significantly less likely to undergo radical prostatectomy or radiation therapy across age groups, despite having lower stage and histologic grade at diagnosis. CONCLUSION TURP-detected prostate cancer rates have leveled off in the latter part of the 1990s, explaining about 10% of all detected cases. These cases have relatively good biologic potential and are less likely to pursue aggressive therapy.
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Affiliation(s)
- Ray M Merrill
- Department of Health Science, College of Health and Human Performance, 229-A Richards Building, Brigham Young University, Provo, UT 84602, USA.
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43
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Abstract
OBJECTIVES To describe the changes in the rates of radical prostatectomy procedures, prostate-specific antigen (PSA) screening tests among Medicare beneficiaries, and the incidence of prostate cancer in the United States and to explain the exaggerated increase and decrease in the frequency of radical prostatectomy from 1989 to 1996. METHODS Medicare claims data on radical prostatectomy procedures and screening PSA tests and the National Cancer Institute's Surveillance, Epidemiology, and End Results prostate cancer incidence data were used to estimate the rates of PSA testing and radical prostatectomy among Medicare beneficiaries aged 65 to 74 years and 75 years and older (population rates). The age-specific true rates of the procedure were also estimated for the incident cases of prostate cancer (the population at risk of undergoing radical prostatectomy) among the beneficiaries. RESULTS The PSA test, prostate cancer incidence, and radical prostatectomy rates increased from 1989 to 1992. Thereafter, the incidence of prostate cancer, and the population and true rates of radical prostatectomy declined. The percentage of increase and decrease in the population rate of radical prostatectomy was approximately twice that in its true rate. CONCLUSIONS The radical prostatectomy rates based on all Medicare beneficiaries grossly exaggerated the changes in the use of the procedure. Where possible, true rates, using the population at risk as the denominator, should be used in the studies of diagnostic and therapeutic procedures, complications, and adverse effects.
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Affiliation(s)
- Kazim Sheikh
- U.S. Department of Health and Human Services, Centers for Medicare & Medicaid, Kansas City, Missouri 64106, USA
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44
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Stephenson RA. Prostate cancer trends in the era of prostate-specific antigen. An update of incidence, mortality, and clinical factors from the SEER database. Urol Clin North Am 2002; 29:173-81. [PMID: 12109343 DOI: 10.1016/s0094-0143(02)00002-2] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Concurrent with the successful life-saving efforts in terms of prostate cancer diagnosis and treatment, some men who do not need treatment are receiving it. These are men destined to die of causes other than prostate cancer. Unfortunately, at diagnosis, men needing treatment for prostate cancer cannot be differentiated from men who do not. To make such decisions correctly for individual patients would require extremely precise measures of the time to death from prostate cancer versus when the patient would die from a competing cause. Predictive tools with this level of accuracy will never be available given the inherent uncertainty of life. At the time of prostate cancer diagnosis, the date and the cause of death for the patient are matters of weak statistical speculation. Unless the date of death from prostate cancer and the date of death from non-prostate cancer causes can be precisely determined for each patient, some men will always be overtreated or undertreated. Conservative strategies result in the undertreatment of some patients who would benefit from treatment while sparing other patients unneeded treatment. Aggressive strategies result in the overtreatment of patients who do not need therapy while curing other men of prostate cancer. Both strategies are correct, but only some of the time. Better methods of determining the length of life and cause of death may improve this situation, but not by much. [figure: see text] Dramatic shifts in the incidence, grade, stage, and age of men with prostate cancer have been observed with the advent of widespread PSA-based cancer detection in the United States. Grade and stage trends suggest that more biologically relevant (the shift from well-differentiated to moderately differentiated tumors) and yet therapeutically amenable (earlier stage) tumors have been identified in large numbers of patients during the PSA era. Clearly many men have been diagnosed and treated who will not benefit from such treatment. The relative mix of these two groups of men is not known. Given the long delay between treatment and mortality that is inherent in prostate cancer (Fig. 14), the full effects of treatment on prostate cancer mortality are probably not yet seen in prostate cancer mortality data.
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Affiliation(s)
- Robert A Stephenson
- Division of Urology, Department of Surgery, University of Utah School of Medicine, 50 North Medical Drive, Room 3B420, Salt Lake City, UT 84132, USA.
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45
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Abstract
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.
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Affiliation(s)
- D E Neal
- School of Surgical Sciences, Medical School, University of Newcastle upon Tyne, UK.
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