Screening for prostate cancer: systematic review and meta-analysis of randomised controlled trials

Survival Outcomes for Men over 80 Years Undergoing Transrectal Ultrasound-Guided Prostate Biopsy: A Prospective Analysis

Introduction: Prostate cancer is the second most prevalent cancer among elderly males in Western countries. TRUS biopsy remains a standard diagnosing approach for prostate cancer but poses notable risks, particularly in older men, including complications such as sepsis, acute retention, and rectal bleeding, which can lead to substantial morbidity and mortality. This study aimed to evaluate cancer-specific survival outcomes in men aged over 80 years and whether there is any cancer-specific survival advantage for TRUS biopsy procedure. Methods: Between January 2005 and December 2015, we studied outcomes of 200 patients (median age, 82 years) with elevated prostate-specific antigen (PSA) levels (>4.0 ng/mL) and/or abnormal digital rectal examination (DRE) who underwent TRUS biopsy. Each participant was followed up until death using an electronic system and a unique identifier in a defined geographical area. Cancer-specific and overall survival analyses were carried out utilising SPSS, while R Project was employed to construct and evaluate two nomograms survival duration and predict the risk of death post-biopsy. All statistical tests were two-tailed, with significance set at p < 0.05. Results: Amongst the participants, only 24 patients were alive at the end of follow-up (median age, 91 years). The PSA levels ranged from 4.88 to 102.7 ng/mL. Log-rank and Breslow tests indicated that higher PSA levels, the development of metastases, and ISUP grade group 8-10 were associated with shorter survival times. Age, co-morbid conditions, and tumour type were incorporated into the nomogram due to their clinical significance. Patients aged <81 years had lower mortality risk, while those aged >88 years faced higher mortality risks. Complications from the biopsy increased mortality risks in both cancerous and benign cases, and metastasis significantly heightened the likelihood of death. However, co-morbid conditions did not influence survival probability. Conclusions: Our findings underscore that older age (specifically 80 years and above), high Gleason score, metastasis, and elevated PSA levels are predictive of poorer survival outcomes in elderly men following TRUS biopsy.

Discrimination of serum samples of prostate cancer and benign prostatic hyperplasia with 1H-NMR metabolomics

Prostate cancer continues to be a prominent health concern for men globally. Current screening techniques, primarily the prostate-specific antigen (PSA) test and digital rectal examination (DRE), possess inherent limitations, with prostate biopsy being the definitive diagnostic procedure. The invasive nature of the biopsy and other drawbacks of current screening tests create the need for non-invasive and more accurate diagnostic methods. This study utilized 1H-NMR (Proton Nuclear Magnetic Resonance) based serum metabolomics to differentiate between prostate cancer (PCa) and benign prostatic hyperplasia (BPH). Serum samples from 40 PCa and 41 BPH patients were analysed using 1H-NMR spectroscopy. PepsNMR was utilized for preprocessing the raw NMR data, and the binned spectra were examined for patterns distinguishing PCa and BPH. Principal component analysis (PCA) showed a moderate separation between PCa and BPH, highlighting the distinct metabolic profiles of both conditions. A logistic regression model was then developed, which demonstrated good performance in distinguishing between the two conditions. The results showed significant variance in multiple metabolites between PCa and BPH, such as isovaleric acid, ethylmalonic acid, formate, and glutamic acid. This research underlines the potential of 1H-NMR-based serum metabolomics as a promising tool for improved prostate cancer screening, offering an alternative to the limitations of current screening methods.

Association of Prostate-Specific Antigen With Age, Digital Rectal Examination, and Lower Urinary Tract Symptoms in the Lebanese Population: A Cross-Sectional Study

BACKGROUND

Prostate cancer (PCa) is a leading cause of mortality in men worldwide. Prostate-specific antigen (PSA) testing is a standard method for PCa detection, yet its association with age, digital rectal examination (DRE) results, and lower urinary tract symptoms (LUTS) remains understudied, particularly in the Lebanese population.

OBJECTIVE

This study aimed to investigate the association of PSA levels with age, DRE results, and LUTS severity among Lebanese men.

METHODS

A total of 725 men aged 55-70 years were recruited from a men's health campaign at Saint George Hospital University Medical Center in Lebanon. PSA levels, DRE results, and International Prostate Symptom Score (IPSS) were assessed. Statistical analysis included Kruskal-Wallis tests and Spearman's rho correlation coefficient.

RESULTS

Participants exhibited a significant correlation between age and PSA levels (r = 0.138, p < 0.01). PSA levels varied significantly across age groups (p = 0.029), with higher mean PSA levels observed in older age groups. IPSS status correlated positively with PSA levels (r = 0.23, p < 0.001), indicating higher PSA levels associated with increased LUTS severity. Abnormal DRE findings were significantly associated with elevated PSA levels (p < 0.00), suggesting their potential as an indicator of prostate abnormalities.

CONCLUSION

This study highlights the importance of age-specific reference ranges for PSA levels in the Lebanese population. Elevated PSA levels were associated with older age, increased LUTS severity, and abnormal DRE findings. These findings highlight the significance of integrating PSA testing with clinical assessments for PCa detection and risk stratification in Lebanon.

Descriptive epidemiology of prostate cancer in India, 2012-2019: Insights from the National Cancer Registry Programme

Purpose

This study describes the epidemiology, clinical extent at diagnosis, and treatment modalities for prostate cancer in India.

Methodology

This study is a secondary analysis of primary prostate cancer data sourced from the National Cancer Registry Programme. Data from population-based cancer registry for the period 2012-2016 were used to estimate the incidence rates, including crude incidence rate (CR), age-adjusted incidence rate (AAR), age-specific rate, and cumulative risk. Trends in the AAR were assessed using join-point regression. Hospital-Based Cancer Registry data from 2012 to 2019 were used to describe the clinical extent of the cancer at diagnosis and the treatment modalities.

Results

The incidence of prostate cancers was higher in urban registries such as Delhi, Kamrup Urban, and Mumbai (AAR of 11.8 per 100,000, 10.9 per 100,000, and 9.7 per 100,000, respectively). Prostate cancer incidence showed a rise after the age of 50, with a notable acceleration after age 64. The overall annual percentage change for prostate cancer incidence from 1982 to 2016 was 2.6. Around 43.0% of all prostate cancers were diagnosed at the distant metastatic stage. Surgery and radiotherapy, either as standalone treatments or in combination with other modalities, contributed to the treatment of 78.5% of localized cancer, 74.2% of locoregional cancer, and 57.2% of distant metastatic stage of prostate cancer.

Conclusion

There is heterogeneity in the incidence of prostate cancer, as evidenced by urban registries. Additionally, there is a need for downstaging the disease, without risking overdiagnosis.

Psychobiological screening among patients affected by prostate cancer: Identification of potential psychobiological markers

Prostate cancer is a common oncological disease of old age with the highest rates of incidence among males older than 65 years old. Diagnosis and treatment may be associated with the onset of adjustment, depressive, and anxiety disorders. The comorbidity with depression and anxiety may lead to a higher risk of suicide, and mortality as well as lower adherence to medical treatments and adverse functional outcomes in patients affected by urologic cancers. The role of genetic vulnerability and pre-morbid personality in predicting the development of mental disorders during cancer disease is debated. For instance, some genetic polymorphisms of the serotonin transporter-related promoter region (5-HTTLPR polymorphism) are associated with higher vulnerability for mental disorders as well as personality traits of neuroticism; both factors are potentially useful for identifying risk of depressive and anxious symptoms among cancer patients. This communication proposes the development of individualized psychobiological approaches to identify possible 'psychobiological' markers associated with the risk of mental disorders in prostate cancer patients.

Cancer Associated Macrophage-like Cells Are Prognostic for Highly Aggressive Prostate Cancer in Both the Non-Metastatic and Metastatic Settings

Despite advancements in the early-stage detection and expansion of treatments for prostate cancer (PCa), patient mortality rates remain high in patients with aggressive disease and the overtreatment of indolent disease remains a major issue. Prostate-specific antigen (PSA), a standard PCa blood biomarker, is limited in its ability to differentiate disease subtypes resulting in the overtreatment of non-aggressive indolent disease. Here we assess engorged cancer-associated macrophage-like cells (CAMLs), a ≥50 µm, cancer-specific, polynucleated circulating cell type found in the blood of patients with PCa as a potential companion biomarker to PSA for patient risk stratification. We found that rising PSA is positively correlated with increasing CAML size (r = 0.307, p = 0.004) and number of CAMLs in circulation (r = 0.399, p < 0.001). Over a 2-year period, the presence of a single engorged CAML was associated with 20.9 times increased likelihood of progression (p = 0.016) in non-metastatic PCa, and 2.4 times likelihood of progression (p = 0.031) with 5.4 times likelihood of death (p < 0.001) in metastatic PCa. These preliminary data suggest that CAML cell monitoring, in combination with PSA, may aid in differentiating non-aggressive from aggressive PCas by adding biological information that complements traditional clinical biomarkers, thereby helping guide treatment strategies.

Covariate-specific evaluation of continuous biomarker

Diagnostic tests usually need to operate at a high sensitivity or specificity level in practice. Accordingly, specificity at the controlled sensitivity, or vice versa, is a clinically sensible performance metric for evaluating continuous biomarkers. Meanwhile, the performance of a biomarker may vary across sub-populations as defined by covariates, and covariate-specific evaluation can be informative. In this article, we develop a novel modeling and estimation method for covariate-specific specificity at a controlled sensitivity level. Unlike existing methods which typically adopt elaborate models of covariate effects over the entire biomarker distribution, our approach models covariate effects locally at a specific sensitivity level of interest. We also extend our proposed model to handle the whole continuum of sensitivities via dynamic regression and derive covariate-specific ROC curves. We provide the variance estimation through bootstrapping. The asymptotic properties are established. We conduct extensive simulation studies to evaluate the performance of our proposed methods in comparison with existing methods, and further illustrate the applications in two clinical studies for aggressive prostate cancer.

A Highly Sensitive Urinary Exosomal miRNAs Biosensor Applied to Evaluation of Prostate Cancer Progression

Prostate cancer is the most common cancer in the male population, carrying a significant disease burden. PSA is a widely available screening tools for this disease. Current screen-printed carbon electrode (SPCE)-based biosensors use a two-pronged probe approach to capture urinary miRNA. We were able to successfully detect specific exosomal miRNAs (exomiRs) in the urine of patients with prostate cancer, including exomiR-451 and exomiR-21, and used electrochemistry for measurement and analysis. Our results significantly reaffirmed the presence of exomiR-451 in urine and that a CV value higher than 220 nA is capable of identifying the presence of disease (p-value = 0.005). Similar results were further proven by a PAS greater than 4 (p-value = 0.001). Moreover, a higher urinary exomiR-21 was observed in the high-T3b stage; this significantly decreased following tumor removal (p-values were 0.016 and 0.907, respectively). According to analysis of the correlation with tumor metastasis, a higher exomiR-21 was associated with lymphatic metastasis (p-value 0.042), and higher exomiR-461 expression was correlated with tumor stage (p-value 0.031), demonstrating that the present exomiR biosensor can usefully predict tumor progression. In conclusion, this biosensor represents an easy-to-use, non-invasive screening tool that is both sensitive and specific. We strongly believe that this can be used in conjunction with PSA for the screening of prostate cancer.

Racial Disparities in Prostate Cancer: Evaluation of Diet, Lifestyle, Family History, and Screening Patterns

BACKGROUND

Racial disparities in prostate cancer incidence and mortality rates are considerable. We previously found in the Health Professionals Follow-up Study (HPFS) that African-American men had an 80% higher prostate cancer risk than White men. With 21 additional years of follow-up and four-fold increase in cases, we undertook a contemporary analysis of racial differences in prostate cancer incidence and mortality in HPFS.

METHODS

For 47,679 men, we estimated HRs and 95% confidence intervals (CI) for the association between race and risk of prostate cancer through 2016 using Cox proportional hazards regression. Multivariable models (mHR) were adjusted for lifestyle, diet, family history, and PSA screening collected on biennial questionnaires.

RESULTS

6,909 prostate cancer cases were diagnosed in White, 89 in African-American, and 90 in Asian-American men. African-Americans had higher prostate cancer incidence (mHR = 1.31; 95% CI, 1.06-1.62) and mortality (mHR = 1.67; 95% CI, 1.00-2.78), and lower PSA screening prevalence than White men. The excess risk was greater in the pre-PSA screening era (HR = 1.68; 95% CI, 1.14-2.48) than the PSA screening era (HR = 1.20; 95% CI, 0.93-1.56). Asian-Americans had lower prostate cancer risk (mHR = 0.74; 95% CI, 0.60-0.92), but similar risk of fatal disease compared with white men.

CONCLUSIONS

Racial differences in prostate cancer incidence and mortality in HPFS are not fully explained by differences in lifestyle, diet, family history, or PSA screening.

IMPACT

Additional research is necessary to address the disproportionately higher rates of prostate cancer in African-American men.

How Much Information Do Icelandic Men Receive on Pros and Cons of Prostate-Specific Antigen Testing Prior to Undergoing Testing?

Prostate-specific antigen (PSA) testing for asymptomatic men is neither encouraged nor discouraged in most countries; however, shared decision-making is emphasized prior to PSA testing. The objective of this study was to examine to what extent Icelandic men receive information about the pros and cons of PSA testing. Furthermore, to explore if patient–provider communication about pros and cons of PSA testing has improved in the last decade during which time more emphasis has been placed on shared decision-making. All Icelandic men diagnosed with prostate cancer in the years 2015 to 2020 were invited to participate, and a total of 471 out of 1002 men participated (response rate 47.0%). Participants’ age ranged from 51 to 95 years (M = 71.9, SD = 7.3). Only half of the men received information about the pros and cons of PSA testing, a third did not receive any information prior to testing and, alarmingly, 22.2% of the men did not even know that they were being tested. A majority of the participants lacked knowledge about the testing with half of the men reporting that they had no knowledge about pros and cons of PSA testing prior to testing. The findings have major public health relevance as they indicate that information provided prior to PSA testing continue to be deficient and that there is a pressing need for interventions that educate men about the benefits and limitations of PSA testing before men undergo medical procedures that can seriously affect their quality of life.

[Collective interest cycles and trends in Google searches related to institutional campaigns on prostate cancer: promoting health or illness?]

Google algorithms record trends in interest on topics relevant to public health. WEB searches were analyzed (2014-2019) to identify patterns linked to prostate cancer. Relative Search Volumes (RSV) were analyzed by Google Trends on "prostate cancer" (PC), "prostate examination" (PE) and "PSA"; 260-week time series; Brazil region; Health category; Trend lines (degree 2 polynomials) to identify patterns; Averages compared by ANOVA; Sudden increase in November searches; Searches on PC greatly surpass PE and PSA; Stable annual PC averages; Discreet reduction in PE; Marked increase in PSA. In campaign months: Discreet increase in PC; stability in PE; Marked increase in PSA. "Blue November" campaigns encourage early identification of prostate cancer, although interest is seen to be focused on the disease per se with a lack of interest in diagnosis throughout the year. Differences in relation to "Pink October" are discussed - tenuous relation to educational level on prevention habits and the influence of celebrities. The conclusion drawn is that RSV analysis might be useful in tracking trends in prostate cancer screening to provide input for campaign developers.

Fourteen-Core Systematic Biopsy That Includes Two Anterior Cores in Men With PI-RADS Lesion ≥ 3 is Comparable With Magnetic Resonance Imaging-ultrasound Fusion Biopsy in Detecting Clinically Significant Prostate Cancer: A Single-institution Experience

INTRODUCTION

Magnetic resonance imaging (MRI)-ultrasound fusion targeted prostate biopsy (FB) has been advocated by many experts as a replacement for the standard template biopsy. Herein, we compared pathology results and cancer detection rates of FB with our standard 14-core systematic prostate biopsy (SB) that includes 2 anterior cores.

MATERIALS AND METHODS

One hundred two men with elevated prostate-specific antigen and suspicious lesions on multiparametric MRI, Prostate Imaging Reporting And Data System (PI-RADS) v2 score ≥ 3, underwent FB. Each target lesion was biopsied 3 times; our SB was performed concurrently. Biopsy results were compared for overall and clinically significant (cs), defined as Gleason score ≥ 7, cancer detection.

RESULTS

Fifty-two percent of patients had positive biopsy results, and of those, 44 had cs prostate cancer (PCa). The overall detection rates for FB and SB were 39% and 50%, respectively, and there was no statistical difference in the detection rate of csPCa detection rate (P = .42). Of 17 patients diagnosed with a high-risk PCa, defined as Gleason score ≥ 8, SB identified 15, whereas FB identified 10. Within the SB group, 21 had positive anterior core biopsies, of which 11 were cs.

CONCLUSION

Expanding the standard template prostate biopsies to include 2 anterior horn sampling may be just as effective as FB in men with PI-RADS lesion ≥ 3, thereby mitigating the increased cost associated with FB.

Risk of Genitourinary Malignancy in the Renal Transplant Patient

OBJECTIVE

To better understand the risk of genitourinary malignancies in the renal transplant patient. Currently, no consensus exists regarding screening and intervention, with much of the clinical decision-making based on historical practices established before recent progress in immunosuppression protocols and in genitourinary cancer diagnosis and management.

METHODS

A database of all solid organ transplants performed at the University of Minnesota from 1984 to 2019 was queried for renal transplant recipients in whom development of subsequent urologic malignancies (prostate, bladder, renal, penile, and testicular cancer) was found.

RESULTS

Among 6172 renal transplant recipients examined, cumulative incidence of all cancers of genitourinary etiology are presented over an average follow-up time of 10 years. Kidney cancer (combined graft and native), prostate cancer, and bladder cancer each demonstrated respective 30-year incidence of 4.6%, 8.7%, and 1.5% from the time of transplant. By comparison, age-matched data from the Surveillance, Epidemiology, and End Results database demonstrated 30-year cumulative incidence of 1.1%, 11.1%, and 1.7% for kidney cancer, prostate cancer, and bladder cancer respectively. The predominant genitourinary cancer was renal cell cancer, both of the native and of the transplanted kidney (native, n = 64; transplanted, n =11), followed by prostate cancer (n = 63), and bladder cancer (n = 37).

CONCLUSION

In this closely followed cohort of renal transplant recipients, renal cancer occurs at a higher incidence rate than in the non-transplanted population, while a lower rate of prostate cancer was found, with bladder cancer demonstrating a comparable cumulative incidence between transplant patients and the national age-matched population.

MicroRNAs as Guardians of the Prostate: Those Who Stand before Cancer. What Do We Really Know about the Role of microRNAs in Prostate Biology?

Prostate cancer is the second leading cause of cancer-related deaths of men in the Western world. Despite recent advancement in genomics, transcriptomics and proteomics to understand prostate cancer biology and disease progression, castration resistant metastatic prostate cancer remains a major clinical challenge and often becomes incurable. MicroRNAs (miRNAs), about 22-nucleotide-long non-coding RNAs, are a group of regulatory molecules that mainly work through post-transcriptional gene silencing via translational repression. Expression analysis studies have revealed that miRNAs are aberrantly expressed in cancers and have been recognized as regulators of prostate cancer progression. In this critical review, we provide an analysis of reported miRNA functions and conflicting studies as they relate to expression levels of specific miRNAs and prostate cancer progression; oncogenic and/or tumor suppressor roles; androgen receptor signaling; epithelial plasticity; and the current status of diagnostic and therapeutic applications. This review focuses on select miRNAs, highly expressed in normal and cancer tissue, to emphasize the current obstacles faced in utilizing miRNA data for significant impacts on prostate cancer therapeutics.

Prostate-specific antigen (PSA) screening rates and factors associated with screening in Eastern Canadian men: Findings from cross-sectional survey data

INTRODUCTION

The prostate-specific antigen (PSA) test is used in Canada to detect prostate cancer (PCa) despite mixed recommendations. Complications arising from false-positives are common, posing as a cancer-screening concern. This work estimates some Canadian rates of PSA screening and identifies men at increased odds for PSA screening.

METHODS

The Canadian Community Health Survey (CCHS) from 2009/10 (Atlantic Canada; ATL), 2011/2012 (Ontario; ON), and 2013/2014 (Quebec; QC) were used. Lifetime and recent PSA screening with confidence intervals were constructed to estimate PSA screening in ATL, ON, and QC. Two logistic regression models (for men <50 and ≥50 years of age) were used to determine associations between factors and lifetime PSA screening.

RESULTS

PSA screening rates have increased in most age groups for ATL, ON, and QC since 2000/2001. Factors positively associated with lifetime PSA screening in men of all ages were: having a digital rectal exam, having a regular doctor, and having a colorectal exam. Fruit and vegetables consumption and non-smoking status were positively associated with lifetime PSA screening in men <50 years of age. High income and the presence of chronic health conditions were positively associated with lifetime PSA screening in men ≥50 years of age.

CONCLUSIONS

PSA screening rates have generally increased since 2000/2001 in Canada. Physician-related factors play a role in men at all ages, while different factors are associated in men <50 years of age and men ≥50 years of age. Limitations include the generalizability to all of Canada and the potential for recall bias.

[GRADE: Evidence to Decision (EtD) framework for coverage decisions]

BACKGROUND

Coverage decisions are decisions by third party payers about whether and how much to pay for technologies or services, and under what conditions. Given their complexity, a systematic and transparent approach is needed. The DECIDE project, a GRADE working group initiative funded by the European Union, has developed GRADE Evidence to Decision (EtD) frameworks for different types of decisions, including coverage ones.

METHODS

We used an iterative approach, including brainstorming to generate ideas, consultation with stakeholders, user testing, and pilot testing of the framework.

RESULTS

The general structure of the EtD includes formulation of the question, an assessment using 12 criteria, and conclusions. Criteria that are relevant for coverage decisions are similar to those for clinical recommendations from a population perspective. Important differences between the two include the decision-making processes, accountability, and the nature of the judgments that need to be made for some criteria. Although cost-effectiveness is a key consideration when making coverage decisions, it may not be the determining factor. Strength of recommendation is not directly linked to the type of coverage decisions, but when there are important uncertainties, it may be possible to cover an intervention for a subgroup, in the context of research, with price negotiation, or with restrictions.

CONCLUSION

The EtD provides a systematic and transparent approach for making coverage decisions. It helps ensure consideration of key criteria that determine whether a technology or service should be covered and that judgments are informed by the best available evidence.

Middle ear pathologies in adults within the mining industry: A systematic review

BACKGROUND

Literature suggests that risk factors for middle ear pathologies, such as traumatic injuries and human immunodeficiency virus (HIV), exist in mines. However, studies on hearing health in mines seem to focus primarily on occupational noise-induced hearing loss and ignore middle ear pathologies. As a result, there is little documented evidence on the trends of middle ear pathologies in mine workers.

OBJECTIVES

The aim of this study was to explore and document published evidence reflecting trends in middle ear pathologies in mine workers.

METHOD

A systematic literature review of studies that reported middle ear pathologies in mine workers was conducted. Medline, CINAHL, PubMed, PsychInfo and Google Scholar databases were searched for studies in English published between January 1994 and December 2018 and reporting on trends in middle ear pathologies in mine workers.

RESULTS

Two research studies met the selection criteria and were included for analysis. One research study used tympanometry with 226 Hz probe tone, while another study used interviews to determine the presence of middle ear pathologies. While these studies indicate that middle ear pathologies exist in individuals working in mines, the evidence is limited.

CONCLUSION

While current data indicate that individuals working in mines may present with middle ear pathologies of varying severities, the evidence is too small to provide a clear trend of middle ear pathologies in individuals working in mines. Therefore, the current limited data suggest a need for further studies to examine middle ear pathologies in individuals working in mines.

Epidemiology of Prostate Cancer in the Republic of Kazakhstan

BACKGROUND

The incidence and mortality from prostate cancer in most native Asian populations remain low although a gradual increase is observed over the last years.

METHODS

The statistical analysis of official data on prostate cancer mortality and morbidity was performed for the whole country and for Pavlodar Region.

RESULTS

The increase in the incidence of prostate cancer among the population of Kazakhstan is observed, which may be attributed to the introduction of screening program based on serum PSA. Still, the crude incidence rates in Kazakhstan are below world indices. Over the last few years, the decreasing prostate cancer mortality is observed that might be influenced by early diagnosis. The age-standardized incidence rates show that the majority of prostate cancer cases occur in advanced ages (70 years and older).

CONCLUSION

More research is needed to determine the risk factors for prostate cancer, as well as ethnic and geographical trends for the population of Kazakhstan.

The Translational Status of Cancer Liquid Biopsies

Abstract

Precision oncology aims to tailor clinical decisions specifically to patients with the objective of improving treatment outcomes. This can be achieved by leveraging omics information for accurate molecular characterization of tumors. Tumor tissue biopsies are currently the main source of information for molecular profiling. However, biopsies are invasive and limited in resolving spatiotemporal heterogeneity in tumor tissues. Alternative non-invasive liquid biopsies can exploit patient’s body fluids to access multiple layers of tumor-specific biological information (genomes, epigenomes, transcriptomes, proteomes, metabolomes, circulating tumor cells, and exosomes). Analysis and integration of these large and diverse datasets using statistical and machine learning approaches can yield important insights into tumor biology and lead to discovery of new diagnostic, predictive, and prognostic biomarkers. Translation of these new diagnostic tools into standard clinical practice could transform oncology, as demonstrated by a number of liquid biopsy assays already entering clinical use. In this review, we highlight successes and challenges facing the rapidly evolving field of cancer biomarker research.

Lay Summary

Precision oncology aims to tailor clinical decisions specifically to patients with the objective of improving treatment outcomes. The discovery of biomarkers for precision oncology has been accelerated by high-throughput experimental and computational methods, which can inform fine-grained characterization of tumors for clinical decision-making. Moreover, advances in the liquid biopsy field allow non-invasive sampling of patient’s body fluids with the aim of analyzing circulating biomarkers, obviating the need for invasive tumor tissue biopsies. In this review, we highlight successes and challenges facing the rapidly evolving field of liquid biopsy cancer biomarker research.

Questioning the Status Quo: Should Gleason Grade Group 1 Prostate Cancer be Considered a "Negative Core" in Pre-Radical Prostatectomy Risk Nomograms? An International Multicenter Analysis

OBJECTIVE

To assess the impact of excluding Gleason Grade Group 1 (GG1) prostate cancer (CaP) cores from current pre-radical prostatectomy (RP) nomograms.

METHODS

Multi-institutional retrospective chart review was performed on all RP patients with prostate biopsy between 2008 and 2018. Patients were individually assessed using the Memorial Sloan Kettering Cancer Center (MSKCC) and Briganti nomograms using the following iterations: (1) Original [ORIG] - all available core data and (2) Selective [SEL] - GG1 cores considered negative. Nomogram outcomes - lymph node invasion (LNI), extracapsular extension (ECE), organ-confined disease (OCD), seminal vesicle invasion (SVI), were compared across iterations and stratified based on biopsy GG. Clinically significant impact on management (CSIM) was defined as change in LNI risk above or below 2% or 5% (Δ2/Δ5). Nomogram outcomes were validated with RP pathology.

RESULTS

7718 men met inclusion criteria. In men with GG2 who also had GG1 cores, SEL better predicted LNI (MSKCC - ORIG 4.97% vs SEL 3.50%; Briganti - ORIG 4.81% vs SEL 2.49%, RP outcome 2.46%), OCD (MSKCC - ORIG 40.91% vs SEL 48.44%, RP outcome: 68.46%) and ECE (MSKCC - ORIG 57.87% vs SEL 50.38%, RP outcome: 30.41%), but not SVI (MSKCC - ORIG 5.42% vs SEL 3.34%, RP outcome: 5.62%). This was also consistent in patients with GG3-5 disease. The greatest CSIM was on GG1-2 CaP; Δ2 and Δ5 in GG1 patients was 26.3%-31.0% and 1.5%-5.2%, respectively, and Δ2 and Δ5 in GG2 patients was 3.4%-22.2% and 12.3%-13.6%, respectively.

CONCLUSION

Excluding GG1 CaP cores from pre-RP nomograms better predicts final RP pathologic outcomes. More importantly, this may better reflect extent of true cancer burden.

Current and Future Burden of Prostate Cancer in Songkhla, Thailand: Analysis of Incidence and Mortality Trends From 1990 to 2030

PURPOSE

Prostate cancer is the second most common malignancy among men worldwide, and it poses a significant public health burden that has traditionally been limited mostly to developed countries. However, the burden of the disease is expected to increase, affecting developing countries, including Thailand. We undertook an analysis to investigate current and future trends of prostate cancer in the province of Songkhla, Thailand, using data from the Songkhla Cancer Registry from 1990 to 2013.

METHODS

Joinpoint regression analysis was used to examine trends in age-adjusted incidence and mortality rates of prostate cancer and provide estimated annual percent change (EAPC) with 95% CIs. Age-period-cohort (APC) models were used to assess the effect of age, calendar year, and birth cohort on incidence and mortality rates. Three different methods (Joinpoint, Nordpred, and APC) were used to project trends from 2013 to 2030.

RESULTS

Eight hundred fifty-five cases of prostate cancer were diagnosed from 1990 to 2013 in Songkhla, Thailand. The incidence rates of prostate cancer significantly increased since 1990 at an EAPC of 4.8% (95% CI, 3.6% to 5.9%). Similarly, mortality rates increased at an EAPC of 5.3% (95% CI, 3.4% to 7.2%). The APC models suggest that birth cohort is the most important factor driving the increased incidence and mortality rates of prostate cancer. Future incidence and mortality of prostate cancer are projected to continue to increase, doubling the rates observed in 2013 by 2030.

CONCLUSION

It is critical to allocate resources to provide care for the men who will be affected by this increase in prostate cancer incidence in Songkhla, Thailand, and to design context-appropriate interventions to prevent its increasing burden.

Is it safe to continue antithrombotic agents before prostate biopsy?

Background

Whether antithrombotic agents should be stopped before prostate biopsy is unsettled. We investigated the impact of antithrombotic agents on bleeding complications after prostate biopsy.

Materials and methods

Among the patients who underwent transrectal ultrasound-guided prostate biopsy from June 2006 to December 2013 at Ebina General Hospital, Kanagawa, Japan, 1817 cases were retrospectively assessed. Patients were divided into two groups: those not taking antithrombotic agents (control group) and those taking them (experimental group). The frequency and severity of bleeding complications after the procedure were compared. The severity of bleeding events was graded using the Common Terminology Criteria for Advanced Events vol. 4.0.

Results

Hemorrhagic complications were classified into grades 1 to 3. Patients with complications of Grade 2 and above needed treatment. As for the Grade 1 event, there were no differences between two groups. The frequency of more than Grade 2 bleeding events was 1.7% and 3.5% in the control and experimental group, respectively; the odds ratio was 2.18 (P = 0.039). Grade 3 events occurred in seven patients of the control group (0.5%) and four patients of the experimental group (1.2%).

Conclusions

The present study showed that continuation of antithrombotic agents increased the frequency of hemorrhagic complications requiring intervention. It suggests that attention should be paid to the patients taking antithrombotic agents before prostate biopsy.

NMR-Based Metabolomic Profiling of Urine: Evaluation for Application in Prostate Cancer Detection

Detection of prostate cancer (PCa) and distinguishing indolent versus aggressive forms of the disease is a critical clinical challenge. The current clinical test is circulating prostate-specific antigen levels, which faces particular challenges in cancer diagnosis in the range of 4 to 10 ng/mL. Thus, a concerted effort toward building a noninvasive biomarker panel has developed. In this report, the hypothesis that nuclear magnetic resonance (NMR)-derived metabolomic profiles measured in the urine of biopsy-negative versus biopsy-positive individuals would nominate a selection of potential biomarker signals was investigated. 1H NMR spectra of urine samples from 317 individuals (111 biopsy-negative, 206 biopsy-positive) were analyzed. A double cross-validation partial least squares-discriminant analysis modeling technique was utilized to nominate signals capable of distinguishing the two classes. It was observed that after variable selection protocols were applied, a subset of 29 variables produced an area under the curve (AUC) value of 0.94 after logistic regression analysis, whereas a “master list” of 18 variables produced a receiver operating characteristic ROC) AUC of 0.80. As proof of principle, this study demonstrates the utility of NMR-based metabolomic profiling of urine biospecimens in the nomination of PCa-specific biomarker signals and suggests that further investigation is certainly warranted.

PSA screening - for whom and when?

Reasons for and against screening of prostate cancer have been discussed widely over the last decade. In 2014, the European Randomized Trial for Screening of Prostate Cancer (ERSPC) has reported a relative reduction of the cancer-specific survival of 27% in participants who definitely followed the screening protocol. This relative advantage has proven to be stable from year 7 to year 13 after the beginning of screening. Still, the disadvantages of overdiagnosis and overtreatment are the downsides of a population-based screening approach. But given the overall advantage of screening, a risk-adapted prostate-specific antigen (PSA) screening using a baseline PSA value at ages 45-50 may significantly reduce the number needed to diagnose maintaining the benefits of screening. PROBASE is a randomized risk-adapted screening trial currently ongoing in Germany to answer this important question.

Downregulation of lnRNA-NEF is involved in the postoperative cancer distant recurrence in prostate carcinoma patients

LnRNA-NEF has characterized functionality only in liver cancer. In the present study, we observed that plasma lnRNA-NEF was downregulated, while plasma transforming growth factor-β1 (TGF-β1) was upregulated in patients with early-stage prostate carcinoma (PC) than in healthy controls. The levels of plasma lnRNA-NEF and plasma TGF-β1 were inversely correlated in patients with PC but not in healthy controls. After surgical resection, the follow-up was performed for 5 years. It was observed that lnRNA-NEF was further decreased in patients with distant recurrence (DR), but not in patients with local recurrence and nonrecurrence. lnRNA-NEF overexpression caused inhibited TGF-β1 expression in cells of PC cell lines, while TGF-β1 overexpression failed to affect lnRNA-NEF expression. LnRNA-NEF overexpression inhibited, while the TGF-β1 overexpression promoted the migration and invasion of cells of PC cell lines. TGF-β1 overexpression partially rescued the inhibited migration and invasion of cells of PC cell lines caused by the lnRNA-NEF overexpression. Therefore, the downregulation of lnRNA-NEF may contribute to the postoperative DR in patients with PC through the interactions with TGF-β1.

Identification of the key genes and pathways in prostate cancer

Prostate cancer (PCa) is one of the most common malignancies in men globally. The aim of the present study was to identify the key genes and pathways involved in the occurrence of PCa. Gene expression profile (GSE55945) was downloaded from Gene Expression Omnibus, and the differentially expressed genes (DEGs) were identified. Subsequently, Gene ontology analysis, KEGG pathway analysis and protein-protein interaction (PPI) analysis of DEGs were performed. Finally, the identified key genes were confirmed by immunohistochemistry. The GO analysis results showed that the DEGs were mainly participated in cell cycle, cell division, cell development and cell junction. The KEGG pathway analysis showed that the DEGs were mainly enriched in proteoglycans in cancer, endocytosis, focal adhesion and hippo signaling pathway. The PPI analysis results showed that RPS21, FOXO1, BIRC5, POLR2H, RPL22L1 and NPM1 were the key genes involved in the occurrence of PCa, and the Module analysis indicated that the occurrence of PCa was associated with cell cycle, oocyte meiosis and ribosome biogenesis. IHC result showed that the expression of RPS21, BIRC5, POLR2H, RPL22L1 and NPM1 were significantly upregulated in PCa, while the expression of FOXO1 was significantly downregulated in PCa, matching with the bioinformatics analysis. Taken together, several key genes and pathways were identified involved in PCa, which might provide the potential biomarker for prognosis, diagnosis and drug targets.

Exnovation of Low Value Care: A Decade of Prostate-Specific Antigen Screening Practices

OBJECTIVES

To examine prostate-specific antigen (PSA) screening practice change in subgroups of men defined in guidelines and in various regions and to identify factors associated with change in screening practices.

DESIGN

Observational study using serial cross-sections, 2003 to 2013.

SETTING

National fee-for-service Medicare.

PARTICIPANTS

Men aged 68 and older eligible for prostate cancer screening.

MEASUREMENTS

National PSA screening practices in men aged 68 and older from 2003 to 2013 and change in regional screening rates in men aged 75 and older.

RESULTS

The PSA screening rate in men aged 68 and older was 17.2% in 2003, 22.3% in 2008, and 18.6% in 2013 (p < .001 for all differences); rates ended slightly lower than rates in 2003 only in men 80 and older. Racial disparities in screening became less pronounced over this period. In men aged 75 and older, change in regional screening rates varied widely, with absolute rates growing by 15 per 100 enrollees in some areas and declining by the same amount in others. Areas with high social capital, a measure associated with diffusion of new ideas, were more likely to decline; malpractice intensity and managed care penetration had no effect.

CONCLUSION

Studying Medicare enrollees over time, we found little reduction in PSA screening and even increases according to race and in some regions. The heterogeneous changes across regions suggest that consistent reduction in the use of low-value care may require change strategies that go beyond evidence and guidelines to include monitoring and feedback on performance. J Am Geriatr Soc 67:29-36, 2019.

No differences were found between effect estimates from conventional and registry-based randomized controlled trials

OBJECTIVES

The study aims to assess whether the results from registry-based randomized controlled trials (RRCTs) systematically differ from the results of conventional randomized controlled trials (CRCTs).

STUDY DESIGN

The study was meta-epidemiological study. We identified RRCTs (February 2016) and subsequent systematic reviews (SRs) that included one RRCT (04/2017). We calculated pooled odds ratios for RRCTs and CRCTs for mortality and other incidence measures (e.g., cardiovascular events). We assessed the agreement between RRCTs and CRCTs using various measures with descriptive statistics and the odds ratio of pooled odds ratios (OROR) for RRCT(s) vs. CRCTs. An OROR of >1 indicates that the effect estimates from RRCTs were larger than the effects estimates from CRCTs.

RESULTS

Overall, we compared 15 and 14 effect estimates for mortality and incidence measures, respectively. The 95% confidence interval (CI) overlap was 100% for any outcome. Conflicting effect directions were observed in 27% (4/15) of mortality and 7% (1/14) of incidence measures. The ORORs for RRCT(s) vs. CRCTs was 1.03 (95% CI 0.97-1.09) for mortality and 1.05 (95% CI 0.98-1.12) for other incidence measures.

CONCLUSIONS

Our analysis indicates that for objective outcomes, there is no systematic difference between effect estimates from RRCTs and CRCTs.

Prostate cancer screening with prostate-specific antigen (PSA) test: a systematic review and meta-analysis

OBJECTIVE

To investigate the efficacy and safety of prostate-specific antigen (PSA) testing to screen for prostate cancer.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Electronic search of Cochrane Central Register of Controlled Trials, Web of Science, Embase, Scopus, OpenGrey, LILACS, and Medline, and search of scientific meeting abstracts and trial registers to April 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials comparing PSA screening with usual care in men without a diagnosis of prostate cancer.

DATA EXTRACTION

At least two reviewers screened studies, extracted data, and assessed the quality of eligible studies. A parallel guideline committee (BMJ Rapid Recommendation) provided input on the design and interpretation of the systematic review, including selection of outcomes important to patients. We used a random effects model to obtain pooled incidence rate ratios (IRR) and, when feasible, conducted subgroup analyses (defined a priori) based on age, frequency of screening, family history, ethnicity, and socioeconomic level, as well as a sensitivity analysis based on the risk of bias. The quality of the evidence was assessed with the GRADE approach.

RESULTS

Five randomised controlled trials, enrolling 721 718 men, were included. Studies varied with respect to screening frequency and intervals, PSA thresholds for biopsy, and risk of bias. When considering the whole body of evidence, screening probably has no effect on all-cause mortality (IRR 0.99, 95% CI 0.98 to 1.01; moderate certainty) and may have no effect on prostate-specific mortality (IRR 0.96, 0.85 to 1.08; low certainty). Sensitivity analysis of studies at lower risk of bias (n=1) also demonstrates that screening seems to have no effect on all-cause mortality (IRR 1.0, 0.98 to 1.02; moderate certainty) but may have a small effect on prostate-specific mortality (IRR 0.79, 0.69 to 0.91; moderate certainty). This corresponds to one less death from prostate cancer per 1000 men screened over 10 years. Direct comparative data on biopsy and treatment related complications from the included trials were limited. Using modelling, we estimated that for every 1000 men screened, approximately 1, 3, and 25 more men would be hospitalised for sepsis, require pads for urinary incontinence, and report erectile dysfunction, respectively.

CONCLUSIONS

At best, screening for prostate cancer leads to a small reduction in disease-specific mortality over 10 years but has does not affect overall mortality. Clinicians and patients considering PSA based screening need to weigh these benefits against the potential short and long term harms of screening, including complications from biopsies and subsequent treatment, as well as the risk of overdiagnosis and overtreatment.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42016042347.

A pilot study of prostate cancer knowledge among African American men and their health care advocates: implications for screening decisions

PURPOSE

Prostate cancer (PCa) is the second leading cause of cancer death in U.S. men [American Cancer Society (ACS)], most often affecting men age 50 and older. The study provides information about factors that influence rural AA men in their decision to undergo screening for PCa with a specific focus on PCa knowledge among AA men and their health care advocates.

METHODS

A longitudinal quantitative study included AA males and their health care advocates. Participants were from three Alabama rural counties. Measures included demographics, PCa knowledge, decisional conflict, and health literacy scales.

RESULTS

Thirty-three men with a mean age of 54.61 and 35 health care advocates were included in the study. PROCASE Knowledge Index measure results indicate a lack of PCa knowledge among both male primary participants and their advocates. The knowledge of AA men in the study was somewhat low, with individuals correctly answering approximately six questions out of ten at multiple time points (baseline total M = 6.42, SD = 1.52). Decisional conflict responses at 12 months (38.64) were lower than at baseline (M = 62.88) and at 6 months (M = 58.33), p < .005.

CONCLUSION

Health care advocates of the 33 male participants were usually women, spouses, or significant others, supporting the vital role women play in men's health specifically in rural underserved communities. Low overall PCa knowledge, including their risk for PCa, among these participants indicates a need for PCa and screening educational interventions and dialogue that include males and their significant others.

An integrative review exploring black men of African and Caribbean backgrounds, their fears of prostate cancer and their attitudes towards screening

Evidence suggests that black men are disproportionately more affected than any other ethnicity by prostate cancer. The aim of this review is to identify studies exploring black men of African and Caribbean descent, their fears of prostate cancer and their attitudes towards screening. Four databases were searched and reference lists of relevant papers were hand searched. The inclusion criteria were studies exploring attitudes towards screening and fear of prostate cancer in black men of African and Caribbean backgrounds, peer-reviewed research, qualitative studies, surveys, questionnaires and English language publications. Qualitative findings were synthesized using a thematic framework to which quantitative findings were integrated. Of the 16 papers, 10 were quantitative and 6 were qualitative, all of which were conducted in the United States of America. Poorer and less educated black men were reluctant to seek help for prostate cancer. They may not visit their doctors for fear of intrusion into their personal lives. Moreover, they were fearful of being emasculated as a result of the digital rectal examination. The review identifies a paucity of UK literature on black men's fears and perceptions of prostate cancer. Further studies are needed in the United Kingdom to address this gap in the literature.

Prostate Cancer Screening

During the prostate-specific antigen-based prostate cancer (PCa) screening era there has been a 53% decrease in the US PCa mortality rate. Concerns about overdiagnosis and overtreatment combined with misinterpretation of clinical trial data led to a recommendation against PCa screening, resulting in a subsequent reversion to more high-risk disease at diagnosis. Re-evaluation of trial data and increasing acceptance of active surveillance led to a new draft recommendation for shared decision making for men aged 55 to 69 years old. Further consideration is needed for more intensive screening in men with high-risk factors. PCa screening significantly reduces PCa morbidity and mortality.

A spliced form of CD44 expresses the unique glycan that is recognized by the prostate cancer specific antibody F77

Prostate cancer is the most common cancer occurring in men in the United States. The monoclonal antibody F77 that was originally developed in our laboratory recognizes mainly glycolipids as well as O-linked glycosylation on proteins in prostate cancer cells. We have identified a spliced form of glycoprotein CD44 as one critical protein expressing the F77 antigen. The F77-specific glycosylation occurs on multiple potential glycosylation sites on the CD44 protein encoded by the fourteenth exon. CD44 is a tumor stem cell marker and is known to induce tumor stemness and metastasis. Knockdown of CD44 or FUT1 genes dramatically reduced F77-induced apoptosis in prostate cancer cell lines. We developed an ELISA using both a CD44 antibody and F77 to identify the special form of glycosylated CD44 from prostate cancer cells as well as from serum samples of prostate cancer patients. These results reveal a CD44-dependent mechanism for F77 to induce tumor cell apoptosis, and a new strategy for the detection of glycosylated CD44 proteins secreted by prostate cancer cells.

Identification of candidate genes that may contribute to the metastasis of prostate cancer by bioinformatics analysis

To screen for marker genes associated with to the metastasis of prostate cancer (PCa), in silico analysis of the Gene Expression Omnibus dataset GSE27616, which included 4 metastatic and 5 localized PCa tissue samples, was performed. Differentially expressed genes (DEGs) were identified. Their potential functions were identified by Gene Ontology and Kyoto Encyclopedia of Gene Genomes pathway enrichment analyses. Furthermore, protein-protein interaction (PPI) networks for DEGs were constructed using Cytoscape. Module analysis of the PPI networks was performed with Cluster ONE. A total of 561 DEGs were screened, including 208 upregulated and 353 downregulated genes. Proliferating cell nuclear antigen (PCNA) and cluster of differentiation 4 (CD4) exhibited the highest degrees of connectivity in the PPI networks for up- and down-regulated DEGs, respectively. The DEGs in module A, including CD58, 2, 4 and major histocompatibility complex, class II DP-β1 were enriched in 'cell adhesion molecules'. Anaphase promoting complex subunit 4, cell division cycle 20 and cell division cycle 16 in module B were primarily enriched in 'cell cycle'. The DEGs, including CD4, PCNA and baculoviral IAP repeat containing 5, may have critical roles in PCa metastasis and could thus be used as novel biomarker candidates for metastatic PCa. However, further studies are required to verify these results.

Mammography screening: A major issue in medicine

Breast cancer mortality is declining in most high-income countries. The role of mammography screening in these declines is much debated. Screening impacts cancer mortality through decreasing the incidence of number of advanced cancers with poor prognosis, while therapies and patient management impact cancer mortality through decreasing the fatality of cancers. The effectiveness of cancer screening is the ability of a screening method to curb the incidence of advanced cancers in populations. Methods for evaluating cancer screening effectiveness are based on the monitoring of age-adjusted incidence rates of advanced cancers that should decrease after the introduction of screening. Likewise, cancer-specific mortality rates should decline more rapidly in areas with screening than in areas without or with lower levels of screening but where patient management is similar. These two criteria have provided evidence that screening for colorectal and cervical cancer contributes to decreasing the mortality associated with these two cancers. In contrast, screening for neuroblastoma in children was discontinued in the early 2000s because these two criteria were not met. In addition, overdiagnosis - i.e. the detection of non-progressing occult neuroblastoma that would not have been life-threatening during the subject's lifetime - is a major undesirable consequence of screening. Accumulating epidemiological data show that in populations where mammography screening has been widespread for a long time, there has been no or only a modest decline in the incidence of advanced cancers, including that of de novo metastatic (stage IV) cancers at diagnosis. Moreover, breast cancer mortality reductions are similar in areas with early introduction and high penetration of screening and in areas with late introduction and low penetration of screening. Overdiagnosis is commonplace, representing 20% or more of all breast cancers among women invited to screening and 30-50% of screen-detected cancers. Overdiagnosis leads to overtreatment and inflicts considerable physical, psychological and economic harm on many women. Overdiagnosis has also exerted considerable disruptive effects on the interpretation of clinical outcomes expressed in percentages (instead of rates) or as overall survival (instead of mortality rates or stage-specific survival). Rates of radical mastectomies have not decreased following the introduction of screening and keep rising in some countries (e.g. the United States of America (USA)). Hence, the epidemiological picture of mammography screening closely resembles that of screening for neuroblastoma. Reappraisals of Swedish mammography trials demonstrate that the design and statistical analysis of these trials were different from those of all trials on screening for cancers other than breast cancer. We found compelling indications that these trials overestimated reductions in breast cancer mortality associated with screening, in part because of the statistical analyses themselves, in part because of improved therapies and underreporting of breast cancer as the underlying cause of death in screening groups. In this regard, Swedish trials should publish the stage-specific breast cancer mortality rates for the screening and control groups separately. Results of the Greater New York Health Insurance Plan trial are biased because of the underreporting of breast cancer cases and deaths that occurred in women who did not participate in screening. After 17 years of follow-up, the United Kingdom (UK) Age Trial showed no benefit from mammography screening starting at age 39-41. Until around 2005, most proponents of breast screening backed the monitoring of changes in advanced cancer incidence and comparative studies on breast cancer mortality for the evaluation of breast screening effectiveness. However, in an attempt to mitigate the contradictions between results of mammography trials and population data, breast-screening proponents have elected to change the criteria for the evaluation of cancer screening effectiveness, giving precedence to incidence-based mortality (IBM) and case-control studies. But practically all IBM studies on mammography screening have a strong ecological component in their design. The two IBM studies done in Norway that meet all methodological requirements do not document significant reductions in breast cancer mortality associated with mammography screening. Because of their propensity to exaggerate the health benefits of screening, case-control studies may demonstrate that mammography screening could reduce the risk of death from diseases other than breast cancer. Numerous statistical model approaches have been conducted for estimating the contributions of screening and of patient management to reductions in breast cancer mortality. Unverified assumptions are needed for running these models. For instance, many models assume that if screening had not occurred, the majority of screen-detected asymptomatic cancers would have progressed to symptomatic advanced cancers. This assumption is not grounded in evidence because a large proportion of screen-detected breast cancers represent overdiagnosis and hence non-progressing tumours. The accumulation of population data in well-screened populations diminishes the relevance of model approaches. The comparison of the performance of different screening modalities - e.g. mammography, digital mammography, ultrasonography, magnetic resonance imaging (MRI), three-dimensional tomosynthesis (TDT) - concentrates on detection rates, which is the ability of a technique to detect more cancers than other techniques. However, a greater detection rate tells little about the capacity to prevent interval and advanced cancers and could just reflect additional overdiagnosis. Studies based on the incidence of advanced cancers and on the evaluation of overdiagnosis should be conducted before marketing new breast-imaging technologies. Women at high risk of breast cancer (i.e. 30% lifetime risk and more), such as women with BRCA1/2 mutations, require a close breast surveillance. MRI is the preferred imaging method until more radical risk-reduction options are eventually adopted. For women with an intermediate risk of breast cancer (i.e. 10-29% lifetime risk), including women with extremely dense breast at mammography, there is no evidence that more frequent mammography screening or screening with other modalities actually reduces the risk of breast cancer death. A plethora of epidemiological data shows that, since 1985, progress in the management of breast cancer patients has led to marked reductions in stage-specific breast cancer mortality, even for patients with disseminated disease (i.e. stage IV cancer) at diagnosis. In contrast, the epidemiological data point to a marginal contribution of mammography screening in the decline in breast cancer mortality. Moreover, the more effective the treatments, the less favourable are the harm-benefit balance of screening mammography. New, effective methods for breast screening are needed, as well as research on risk-based screening strategies.

The efficacy of prostate-specific antigen screening: Impact of key components in the ERSPC and PLCO trials

BACKGROUND

The European Randomized Study of Screening for Prostate Cancer (ERSPC) demonstrated that prostate-specific antigen (PSA) screening significantly reduced prostate cancer mortality (rate ratio, 0.79; 95% confidence interval, 0.69-0.91). The US Prostate, Lung, Colorectal, and Ovarian (PLCO) trial indicated no such reduction but had a wide 95% CI (rate ratio for prostate cancer mortality, 1.09; 95% CI, 0.87-1.36). Standard meta-analyses are unable to account for key differences between the trials that can impact the estimated effects of screening and the trials' point estimates.

METHODS

The authors calibrated 2 microsimulation models to individual-level incidence and mortality data from 238,936 men participating in the ERSPC and PLCO trials. A cure parameter for the underlying efficacy of screening was estimated by the models separately for each trial. The authors changed step-by-step major known differences in trial settings, including enrollment and attendance patterns, screening intervals, PSA thresholds, biopsy receipt, control arm contamination, and primary treatment, to reflect a more ideal protocol situation and differences between the trials.

RESULTS

Using the cure parameter estimated for the ERSPC, the models projected 19% to 21% and 6% to 8%, respectively, prostate cancer mortality reductions in the ERSPC and PLCO settings. Using this cure parameter, the models projected a reduction of 37% to 43% under annual screening with 100% attendance and biopsy compliance and no contamination. The cure parameter estimated for the PLCO trial was 0.

CONCLUSIONS

The observed cancer mortality reduction in screening trials appears to be highly sensitive to trial protocol and practice settings. Accounting for these differences, the efficacy of PSA screening in the PLCO setting is not necessarily inconsistent with ERSPC results. Cancer 2018;124:1197-206. © 2017 American Cancer Society.

Disaggregating the mortality reductions due to cancer screening: model-based estimates from population-based data

The mortality impact in cancer screening trials and population programs is usually expressed as a single hazard ratio or percentage reduction. This measure ignores the number/spacing of rounds of screening, and the location in follow-up time of the averted deaths vis-a-vis the first and last screens. If screening works as intended, hazard ratios are a strong function of the two Lexis time-dimensions. We show how the number and timing of the rounds of screening can be included in a model that specifies what each round of screening accomplishes. We show how this model can be used to disaggregate the observed reductions (i.e., make them time-and screening-history specific), and to project the impact of other regimens. We use data on breast cancer screening to illustrate this model, which we had already described in technical terms in a statistical journal. Using the numbers of invitations different cohorts received, we fitted the model to the age- and follow-up-year-specific numbers of breast cancer deaths in Funen, Denmark. From November 1993 onwards, women aged 50-69 in Funen were invited to mammography screening every two years, while those in comparison regions were not. Under the proportional hazards model, the overall fitted hazard ratio was 0.82 (average reduction 18%). Using a (non-proportional-hazards) model that included the timing information, the fitted reductions ranged from 0 to 30%, being largest in those Lexis cells that had received the greatest number of invitations and where sufficient time had elapsed for the impacts to manifest. The reductions produced by cancer screening have been underestimated by inattention to their timing. By including the determinants of the hazard ratios in a regression-type model, the proposed approach provides a way to disaggregate the mortality reductions and project the reductions produced by other regimes/durations.

Prevalence and associations of general practitioners' ordering of "non-symptomatic" prostate-specific antigen tests: A cross-sectional analysis

AIMS

Testing for asymptomatic prostate cancer with prostate specific antigen (PSA) is of uncertain benefit. Most relevant authorities recommend against screening, and for informed patient choice. We aimed to establish the prevalence and associations of "non-symptomatic" PSA-testing of men aged 40 or older by early-career general practitioners (GP registrars).

METHODS

A cross-sectional analysis from the ReCEnT cohort study of registrars' consultations, 2010-2014 (analysed in 2016). Registrars record 60 consecutive consultations each 6-month training term. The outcome factor was ordering an "asymptomatic" PSA test (a PSA ordered for an indication that was not prostate-related symptoms or prostatic disease monitoring). Independent variables were patient, registrar, practice, consultation and educational factors.

RESULTS

A total of 856 registrars contributed details of 21,372 individual consultations and 35,696 problems/diagnoses of males 40 or older. Asymptomatic PSAs were ordered for 1.8% (95%CI: 1.7-2.0%) of consultations and for 1.1% (95%CI: 1.0-1.2%) of problems/diagnoses. Multivariable associations of asymptomatic PSA testing (compared with problems/diagnoses for which a PSA was not ordered) included patient age (OR 2.32 [95%CI: 1.53-3.53] for 60-69 years compared with 40-49), patient ethnicity (OR 0.40 [95%CI: 0.19-0.86] for non-English speaking background), the patient being new to both the registrar and practice (ORs 1.46 [95%CI: 1.08-1.99] and 1.79 [95%CI: 1.03-3.10]), the number of problems/diagnoses addressed (OR 1.44 [95%CI: 1.25-1.66] for each extra problem) and more pathology tests being ordered (OR 1.88 [95%CI: 1.79-1.97] for each extra test).

CONCLUSION

GP registrars frequently order "asymptomatic" PSA tests. Our findings suggest that non-compliance with current guidelines for PSA screening may be relatively common and that targeted education is warranted.

The tyranny of the averages and the indiscriminate use of risk factors in public health: The case of coronary heart disease

Modern medicine is overwhelmed by a plethora of both established risk factors and novel biomarkers for diseases. The majority of this information is expressed by probabilistic measures of association such as the odds ratio (OR) obtained by calculating differences in average “risk” between exposed and unexposed groups. However, recent research demonstrates that even ORs of considerable magnitude are insufficient for assessing the ability of risk factors or biomarkers to distinguish the individuals who will develop the disease from those who will not. In regards to coronary heart disease (CHD), we already know that novel biomarkers add very little to the discriminatory accuracy (DA) of traditional risk factors. However, the value added by traditional risk factors alongside simple demographic variables such as age and sex has been the subject of less discussion. Moreover, in public health, we use the OR to calculate the population attributable fraction (PAF), although this measure fails to consider the DA of the risk factor it represents. Therefore, focusing on CHD and applying measures of DA, we re-examine the role of individual demographic characteristics, risk factors, novel biomarkers and PAFs in public health and epidemiology. In so doing, we also raise a more general criticism of the traditional risk factors’ epidemiology. We investigated a cohort of 6103 men and women who participated in the baseline (1991–1996) of the Malmö Diet and Cancer study and were followed for 18 years. We found that neither traditional risk factors nor biomarkers substantially improved the DA obtained by models considering only age and sex. We concluded that the PAF measure provided insufficient information for the planning of preventive strategies in the population. We need a better understanding of the individual heterogeneity around the averages and, thereby, a fundamental change in the way we interpret risk factors in public health and epidemiology.

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There is a plethora of differences in “average” risk between exposed and unexposed groups of individuals.

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Individual heterogeneity around average values is seldom considered in Public Health.

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Measures of discriminatory accuracy (DA) informs on the underlying individual heterogeneity.

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Most know risk factors and other categorizations associated with diseases have low DA.

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We need a fundamental change in the way we investigate risk factors and other categorizations in Public Health.